Policy analysis of the Comprehensive Addiction and Recovery Act of 2016: With an emphasis on how it may impact women with substance use disorder.
Cori L. Raddigan
SOWK 604, Social Policy Welfare I
April 17, 2016
Policy analysis of the Comprehensive Addiction and Recovery Act of 2016:
With an emphasis on how it may impact women with substance use disorder.
An Overview of The Comprehensive Addiction and Recovery Act (CARA)
Summary
The current epidemic of opioid drug use in the United States has become a national public health and safety issue. According to the CDC, in 2015 the leading cause of injury-related death was overdose of heroin and prescription opioid drugs, surpassing motor vehicle accidents for the first time in our history (Civic Impulse, 2016). Controlled prescription drugs (CPD’s) are the most abused opioid accounting for a 112% increase in emergency room visits between 2006-1010 (Civic Impulse, 2016). The incidence of heroin overdoses has tripled in five years and the low cost of heroin has made it an ideal replacement for persons addicted to CPD’s (Center for Disease Control and Prevention, 2016). Nearly 1 million people reported using heroin last year (Center for Disease Control and Prevention, 2016). In response to this growing problem, The Comprehensive Addiction and Recovery Act (CARA) was introduced to congress in 2014 and has continued to gain support each session (Rudolf, 2016). It passed the senate this March and an identical version of the bill in the house (H.R. 953) is already well supported with 92 co-sponsors (Carney, 2016).
Purpose
The CARA is a beefy 126-page proposal that is designed to tackle the many facets of the substance abuse epidemic. It is extremely expansive and encompasses prevention, education, law enforcement treatment, treatment and recovery, addiction and treatment services for special populations, prescription practice and monitoring, state incentives, and drug trafficking (Civic Impulse, 2016). Although there is great emphasis on opioids, the act encompasses all substance abuse. Title V of the bill addresses specific addiction and treatment services for women, families, and veterans. Section 501 within Title V encompasses the objective of improving treatment for pregnant and postpartum women and would allocate funds specifically to meet this need (Civic Impulse, 2016). Section 502 would access grants for family based substance treatment. This student is currently working with a panel of professionals who are developing an inpatient treatment program for women with children in eastern North Carolina. The passage of the CARA would be instrumental in offering state and federal support to maintain the program, and is therefore of great importance to explore.
Opposition
There is very little opposition to this bill, in fact it recently passed the Senate with a 94-1 vote indicating the support for the legislation that is attempting to move substance abuse policy away from punishment and toward a public health approach (Barron, Cherkis, & Grim, 2016).
Women with Substance Abuse Disorder
Summary
Although 2014 demonstrated the first year that opioid overdose deaths have surpassed motor vehicle accidents for the overall population, this has been the case for women since 2007 (Center for Disease Control and Prevention, 2013). In fact, while opioid related deaths increased among men by 265% between 1999-2010, women saw a 415% increase during the same time period (Center for Disease Control and Prevention, 2013). Women make up 1/3 of the 2 million Americans who are recovering from addiction. Two-thirds of these women are of childbearing age, which means the potential for negative impact on the next generation are higher (Evan, Levin, Li, & Hsr, 2014). The impact of substance use disorder in women is not only on the health of these women and children, but it also has negative social and economic impacts as well. Women are more likely to have co-existing issues compared to their male counterparts. They have an increased risk of early death, and an increased likelihood of mental illness, injury, trauma, and infectious diseases. Their substance abuse is often a barrier to financial independence, and these women are more likely to stay caught in the cycle of poverty, homelessness, and illegal activity (Evan et al., 2014).
The Research on Women Centered Treatment
Many studies have been conducted across the country examining the effectiveness of women only (WO) treatment programs compared to mixed-gender (MG) programs. Women centered programs give additional consideration to the specific and unique needs of women that MG treatment is not designed to meet. Women in MG centers have less therapeutic alliance with staff, higher treatment drop out rates, and are less likely to sustain their recovery (Evan, et al., 2014). When compared to men, women have an increased likelihood to have higher levels of psychological distress and co-occurring anxiety and/or mood disorders which may necessitate longer treatment (Grella, 2007). In one study, it was found that women who were referred to treatment to a WO program had a higher severity of problems across the alcohol, drug, medical, and psychiatric domains, but actually had better outcomes than women with less severity who attended MG programs (Niv & Hser, 2007). Thus supporting the idea that the specialized treatment provided by WO programs yielded more effective treatment outcomes than the MG programs.
Longitudinal Evidence
A 10-year follow up study took place in California where 4,447 women who were pregnant or parents at the time of their treatment were evaluated for long-term effects associated with treatment in WO centers versus MG facilities. They were all participants from the California Treatment Outcome Project and were women being treated with addictions including methamphetamines, alcohol, heroine, cocaine, and marijuana. These women had other notable factors such as time in the criminal justice system, chronic medical problems, psychiatric medications, and homelessness. The study revealed that women treated in a WO center, when compared to the women treated in a MG treatment program, had a higher rate of successful outcomes. Successful outcomes were operationally defined as having no illicit drug use or involvement within the criminal justice system within the 30 days prior to the follow up. Women who were pregnant while they received the initial treatment were even more likely to experience positive outcomes over the long term (Evan, Levin, Li, & Hsr, 2014).
Women Only Treatment Availability Across the United States
A research article published in the American Journal of Public Health reviewing the access of WO treatment facilities across the United States found that there is a clear discrepancy between the established need for specialized programs and the availability of those services. Despite research and increased federal funding over the years to address this population, the need is unmet in all 50 states. The study did identify that states with a population over 1.2 million, more WO addiction treatment services were available compared to other states. However, across the country there were less WO agencies accepting payment from Medicare, Medicaid, or Tricare. This demonstrated that access is limited to a large majority of people. As most studies have shown positive results including decreased substance use for women treated within women centered facilities, the needed expansion of these services has yet to occur (Terplan, Longinaker, & Appel, 2015).
The Impact of CARA on Women with Substance Abuse Disorder
How CARA addresses the Issue for Women
The bill addresses the issue by allocating funds directly to the specific population of women who are pregnant or with children struggling with addiction. The specificity of these section of the bill indicates the governments acceptance of the severity of the problem and the unique treatment needs of women.
Potential Impact and Consequences
The impact for the women with children who receive the services proposed by this bill will increase their chances of achieving sobriety. If a support system is properly built, and the many areas of a woman’s psychosocial, emotional, and physical health needs are addressed in the design of their treatment, they will have a greater potential for long-term success.
There is also great potential to positively impact child welfare. Children of parents who have substance use disorders account for a high number of child abuse and neglect reports (Grella, 2006). Testimony given in 1997 to the Subcommittee on Human Resources, the Committee on Ways and Means, and the House of Representatives still holds valuable information today in consideration of the impact of substance abuse on the foster care system. Investigations are often triggered by events involving parental substance abuse. Infants born with exposure to alcohol or drugs are referred to the Department of Social Services (United States General Accounting Office, 1997) . The treatment required poses a barrier to reuniting families, and the likelihood of long-term success for women is increased when mothers receive women centered treatment (Niv & Hsr, 2014).
One cannot discuss the potential positive impact of specific and effective treatment for pregnant women with substance use disorder without discussing the impact it could have on their newborns. In 2013 there were a reported 27,000 cases of drug addicted babies born in the U.S. (Wilson & Shiffman, 2015). In the United States, there is a newborn born with neonatal abstinence syndrome (NAS) every 25 minutes. This is associated with maternal opioid drug use and symptoms include seizures, difficulty breathing, low birth weight, and vomiting (Georges, 2015). This does not account for fetal alcohol syndrome (FAS) that is present in infants whose mothers abused alcohol during pregnancy. The allocation of funds to serve women in treatment can have an untold positive effect on the quality of lives for their children.
Arguments for and Against the Bill
With the costly public health problem of substance abuse, with opioid use steadly increasing at a high rate, there are little arguments that can be made in opposition to this bill. It is the opinion of this student that this is due to the comprehensive nature of the bill that encompasses so many aspects in order to address the problem. The arguments that do exist center around funding amounts and funding sources.
Financial Impact
The current drug epidemic brings a high cost to the country. According to the National Institute on Drug Abuse (NIDA), the United States currently spends 700 billion dollars a year paying for the health care and criminal justice costs of those struggling with addiction (Civic Impulse, 2016). Overall, the bill as it passed the senate in March would allocate 80 million in funds through the Department of Health and Human Services and the Department of Justice (McIntire, 2016). The text of the most currently published bill indicates a proposal of $15,900,000 for each fiscal year from 2016-2020 to address section 501, which specifically addresses the needs of women for which has been the basis of this analysis (Civic Impuls, 2016). In the final research for this paper, this student uncovered one resource that disclosed that the funding allocated for section 501 fell under an amendment proposed by Senator Jeanne Shaheen (D-NH). The $600 million dollar amendment proposed by Senator Shaheen fell under the umbrella of emergency funding. Sadly, this amendment was rejected in a 48-47 vote. Senator Shaheen expressed her disappointment and compared the exclusion of these funds as the “…equivalent of offering a life preserver without air in it” (State of New Hampshire, 2016, paragraph 2). Senator Shaheen pledged to continue to advocate and push for this funding. The largest critique of the bill since passing the house has related to the removal of this amendment, which would have provided immediate funds to implement assistance to combat the epidemic.
Funding Source
Although the bill has a majority approval within the Congress, there have been many criticisms or concerns regarding where the funding will come from. In an editorial piece the bill’s passage in the senate, Senator Sheldon Whitehouse (D- R.I.), one of the co-sponsors on the bill, was quoted as saying; “Let’s not pretend there’s money for this” (Barron-Lopez et al., 2016, para. 20). There has also been concern raised about the allocation of funds to the Justice department, which has a history of misappropriating funds ( It has also been criticized by the White House as offering only 1/3 of the funds necessary to address the problem (Barron-Lopez, et al, 2016). In their defense, republicans who are charged with blocking the $600 million amendment, argued that the $400 million from last years Omnibus could be utilized to fulfill the needs designated in the CARA (Carney, 2016).
Issues Remaining Unaddressed
The bill as it was approved without the $600 million amendment leaves all of the issues this student has attempted to describe unaddressed. There appears to be an ongoing disregard for the facts presented on the effectiveness of women centered treatment. Evidence far back as the 1970’s has shown the impact specialized treatment can have on women in treatment (Grella, 2007).
References
Barron-Lopez, L. & Cherkis, J., & Grim R. (2016, March 10). The senate finally did something to help combat the opioid epidemic. Retrieved April 15, 2016 from http://www.huffingtonpost.com/entry/senate-opioid- epidemic_us_56e19b41e4b0860f99d80173
Carney, J. (2016, March 10). Senate passes opioid abuse bill. Congress Blog: The Hill’s forum for lawmakers and policy professionals. Retrieved from http://thehill.com/blogs/floor- action/senate/272531-senate-passes-opioid-abuse-bill
Center for Disease Control and Prevention. (2016, March 11). Injury prevention and Control: Opioid Overdose: State Information. Retrieved April 03, 2016, from http://www.cdc.gov/drugoverdose/states/index.html
Center for Disease Control and Prevention. (2013, July 5). Morbidity and Mortality Weekly Report: Vital Signs: Overdoses of Prescription Opioid Pain Relievers and Other Drugs Among Women — United States, 1999–2010. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6226a3.htm
Civic Impulse. (2016). S. 524 — 114th Congress: Comprehensive Addiction and Recovery Act of 2016. Retrieved from https://www.govtrack.us/congress/bills/114/s524
Committee Opinion. (May 2012). Opioid Abuse, Dependence an Addiction in Pregnancy. The American College of Obstetricians and Gynecologists, 524, 1-7. Retrieved from https://www.acog.org/-/media/Committee-Opinions/Committee-on-Health-Care-for- Underserved-Women/co524.pdf?dmc=1&ts=20160403T2104129835.
Evan, E., Levin, D., Li, L., & Hsr, Y. (2014). Long term effects of specialized treatement for women with substance use disorders. Journal of Substance Abuse Treatment.
Georges, E. (2015, December 14). Help for women with opiod addiction: Mother with opioid dependencies have unmet need. Retrieved from http://www.lorainadas.org/2015/12/help- for-women-with-opioid-addiction/
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Grella, C. (Nov, 2008). From generic to gender-responsive treatment: Changes in social policies, treatment services, and outcomes to women in substance abuse treatment. Journal of psychoactive drugs. P. 327-343
Grella, C. E., Hser, Y., & Huang, Y. C. (2006). Mothers in substance abuse treatment: Differences in characteristics based on involvement with child welfare. Child Abuse & Neglect, 30(1), 55-73.
Grella, C. (2007). Substance abuse treatment services for women: A review of policy initiatives and recent research. California Department of Alcohol and Drug Programs.
The Library of Congress (2016). Bill summary and status. 114th Congress. S.AMDT 3374. Retreived from http://thomas.loc.gov/cgi-bin/bdquery/z?d114:SP03374:
McIntire, M. (2016, Mar 10). Senate passes CARA, Opioid bill moves to house. Morning Consultant. Retreived from https://morningconsult.com/alert/senate-passes-cara-opioid-bill-moves-to-the-house/
Niv, N., & Hser, Y. (2007). Women-only and mixed-gender drug abuse treatment programs: Service needs, utilization and outcomes. Drug and Alcohol Dependence, 87(2-3), 194-201.
Rudolph, D. (2015, February 18). The Comprehensive addiction and recovery Act, the legislative process, and the importance of advocacy. Young People in Recovery. Retrieved from http://youngpeopleinrecovery.org/blog/the-comprehensive-addiction-recovery-act-the-legislative-process-and-the-importance-of-advocacy/
State of New Hampshire (2016, March 10). Shaheen-sponsored legislation to address opioid crisis passes senate. Retrieved from http://www.shaheen.senate.gov/news/press/release/?id=43A36F75-BC24-4542-AC39- 8ECF540E343D
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United States General Accounting Office (1997). Parental Substance Abuse: Implications for children, the child welfare system, and foster care outcomes. Retrieved from http://www.gao.gov/products/T-HEHS-98-40
Wilson, D. & Shiffman, J. (Dec 7, 2015). Newborns die after being sent home with mothers struggling to kick drug addictions. Reuters Investigates: Helpless and Hooked. Retrieved from http://www.reuters.com/investigates/special-report/baby- opioids/