MEMORANDUM FOR THE HEADS OF EXECUTIVE DEPARTMENTS AND AGENCIES
SUBJECT: Addressing Prescription Drug Abuse and Heroin Use
By the authority vested in me as President by the Constitution and the laws of the United States of America, and in order to reduce prescription pain medication and heroin overdose deaths, promote the appropriate and effective prescribing of pain medications, and improve access to treatment, I hereby direct the following:
Section 1. Policy. The epidemic of prescription pain medication and heroin deaths is devastating families and communities across the country. Prescription drugs -- especially opioid pain medications -- have been implicated increasingly in drug overdose deaths over the last decade. According to the Centers for Disease Control and Prevention (CDC), the number of overdose deaths involving prescription opioids quadrupled between 1999 and 2013, with more than 16,000 deaths in 2013. In recent years, overdose deaths involving heroin have sharply increased, nearly doubling between 2011 and 2013. The CDC has identified addiction to prescription pain medication as the strongest risk factor for heroin addiction.
One of the most significant ways to address these issues is to ensure that medical professionals receive adequate training on appropriate pain medication prescribing practices, and the risks associated with these medications. The Federal Government must do more to ensure that such training is provided on an ongoing basis to health care professionals prescribing pain medications. Work is already underway to achieve this goal across executive departments and agencies, but these efforts must be accelerated given the urgency of the problem. The training of Federal health care personnel in appropriate prescribing of controlled substances should be a model for similar initiatives developed across the country.
An additional priority in addressing prescription opioid pain medication misuse and heroin use is improved access to medication-assisted treatment (MAT). MAT is the use of Food and Drug Administration (FDA)-approved medications, such as buprenorphine, buprenorphine-naloxone combination products, methadone, and naltrexone -- in combination with counseling, other behavioral therapies, and patient monitoring -- to provide treatment for opioid use disorders. Only a small minority of Americans who might benefit from this treatment are receiving it. Federally administered health benefit programs can help to increase access to these services. These programs also can serve as models for reviewing and modernizing coverage policies and benefit management strategies in response to clinical prescribing guidelines and recommendations for the treatment of chronic pain. For example, a CDC study found that the use of methadone in pain treatment is associated with a disproportionately high number of overdose deaths compared to other opioid pain relievers. Federally administered health benefit programs can use benefit design and formulary management to take steps to reduce the risk of opioid use disorders.
Sec. 2. Training for Federal Prescribers. (a) Executive departments and agencies (agencies) shall, to the extent permitted by law, provide training on the appropriate and effective prescribing of opioid medications to all employees who are health care professionals and who prescribe controlled substances as part of their Federal responsibilities and duties. Agencies also shall require all contractors who are health care professionals, spend 50 percent or more of their clinical time under contract with the Federal Government, and prescribe controlled substances under the terms and conditions of their contract or agreement with the Federal Government to obtain such training. These training requirements shall also be implemented for clinical residents and other clinical trainees who spend 50 percent or more of their clinical time practicing in an executive department or agency facility.
(b) The training must address, at a minimum, best practices for appropriate and effective prescribing of pain medications, principles of pain management, the misuse potential of controlled substances, identification of potential substance use disorders and referral to further evaluation and treatment, and proper methods for disposing of controlled substances. Training approaches may include both traditional continuing education models and models that pair intensive coaching for the highest volume prescribers with case-based courses for other prescribers. To the extent feasible, training adopted by agencies should be consistent with consensus guidelines on pain medication prescribing developed by the CDC.
(c) Agencies shall require all employees, contractors, and clinical residents and trainees described in subsection (a) of this section to complete training within 18 months of the date of this memorandum and a refresher course every 3 years thereafter.
Sec. 3. Improving Access to Medication-Assisted Treatment and Modernizing Benefit Design. (a) Agencies that directly provide health care services, contract to provide health care services, reimburse for health care services, or facilitate access to health benefits shall, to the extent available and permitted by law, review all health benefit requirements, drug formularies, program guidelines, medical management strategies, drug utilization review programs, and all other relevant policies, tools, and strategies in order to identify any barriers individuals with opioid use disorders would encounter in accessing MAT. This review also shall identify any current practices, such as use of methadone as a preferred or first-line pain management drug that are inconsistent with the goals of reducing opioid use disorders and overdoses.
(b) Not later than 90 days after the date of this memorandum, each agency described in subsection (a) of this 3 section shall submit an action plan to the Directors of the White House Domestic Policy Council and the White House Office of National Drug Control Policy addressing the barriers and practices identified in their reviews.
(c) The Secretary of Health and Human Services shall make clinical and other experts from agencies within the Department of Health and Human Services, such as the National Institutes of Health, the CDC, the Substance Abuse and Mental Health Services Administration, and the FDA, available to consult with other agencies on their reviews as necessary.
Sec. 4. General Provisions. (a) Nothing in this memorandum shall be construed to impair or otherwise affect:the authority granted by law to a department or agency, or the head thereof; or the functions of the Director of the Office of Management and Budget relating to budgetary, administrative, or legislative proposals.
(b) This memorandum shall be implemented consistent with applicable law and subject to the availability of appropriations.
(c) This memorandum is not intended to, and does not, create any right or benefit, substantive or procedural, enforceable at law or in equity by any party against the United States, its departments, agencies, or entities, its officers, employees, or agents, or any other person.