Addiction in America has been deemed a public health crisis with the opioid epidemic declared a national emergency. In November 2016, the Surgeon General published a report on addiction in which former Surgeon General Vivek Murthy issued a call to action to end the crisis of addiction. The report, Facing Addiction in America, was the first of its kind, incorporating a robust evidence-base built up over the past several decades (HHS, 2016).
In July 2016, Congress enacted landmark legislation related to addiction. The Comprehensive Addiction and Recovery Act (CARA) addressed the continuum of care from prevention and education to treatment and recovery and included provisions for those on the front lines – criminal justice, emergency responders, and law enforcement, as well as certain vulnerable populations: women, families, and veterans.
Of note, CARA allowed for expanded access to the opioid overdose reversal drug, naloxone, expanded the number of medication-assisted treatment (MAT) patients a provider could see from 30 to 100, and enacted temporary provisions for nurse practitioners and physician assistants to administer MAT under the direction of a qualified physician. The law also expanded education and opportunities for safe storage and disposal of prescription medication. CARA mandated that each state create a plan of safe care for infants born affected by substance abuse, withdrawal symptoms, or a fetal alcohol spectrum disorder.
In February 2018, Senators Whitehouse (D-RI), Capito (R-WV), Klobuchar (D-MN), Sullivan (R-AK), Hassan (D-NH), Cassidy (R-LA), and Cantwell (D-WA) introduced CARA Act 2.0 Act of 2018, a bill to reauthorize and expand the 2016 CARA ACT. The new bill proposes the continuation and expansion of practices and programs established under CARA that represent a comprehensive approach to addiction and recovery in the United States.
CARA funding has increased each year since its inception. For the federal fiscal year (FY) 16 funding was $40.93 million. In FY 17 funding more than tripled at $153 million. An additional $181 million in funding to reduce the opioid impact of opioid use disorder was then authorized through CARA.
For more information on the current proposed funding authorizations for FY 2018, see Section By Section of the CARA 2.0 Act of 2018.
Proposed Funding Authorizations under CARA 2.0
|Section 1.||Short Title: The CARA 2.0 Act of 2018|
|Section 2.||National Education Campaign||Authorizes $10 million annually|
|Three Day Limit on Opioids for Acute Pain||No fiscal note|
|Section 4.||First Responder Training||Authorization increased from $12 million under CARA to $300 million annually under CARA 2.0
|Section 5.||Evidence-Based Prescription Opioid and Heroin Treatment and Intervention Demonstrations||Authorization increased from $25 million under CARA to $300 million annually under CARA 2.0
|Section 6.||Building Communities of Recovery||Authorization increased from $1 million under CARA to $200 million annually under CARA 2.0
|Section 7.||Medication-Assisted Treatment for Recovery from Addiction||No fiscal note
|National Youth Recovery Initiative||Authorizes $10 million annually under CARA 2.0, Program had been removed from CARA|
|Section 9.– to be developed, no fiscal note
|National Recovery Residence Standards||No fiscal note
|Section 10.||Improving Treatment for Pregnant and Postpartum Women||(Authorization increased from $17.9 million under CARA to $100 million annually under CARA 2.0)
|Section 11.||Veterans Treatment Courts||(Authorization increased from $6 million under CARA to $20 million annually under CARA 2.0)
|Section 12.||Infant Plan of Safe Care||(Authorizes $60 million annually)
|Section 13.||Require the Use of Prescription Drug Monitoring Programs (PDMP)||no fiscal note
|Increasing Civil and Criminal Penalties for Opioid Manufacturers
Increases civil and criminal penalties for opioid manufacturers that failing to report suspicious orders for opioids or failing to maintain effective controls against diversion of opioids.
|Maximum Civil Fines – CARA: $10,000 CARA 2.0: $100,000
Maximum Criminal Penalties: CARA: $250,000 CARA 2.0: $500,000
A Summary of CARA 2.0
- Proposes funding for a national educational campaign to raise awareness of the relationship between prescription opioid misuse and heroin use, and the dangers and potential lethal consequences of fentanyl.
- Mandates a three day limit on opioid prescriptions for acute pain and recommends prescription of the lowest effective dose of immediate release opioids. (This does not apply to the treatment chronic pain, pain being treated as part of cancer care, hospice or palliative care, or the use of medication-assisted treatment (MAT) for opioid use disorder).
- Requires use of the prescription drug monitoring programs (PDMPs) by practitioners in states that receive funding under the Harold Rogers Prescription Drug Monitoring Programor under the controlled substance monitoring program under section 3990 of the Public Health Service Act (42 U.S.C. 280g-3).
- Requires that all physicians use their state PDMPs when prescribing and every 30 days thereafter. PDMPs must proactively contact physicians if concerns arise regarding patient use and prescribing patterns
- Mandates data sharing and reporting to the public, key stakeholders, and across state lines
Medication-Assisted Treatment (MAT)
- Expands funding for MAT and requires that patients be offered two types of MAT – not less than 1 FDA approved opioid antagonist medications and not less than 1 FDA approved opioid agonist.
- Makes permanent the CARA temporary provisions for nurse practitioners and physician assistants to prescribe MAT under a qualified physician’s direction.
- At the same time, CARA 2.0 removes the limits on the number of patients that a physician can treat with medication-assisted therapy (raised from a total of 30 patients to 100 under CARA), provided that treatment is evidence-based.
First Responders and Members of Other Key Community Sectors
- Provides expanded training and resources for first responders and members of other key community sectors related to fentanyl and other dangerous illicit drugs
- Supports Evidence-based prescription opioid and heroin treatment and intervention demonstrations
- Building communities of recovery medication-assisted treatment for recovery from addiction
Increases funding for evidence-based treatment, including expanding the availability of MAT and provides grant funding at the local and tribal levels, for areas witnessing a rapid increase in opioid use.
Care coordination and Recovery Support
- Supports connections between recovery and other supportive series, stigma reduction and education and outreach on issues related to substance use disorder and recovery
- Provides funding for recovery community organizations and care coordination
- Mandates the development of national recovery residence standards
- CARA 2.0 adds funding for states to comply with CARA’s reporting requirements for each state’s plan of safe care for infants born exposed to substances. New funding can assist states, hospitals, and state agencies to collect and report data related to infants born dependent upon substances and to provide assistance for those infants and their caregivers.
Pregnant and Post-Partum Women
- Increases funding for treatment of pregnant and post-partum women with a primary diagnosis of substance use disorder (SUD) or opioid use disorder (OUD).
- Increases funding for veterans treatment courts
- Establishes a National youth recovery initiative that had been removed from the original CARA
Nevada is already compliant with the new PDMP guidelines and Nevada’s legislation regarding prescription drug and opioid misuse has been held up as a national model of best practice by former CDC Director Tom Frieden in a 2016 interview: Why Opioid Related Deaths Continue to Rise and What Can Be Done to Reverse the Trend (Rehm, 2016). Senate Bill (SB) 459 was introduced by Governor Brian Sandoval in 2015 and signed into law on May 5th of that year. Governor Sandoval introduced additional legislation in the 2017 legislative session that mandated new prescribing requirements, additional training for providers, PDMP use, and overdose reporting. Nevada prescribers are currently limited to 14 day prescriptions for acute pain, in part to accommodate our rural residents who may have challenges accessing prescription medication. Should CARA 2.0 be signed into law as written, this would be reduced to a period of 3 days.
As part of Nevada’s Plan of Safe Care and efforts through the Nevada National Governor’s Association Learning Network on Improving Birth Outcomes, Nevada recently released a Toolkit that addresses substance use during pregnancy. The Substance Use during Pregnancy Toolkit can be found on the Division of Public and Behavioral Health (DPBH) website and on Nevada’s Sober Moms, Healthy Babies website.
Peer Recovery and Support Services Featured Prominently in CARA 2.0
The Comprehensive Addiction and Recovery Act (CARA) of 2016, signed into law on July 22, 2016 established peer-to-peer services for veterans under Section 502: VETERANS TREATMENT COURTS. Peer-to –Peer Services or Programs were defined as “services or programs that connect qualified veterans with other veterans for the purpose of providing support and mentorship to assist qualified veterans in obtaining treatment, recovery, stabilization, or rehabilitation.”
The Comprehensive Addiction and Recovery Act of 2018 (CARA 2.0) expands the use of peers beyond veteran services. Peer services are an integral part of multiple sections of the act including Section 6: Building Communities of Recovery, Section 8: The National Youth Recovery Initiative, and Section 9: National Recovery Residence Standards.
Peer support services are a key component of the legal definition for both recovery programs and recovery housing.
RECOVERY HOUSING: The term ‘‘recovery housing’’ means a family-like, shared living environment free from alcohol and illicit drug use and centered on peer support and connection to services that promote sustained recovery from substance use disorders.
RECOVERY PROGRAM.—The term ‘‘recovery program’’ means a program— (A) to help youth or young adults who are recovering from substance use disorders to initiate, stabilize, and maintain healthy and productive lives in the community; and (B) that includes peer-to-peer support delivered by individuals with lived experience in recovery, and communal activities to build recovery skills and supportive social networks.
If CARA 2.0 passes as enrolled, grant funds (federal grant dollars) could be used to provide support and technical assistance for the implementation of “regionally driven peer delivered addiction recovery support services before, during, after, or in lieu of addiction treatment.”
As written, peer services would also form an integral part of substance use recovery support services for youth and young adults.
Grants awarded under subsection b may be used for activities to develop, support, or maintain substance use recovery support services for youth and young adults including the coordination of a peer delivered substance use recovery program with:
(A) Substance use disorder treatment programs and systems;
(B) Providers of mental health services;
(C) Primary care providers;
(D) The criminal justice system, including the juvenile justice system;
(F) Recovery housing services;
(G) Child welfare services;
(H) High schools; and
(I) Institutions of higher education;
Funding can also support the development of peer-to-peer support programs or services delivered by individuals with lived experience in addiction recovery.
CADCA. (n.d.). The Comprehensive Addiction and Recovery Act (CARA) Public Law 114-198. Retrieved from https://www.cadca.org/comprehensive-addiction-and-recovery-act-cara
CARA 2.0 Act of 2018, S.2456, 115th Cong., 2nd session. (2018). Retrieved from https://www.congress.gov/bill/115th-congress/senate-bill/2456/text?q=%7B%22search%22%3A%5B%22cara+2.0%22%5D%7D&r=1
Comprehensive Addition and Recovery Act of 2016, 114th Cong. (2016). Retrieved from https://www.congress.gov/bill/114th-congress/senate-bill/524/text
Hernandez-Delgado, H. (2018) CARA, the 21st Century Cures Act: More Tools to Address the Opioid Epidemic. National Health Law Program. Retrieved from https://www.napsw.org/assets/docs/Advocacy/caracuresact%202.22.17%201.pdf.
Rehm, D. (Author and Host). (2016, December 21). Why Opioid Related Deaths Continue To Rise and What Can Be Done To Reverse the Trend. The Diane Rehm Show [Radio Program]. Washington, D.C.: American University Radio.
Rob Portman United States Senator for Ohio. (2018, February 27). Section by section of the CARA act of 2018 [Press Release]. Retrieved from https://www.portman.senate.gov/public/index.cfm/press-releases?ID=5850C669-BF56-4E13-AA12-6A62DFFD1720.
U.S. Department of Health and Human Services (HHS), Office of the Surgeon General. (2016) Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC. HHS. Retrieved from https://addiction.surgeongeneral.gov/sites/default/files/surgeon-generals-report.pdf.