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Dear Mr. President:

I am proud to present to you today the interim report prepared by your Commission on 

Combating Drug Addiction and the Opioid Crisis. This interim report is just a start; our work is 

ongoing and we will have more to share with you and the nation later in the Fall of 2017. We 

now recommend several actions for you to take as our nation’s Chief Executive and someone 

who spoke passionately on this issue in the 2016 campaign. 

Our nation is in a crisis. Your Executive Order recognized that fact. The work of your 

Commission so far acknowledges the severity of this national problem.

According to the Centers for Disease Control (CDC), the most recent data estimates that 142 

Americans die every day from a drug overdose. Our citizens are dying. We must act boldly to 

stop it. The opioid epidemic we are facing is unparalleled. The average American would likely 

be shocked to know that drug overdoses now kill more people than gun homicides and car 

crashes combined. In fact, between 1999 and 2015, more than 560,000 people in this country 

died due to drug overdoses – this is a death toll larger than the entire population of Atlanta. As 

we have all seen, opioids are a prime contributor to our addiction and overdose crisis. In 2015, 

nearly two-thirds of drug overdoses were linked to opioids like Percocet, OxyContin, heroin, 

and fentanyl. This is an epidemic that all Americans face because here is the grim reality: 

Americans consume more opioids than any other country in the world. In fact, in 2015, the 

amount of opioids prescribed in the U.S. was enough for every American to be medicated 

around the clock for three weeks.

Since 1999, the number of opioid overdoses in America have quadrupled according to the CDC. 

Not coincidentally, in that same period, the amount of prescription opioids in America have 

quadrupled as well. This massive increase in prescribing has occurred despite the fact that 

there has not been an overall change in the amount of pain Americans have reported in that 

time period. We have an enormous problem that is often not beginning on street corners; it is 

starting in doctor’s offices and hospitals in every state in our nation.

But, the challenge of reducing opioid supplies has evolved. As access to prescription opioids 

tightens, consumers increasingly are turning to dangerous street opioids, heroin, fentanyl alone 

or combined, and mingled with cocaine or other drugs. In 2016, specific states witnessed an 

escalating number of overdose deaths due to heroin and/or fentanyl(s), in some states vastly 

exceeding deaths due to prescription opioids. 

In 2015, 27 million people reported current use of illegal drugs or abuse of prescription drugs. 

Despite this self-reporting, only 10 percent of the nearly 21 million citizens with a substance use 

disorder (SUD) receive any type of specialty treatment according to the most recent National 

Survey on Drug Use and Health. This is contributing greatly to the increase of deaths from 

overdose.

Over forty percent of people with a substance use disorder also have a mental health problem, 

but less than half of these people receive treatment for either issue. The reasons for these 
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treatment gaps are many, including lack of access to care, fear of shame and discrimination,

and lack of motivation to seek treatment. 

This Commission has been hard at work to meet the goals set for us in the Executive Order on 

March 29th, 2017. As a Commission, we have already met with leading national organizations in 

the addiction space, and we have received information and recommendations from countless 

individuals and groups, all of whom share in our commitment to beating this epidemic. The 

Commission thanks all the individuals and organizations, including Governors and 

representatives from Governors Offices from around the country, that have reached out to 

offer their experiences, expertise, and input. 

In addition to conducting phone calls with Governors and their teams in all 50 states, we also 

held a listening session with bi-partisan members of Congress, and key cabinet members of 

your Administration. Individual Commission members have organized “listening sessions” and 

solicited recommendations from treatment providers, addiction psychiatrists and other 

physicians, data analysts, professional medical and treatment societies, medical educators, 

healthcare organizations, pharmacoepidemiologists, and insurance providers. Outreach also 

has been made to scientists with broad expertise in pain, addiction biology and treatment.

The first public meeting of the Commission was held on June 16th at the White House, and was 

a great success. The Commission members heard comprehensive public testimony by nine 

leading nonprofits, and have received more than 8,000 comments from the public, including 

comments from at least 50 organizations. 

This information was reviewed by the Commission members and helped inform this interim 

report. 

The first and most urgent recommendation of this Commission is direct and completely within 

your control. Declare a national emergency under either the Public Health Service Act or the 

Stafford Act. With approximately 142 Americans dying every day, America is enduring a death 

toll equal to September 11th every three weeks. After September 11th, our President and our 

nation banded together to use every tool at our disposal to prevent any further American 

deaths. Your declaration would empower your cabinet to take bold steps and would force 

Congress to focus on funding and empowering the Executive Branch even further to deal with 

this loss of life. It would also awaken every American to this simple fact: if this scourge has not 

found you or your family yet, without bold action by everyone, it soon will. You, Mr. President, 

are the only person who can bring this type of intensity to the emergency and we believe you 

have the will to do so and to do so immediately.

The Commission is additionally proposing the following recommendations for action:

 Rapidly increase treatment capacity. Grant waiver approvals for all 50 states to quickly 

eliminate barriers to treatment resulting from the federal Institutes for Mental Diseases 
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(IMD) exclusion within the Medicaid program. This will immediately open treatment to 

thousands of Americans in existing facilities in all 50 states. 

The Commission has been urged by every Governor, numerous treatment providers, 

parents, and non-profit advocacy organizations to eliminate the IMD exclusion within the 

Medicaid program. This component of the Social Security Act prohibits federal Medicaid 

funds from reimbursing services provided in an inpatient facility treating “mental diseases” 

(including SUDs) that have more than 16 beds. This exclusion makes states entirely 

responsible for Medicaid-eligible patients in inpatient treatment facilities, including patients 

undergoing withdrawal management in addiction treatment facilities rather than hospitals. 

The Commission members that serve as Governors, as well as individuals and organizations 

that treat Medicaid patients, are intimately aware of how the IMD exclusion impacts the 

ability to serve patients with severe SUDs that are best served in an inpatient setting. The 

Commission recognizes that legislation would be necessary to repeal the exclusion in its 

entirety. However, certainly after an emergency declaration by the President (and arguably 

even without it) the Department of Health and Human Services (HHS) Secretary would be 

empowered to immediately grant waivers to each state that requests one. This is the single 

fastest way to increase treatment availability across the nation. 

 Mandate prescriber education initiatives with the assistance of medical and dental 

schools across the country to enhance prevention efforts. Mandate medical education 

training in opioid prescribing and risks of developing an SUD by amending the Controlled 

Substance Act to require all Drug Enforcement Administration (DEA) registrants to take a 

course in proper treatment of pain. HHS should work with partners to ensure additional 

training opportunities, including continuing education courses for professionals. 

According to a Substance Abuse and Mental Health Services Administration (SAMHSA)

Center for Behavioral Health and Statistics Quality (CBHSQ) report, four out of every five 

new heroin users begin with nonmedical use of prescription opioids.

In other words, Mr. President, this crisis began in our nation’s health care system. While we 

acknowledge that some of this inappropriate overprescribing is done illegally and for profit, 

we believe the overwhelming percentage is due to a lack of education on these issues in our 

nation’s medical and dental schools and a dearth of continuing medical education for 

practicing clinicians. This can and must be solved by using Presidential moral and legal 

authority to change this lack of education leading to addiction and death.

There are several initiatives around the country aimed at ensuring that providers are aware 

of the potential for misuse and abuse of prescription opioids.

Governor Baker’s administration in Massachusetts has worked with the medical and dental 

schools in that state and the Medical Society to develop core competencies related to 

opioids and SUDs that all graduating students are expected to learn and put into practice. 

Other states such as Arizona, Connecticut, Pennsylvania, New York, and Utah have 

expanded continuing medical education requirements for opioid prescribers and 
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dispensers. Alternatively, the American Society of Addiction Medicine (ASAM) has 

recommended implementing a requirement that clinicians who apply for a registration with 

the DEA to prescribe controlled substances demonstrate competency in safe prescribing, 

pain management, and substance use identification. In New Jersey, Governor Christie 

recently signed a law that requires providers themselves to take continuing education 

related to opioids, and requires prescribers to discuss the risks of opioid dependence with 

their patients prior to the first prescription. We urge national implementation of these 

initiatives.

In our first Commission meeting, we heard from several nonprofits about the need to 

promote expanded implementation of the CDC Guideline for Prescribing Opioids for Chronic 

Pain through increased prescriber education initiatives. The Office of National Drug Control 

Policy (ONDCP) estimates that, apart from federal prescribers who are required to be 

trained, fewer than 20% of the over one million prescribers licensed to prescribe controlled 

substances to patients have training on how to prescribe opioids safely. Similarly, it seems 

that many medical providers are not well-versed on how to screen for addiction, and what 

to do if a patient has become dependent on substances or presents with an SUD. We urge 

you to instruct the Department of Justice (DOJ) and the DEA to require continuing medical 

education for every physician requesting an initial DEA license or the renewal of such a 

license.

The CDC and the U.S. Food and Drug Administration (FDA) should finalize, review and 

recommend national training standards working with the Accreditation Council for 

Continuing Medical Education (ACCME) to ensure training courses are coordinated with 

other federal agencies, professional societies, medical schools, and residency programs to 

avoid discrepancies.

The FDA should also work with the ACCME to develop data analytics to determine whether 

courses change practices, increase patient referrals to treatment, and methods to improve 

compliance consistent with opioid prescribing education. 

Clinicians need more detailed and specific guidance on drug choice, dose, and quantity to 

be dispensed in treating specific pain conditions. We also recommend a detailed analysis of, 

and solutions to clinical problems encountered in applying recommended guidelines. 

 Immediately establish and fund a federal incentive to enhance access to MedicationAssisted Treatment (MAT). Require that all modes of MAT are offered at every licensed 

MAT facility and that those decisions are based on what is best for the patient. Partner 

with the National Institutes of Health (NIH) and the industry to facilitate testing and 

development of new MAT treatments.

MAT has proven to reduce overdose deaths, retain persons in treatment, decrease use of 

heroin, reduce relapse, and prevent spread of infectious disease. Expansion of MAT 

availability for qualified individuals and for short- or long-term treatment is an essential 
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component of treatment services. Yet approximately 10 percent of conventional drug 

treatment facilities in the United States provide MAT for opioid use disorder.

Individuals seeking SUD treatment, and even those currently enrolled in a treatment 

system, often find barriers to using MAT as a component of their treatment. Particularly for 

populations with opioid use disorders (OUDs) involved in the criminal justice system, there 

is often inadequate access to FDA-approved medications that are proven to improve 

outcomes as part of a full continuum of care. Multiple studies have shown that individuals 

receiving MAT during and after incarceration have lower mortality risk, remain in treatment 

longer, have fewer positive drug screens, and have lower rates of recidivism than other 

individuals with OUDs that do not receive MAT. The DOJ, in consultation with HHS and 

ONDCP, should be directed to increase the use of MAT for OUDs in these correctional 

settings.

In addition, the Centers for Medicare & Medicaid Services (CMS) should require all 

federally-qualified health centers (FQHCs) to mandate that their staff physicians, physician 

assistants, and nurse practitioners possess waivers to prescribe buprenorphine. 

There are several barriers to the use of MAT, including a prevalent belief that use of MAT 

does not constitute true recovery or sobriety. The Federal Government, as a major 

purchaser of health care services, has a tremendous opportunity to increase the availability 

of MAT for individuals with OUDs. For example, across the Veterans Administration (VA) 

and Indian Health Services, there is a lack of providers able to prescribe/administer MAT. 

For Medicare patients, the Part B physician benefit does not cover methadone treatment 

and the Part D pharmaceutical benefit does not cover it either, as it is administered by a 

medical professional. CMS should send a letter to state health officials requesting that state 

Medicaid programs cover all FDA-approved MAT drugs for OUD.

Additionally, all FDA-approved MAT should be offered by authorized providers, not just one 

or two of these approved options. These decisions of which (if any) MAT to be used must 

be based upon what is best for the patient, not what is best for the provider. This can be 

mandated by the Executive Branch.

Finally, we urge you to instruct the NIH to begin to immediately work with the 

pharmaceutical industry in two areas; the development of additional MAT options and the 

development of new, non-opioid pain relievers based on research to clarify the biology of 

pain. The nation needs more options to treat those already addicted and can help to 

prevent addiction in the first place by avoiding the prescription of opioids. The NIH is best 

positioned, in our opinion, to lead this effort with industry partners.

 Provide model legislation for states to allow naloxone dispensing via standing orders, as 

well as requiring the prescribing of naloxone with high-risk opioid prescriptions; we must 

equip all law enforcement in the United States with naloxone to save lives. 

Naloxone is a lifesaver that rapidly reverses opioid overdose. It is the first line of defense in 

many parts of our country; if we lose someone to overdose we obviously have no chance to 
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treat them and return them to a productive life. We urge you to mandate, with federal 

assistance, that naloxone be in the hands of every law enforcement officer in the United 

States. By declaring a national emergency, you can empower the HHS Secretary to 

negotiate reduced pricing for all governmental units. Forty-seven states have expanded 

access to naloxone in some form. The Federal Government should ensure that naloxone is 

made available when there is the greatest chance for an overdose. Accordingly, model 

legislation should include a requirement that naloxone is prescribed in combination with 

any CDC-defined high-risk opioid being prescribed. 

An impediment to naloxone usage and people seeking help in the event of an overdose is 

the perceived threat of law enforcement involvement. Overly restrictive or punitive laws 

may prevent the uptake of naloxone or the seeking of aid in an emergency. In response, 

most state legislatures and some law enforcement agencies have created a variety of 

immunity and ‘Good Samaritan’ laws to ensure bystanders and those experiencing an 

overdose are not deterred from seeking immediate help. States vary widely in the content 

of ‘Good Samaritan’ laws, but they generally offer protection to people assisting at the 

scene of an overdose, or seeking care for their own or another’s overdose, from civil or 

criminal prosecution. As of July 2017, 40 states and the District of Columbia have enacted 

some form of a ‘Good Samaritan’ or 911 drug immunity law. In addition to enacting 

legislation, it is crucial that states ensure the public fully understands the protections 

provided by the ‘Good Samaritan’ law and how it empowers them to call 911 in the case of

an overdose.

HHS and other federal agencies should be directed by you or your cabinet to make 

recommendations on ways to identify persons who have overdosed and been revived with 

naloxone and the feasibility of notification of their primary care and other physicians caring 

for them. These primary care providers may be prescribing medications that increase future 

risks of another overdose.

 Prioritize funding and manpower to the Department of Homeland Security’s (DHS) 

Customs and Border Protection, the DOJ Federal Bureau of Investigation (FBI), and the 

DEA to quickly develop fentanyl detection sensors and disseminate them to federal, state, 

local, and tribal law enforcement agencies. Support federal legislation to staunch the flow 

of deadly synthetic opioids through the U.S. Postal Service (USPS).

Illicit fentanyl and fentanyl analogs are the next grave challenge on the opioid front and the 

awful news is that it is much, much more deadly than hydrocodone, oxycodone or even 

heroin. Since 2012, the nation has seen an alarming increase in the number of drug 

overdose deaths that involve fentanyl, a synthetic opioid many times more powerful than 

heroin, as well as heroin and cocaine laced with non-pharmaceutical fentanyl. Fentanyl 

defies detection at our borders, as the small quantities involved for psychoactivity of 

fentanyl and fentanyl analogs challenge Customs and Border Protection, USPS, and express 

consignment carriers’ ability to detect and interdict. We are miserably losing this fight to 

prevent fentanyl from entering our country and killing our citizens. We are losing this fight 

predominately through China. This must become a top tier diplomatic issue with the 
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Chinese; American lives are at stake and it threatens our national security. Our inability to 

reliably detect fentanyl at our land borders and at our international mail handling facilities 

creates untenable vulnerabilities. Key federal agencies, including the DEA, DHS, FBI, and 

DOJ, should coordinate pursuant to the Controlled Substances Act to intercept fentanyl 

(and other synthetic opioids) in envelopes and packages at mail processing distribution 

centers, and increase detection efforts using enhanced technology, more manpower, and 

expanded canine deployment. Only a presidential directive will give this issue the top level 

attention it deserves from DOJ, DHS, and USPS.

 Provide federal funding and technical support to states to enhance interstate data sharing 

among state-based prescription drug monitoring programs (PDMPs) to better track 

patient-specific prescription data and support regional law enforcement in cases of 

controlled substance diversion. Ensure federal health care systems, including Veteran’s 

Hospitals, participate in state-based data sharing.

PDMPs are state-run electronic databases used to track the prescribing and dispensing of 

controlled prescription drugs. They are designed to give providers access to critical 

information regarding a patient’s controlled substance prescription history, and can help 

health professionals identify patients who may be or are at risk of misusing prescription 

opioids or other prescription drugs. PDMPs are also used by professional licensing boards to 

identify clinicians with patterns of inappropriate prescribing and dispensing, and to assist 

law enforcement in cases of controlled substance diversion. Multiple published best 

practices for utilizing PDMPs, including guidelines from the Heller School for Social Policy 

and Management at Brandeis University, have identified interstate data sharing among 

PDMPs as a top priority to ensure that healthcare professionals and law enforcement have a 

complete picture of prescribing practices and controlled substances diversion. Numerous 

professional health organizations, including the American Medical Association (AMA) and 

the Association of State and Territorial Health Officials (ASTHO), agree that PDMPs are an 

effective and important clinical tool to combat the addiction crisis; however, they are being 

significantly underutilized in the vast majority of our states. Forty-nine states now have 

PDMPs but not nearly a majority of those are sharing their information. This is 

unacceptable. We urge you to direct the VA and HHS to lead an effort to have all state and 

federal PDMP systems to share information and to set a deadline of July 1, 2018 to achieve 

this data sharing.

In addition to sharing data between states and the federal government, the PDMP needs to 

be improved with regard to its ease of use, and inclusion of other data to assist prescribing 

doctors. Ideally, clinicians should check their state PDMP before making the decision to 

prescribe either an opioid or benzodiazepine (several states already have this requirement 

in place), determine whether their patient has had an overdose, and other relevant 

information that can be summarized into categories of high to low risk.

 Better align, through regulation, patient privacy laws specific to addiction with the Health 

Insurance Portability and Accountability Act (HIPAA) to ensure that information about 

SUDs be made available to medical professionals treating and prescribing medication to a 
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patient. This could be done through the bipartisan Overdose Prevention and Patient 

Safety Act/Jessie’s Law. 

Providers and other advocates have found that certain privacy regulations, while wellintentioned patient protections, act as a barrier to communication between providers, can 

make it difficult for family members to be involved in a loved one’s treatment, and limits 

the ability to use electronic health records to their full potential. 42 CFR Part 2, which 

requires addiction treatment professionals to acquire written patient consent before 

sharing any information with a patient’s other health care providers, including when the 

addiction treatment facility is part of a larger health care system, is a particular hindrance to 

comprehensive health care. Making it administratively difficult for providers to share 

information has ill-effects on patients in both physical and behavioral health settings, by 

restraining physicians’ ability to make informed healthcare decisions.

We urge you to direct that regulation be changed to permit the sharing of this type of 

information among health care providers and the loved ones of those suffering from 

SUDs. Otherwise, drugs with high abuse liability may be prescribed to people with 

OUD. That will lead to even more unnecessary and preventable deaths.

 Enforce the Mental Health Parity and Addiction Equity Act (MHPAEA) with a standardized 

parity compliance tool to ensure health plans cannot impose less favorable benefits for 

mental health and substance use diagnoses verses physical health diagnoses. 

As Congressman Kennedy spoke eloquently about at the first Commission meeting, there 

has long been a difference in how individuals with health insurance receive treatment and 

medication for physical health diagnoses versus mental health and SUD diagnoses. The 

Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) prohibits health insurance 

plans that cover behavioral health from imposing benefit limitations on mental health or 

SUD treatment that are less favorable than limitations imposed on medical or surgical 

benefits. Benefit limitations can be quantitative, such as visit limits, or non-quantitative, 

such as pre-authorization requirements. But not providing real parity is already illegal. The 

Commission urges you to direct the Secretary of Labor to enforce this law aggressively and 

to penalize the violators.

The Commission heard from numerous organizations, including ASAM and the American 

Academy of Addiction Psychiatry, about the need to systematically monitor and enforce 

MHPAEA with a standardized tool, and actual penalties for non-compliance, to ensure parity 

in the coverage of mental health and addiction treatment services. The Labor Secretary, 

with appropriate direction from you, is the person to do this.

At this point, the largest outstanding issue is treatment limits. Patients seeking addiction 

treatment, including MAT, are often subjected to dangerous fail-first protocols, a limited 

provider network, frequent prior authorization requirements, and claim denials without a 

transparent process. The Commission applauds SAMHSA’s work with multidisciplinary 

teams from states to improve parity enforcement and public education. However, we need 
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robust enforcement of the parity law by the state and federal agencies responsible for 

implementing the law. Regulators should be required to levy penalties against health plans 

that violate MHPAEA, and information about parity violations should be made available to 

the public. 

It is not only critical that the Federal Government provide sufficient resources to prevent and 

combat this disease; it must also provide the easiest pathway for private providers and local 

and state governments to achieve success. 

That is why the Commission, as a primary focus of the final report, is undertaking a full-scale 

review of federal programs, regulations, laws, and funding mechanisms targeted toward 

addressing addiction. 

In addition to a full review of federal funding and programs and obstacles and opportunities for 

treatment, the final report will include, but not be limited to, a more thorough examination of 

the following issues: 

 Development of a national prevention strategy using “big data analytics” to devise 

targeted prevention messages that employ cutting-edge methods of marketing and 

communications.

 Evidence-based prevention programs for schools, and tools for teachers and parents to 

enhance youth knowledge of the dangers of drug use, as well as early intervention 

strategies for children with environmental and individual risk factors (trauma, foster 

care, adverse childhood experiences (ACEs), and developmental disorders).

 The need for satisfaction with pain level as a satisfaction criteria through which health 

care providers are evaluated by HHS.

 Workforce access and training needs within the treatment community nationally, with a 

particular focus on the regions of the country with the highest overdose deaths.

 Improvements in treatment programs, based on adherence to principles of evidencebased treatment, continuum of care, outcome measures, and patient education on 

quality treatment.

 Research initiatives and opportunities to combat the epidemic and enhance treatment 

options, including alternative pain management strategies, and treatment for vulnerable 

populations such as pregnant women, and substance-exposed infants through work by 

the NIH, HHS, CDC, FDA, SAMHSA, and pharmaceutical partners.

 Opportunities to further the practice of substance use screenings and referrals through 

CMS quality measures.

 Opportunities for patient protections providing better information about the risks and 

benefits of taking prescription opioids.

 Supply reduction of heroin, fentanyl analogs and counterfeit pills through coordinated 

federal and state law enforcement initiatives.

 Targeted data collection and analytics needed to identify most effective prevention and 

treatment strategies, quality treatment access programs, reimbursements, and aid to 

law enforcement activities. The possibility of a behavioral health surveillance system run 
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through CDC that tracks prevalence rates, treatment modalities, and comorbidities with 

other illnesses in real-time. 

 Regulatory or statutory changes to reduce commercial insurance barriers to MAT, such 

as dangerous fail-first protocols and onerous and frequent prior authorization 

requirements. 

In our final report, we will provide an additional set of detailed recommendations that, if 

implemented, will ensure that the Federal Government operates as a strong partner in the fight 

against addiction and the opioid crisis. 

Finally, our country needs you, Mr. President. We know you care deeply about this issue. We 

also know that you will use the authority of your office to deal with our nation’s problems. The 

Commission looks forward to submitting its final report.

Sincerely, 

Commission members