Testimony from:

Stacey McKenna, Senior Fellow, Integrated Harm Reduction, R Street Institute

In Support of Mobile Access to Medications for Opioid Use Disorder (CA AB 663)

April 11, 2023

Assembly Committee on Business and Professions

Chair Berman and honorable members of the committee,

My name is Stacey McKenna, and I am a senior fellow in Integrated Harm Reduction at the R Street Institute (R Street), a public policy research organization focused on advancing limited, effective government in a number of policy areas, including opioid harm reduction. At least 2.7 million people in the United States are currently living with an opioid use disorder (OUD), and in 2021, opioid-involved overdoses killed more than 80,000 Americans, including 6,843 Californians.[1] From a public health perspective, it would be ideal if people simply abstained from all use of non-prescribed opioids. However, abstinence-driven policies do not work at the population level, and even the best cessation and prevention programs leave people behind.[2] Harm reduction, on the other hand, is a pragmatic, evidence-based approach that saves lives by meeting people where they are and providing them with tools to make safer, health-supportive choices, even if they are not willing or able to quit using drugs.[3] Thus, R Street supports harm reduction-based efforts to address the opioid overdose crisis, including CA AB 663, which would expand access to medications for opioid use disorder (MOUDs) via mobile pharmacy.

MOUDs replace problematic opioid use with safe doses of long-acting, medically prescribed opioids to curb withdrawals and cravings.[4] Compared to people engaged in non-MOUD treatment, those taking MOUDs—especially buprenorphine and methadone—are significantly less likely to revert to problematic opioid use, experience an overdose, or contract or transmit human immunodeficiency virus (HIV) and hepatitis C.[5]

Unfortunately, despite MOUDs’ established efficacy and safety, only 13 to 27 percent of people living with OUD receive medications as part of their recovery.[6] Federal and state governments have placed excessive regulations on who can prescribe or dispense the medications as well as how they may be administered.[7] These restrictions have in turn hindered MOUD access and treatment retention, often disproportionately harming already vulnerable populations.[8] Research reveals racial, economic and geographic disparities in access to buprenorphine and methadone providers.[9] And individuals who are able to access MOUD providers often report experiencing stigma as well as a range of barriers—including long wait times and lengthy travel requirements—that interfere with their ability to work or meet important social obligations.[10]

Although proponents of strict MOUD regulations cite fears related to diversion and misuse, these are largely unfounded.[11] MOUDs have been repeatedly demonstrated to be safe. Diversion rates are comparable to or lower than those of other prescription drugs (i.e., antibiotics or allergy medications), and tend to decline as access improves.[12] Furthermore, when strict regulations on methadone and buprenorphine access were relaxed during COVID-19, MOUD-involved overdose rates did not increase, indicating that the new policies did not lead to increased diversion or misuse of the drugs.[13] As such, policymakers can be confident that laws increasing access to MOUDs benefit the individuals served without risk to their broader communities.

California’s pharmacy vans were introduced to ensure that the state’s most vulnerable and hard-to-reach populations have access to key mediations.[14] CA AB 663 builds on this existing law by allowing these mobile units to carry and dispense MOUDs, a move that will close gaps in who receives this evidence-based OUD treatment. Given MOUDs established history, we can expect that expanding treatment will improve recovery initiation and retention for Californians living with an OUD, and will help reduce risk for overdose, infectious disease and more. As such, R Street urges your favorable report.

Respectfully submitted,

Stacey McKenna
Senior Fellow, Integrated Harm Reduction
R Street Institute
[email protected]

[1] Centers for Disease Control and Prevention, “Opioid Use Disorder,” U.S. Department of Health and Human Services, Aug. 30, 2022. https://www.cdc.gov/dotw/opioid-use-disorder/index.html#:~:text=About%202.7%20million%20people%20in%20the%20United%20States%20report%20suffering%20from%20OUD; National Institute on Drug Abuse, “Drug Overdose Death Rates,” National Institutes of Health, Feb. 9, 2023. https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates; “Fentanyl & Overdose Prevention,” California Department of Public Health, Jan. 23, 2023. https://www.cdph.ca.gov/Programs/OPA/Pages/Communications-Toolkits/Fentanyl-Overdose-Prevention.aspx#:~:text=Fentanyl%20is%20a%20major%20contributor,19%20years%20old%2C%20in%20California

[2] Susan E. Collins, “Sobriety is just one pathway to recovery. Harm reduction is another,” STAT News, April 11, 2019. https://www.statnews.com/2019/04/11/harm-reduction-substance-use-disorder

[3] Ibid.

[4] “Medication for Opioid Use Disorder (MOUD) Overview,” National Harm Reduction Coalition, Sept. 8, 2020. https://harmreduction.org/issues/facts

[5] Sarah E. Wakeman et al., “Comparative Effectiveness of Different Treatment Pathways for Opioid Use Disorder,” JAMA Network Open 3:2 (Feb. 5, 2020). https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2760032#:~:text=Our%20findings%20are%20also%20consistent,treatment%20or%20non%2DMOUD%20treatment; National Institute on Drug Abuse, “Medications to Treat Opioid Use Disorder Research Report: What is the impact of medication for opioid use disorder treatment on HIV/HCV outcomes?”,National Institutes of Health, December 2021.  https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/what-impact-medication-opioid-use-disorder-treatment-hivhcv-outcomes.

[6] Centers for Disease Control and Prevention. https://www.cdc.gov/dotw/opioid-use-disorder/index.html#:~:text=About%202.7%20million%20people%20in%20the%20United%20States%20report%20suffering%20from%20OUD; Noa Krawczyk et al., “Synthesising evidence of the effects of COVID-19 regulatory changes on methadone treatment for opioid use disorder: implications for policy,” The Lancet 8:3 (March 2023), pp. E238-E246. https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(23)00023-3/fulltext#seccestitle60.

[7] National Academies of Sciences, Engineering, and Medicine et al., “Barriers to Broader Use of Medications to Treat Opioid Use Disorder,” Medications for Opioid Use Disorder Save Lives, National Academies Press, March 30, 2019. https://www.ncbi.nlm.nih.gov/books/NBK541389/#sec_ch5-5.

[8] Ibid.

[9] James R. Langabeer et al., “Geographic proximity to buprenorphine treatment providers in the U.S.,” Drug and Alcohol Dependence 213 (Aug. 1, 2020). https://www.sciencedirect.com/science/article/pii/S0376871620302969; C. Holly A. Andrilla and Davis G. Patterson, “Tracking the geographic distribution and growth of clinicians with a DEA waiver to prescribe buprenorphine to treat opioid use disorder,” The Journal of Rural Health 38:1 (January 2022), pp. 87-92. https://onlinelibrary.wiley.com/doi/epdf/10.1111/jrh.12569; William C. Goedel et al., “Association of Racial/Ethnic Segregation With Treatment Capacity for Opioid Use Disorder in Counties in the United States,” JAMA Network Open 3:4 (April 1, 2020). https://pubmed.ncbi.nlm.nih.gov/32320038.

[10] Hannah L.F. Cooper et al., “Buprenorphine dispensing in an epicenter of the U.S. opioid epidemic: A case study of the rural risk environment in Appalachian Kentucky,” International Journal of Drug Policy 85 (November 2020). https://pubmed.ncbi.nlm.nih.gov/32223985; Erin G. Major, “Factors in rural community buprenorphine dispensing,” Exploratory Research in Clinical and Social Pharmacy 9 (March 2023). https://www.sciencedirect.com/science/article/pii/S2667276622001032; Grace Trull et al., “Rural community pharmacist willingness to dispense Suboxoneâ – A secret shopper investigation in South-Central Appalachia,” Exploratory Research in Clinical and Social Pharmacy 4 (December 2021). https://www.sciencedirect.com/science/article/pii/S2667276621000822; Caty Simon et al., “The Methadone Manifesto: Treatment Experiences and Policy Recommendations From Methadone Patient Activists,” American Journal of Public Health 112:S2 (March 29, 2022), pp. S117-S122. https://ajph.aphapublications.org/doi/10.2105/AJPH.2021.306665; David Frank et al., “’It’s like ‘liquid handcuffs’: The effects of take-home dosing policies on Methadone Maintenance Treatment (MMT) patients’ lives,” Harm Reduction Journal 18:88 (Aug. 14, 2021). https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-021-00535-y.

[11] Brandon del Pozo and Josiah D. Rich, “Revising our attitudes towards agonist medications and their diversion in a time of pandemic,” Journal of Substance Abuse Treatment 119 (December 2020). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7505066; K. Michelle Peavy et al., “Rapid Implementation of Service Delivery Changes to Mitigate COVID-19 and Maintain Access to Methadone Among Persons with and at High-Risk for HIV in an Opioid Treatment Program,” AIDS and Behavior 24 (April 28, 2020), pp. 2469-2472. https://link.springer.com/article/10.1007/s10461-020-02887-1.

[12] National Academies of Sciences, Engineering, and Medicine et al. https://www.ncbi.nlm.nih.gov/books/NBK541389.

[13] Krawczyk et al. https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(23)00023-3/fulltext#seccestitle60; Office of Science and Data Policy, “Flexibilities in Controlled Substances Prescribing and Dispensing During the COVID-19 Pandemic,” Assistant Secretary for Planning and Evaluation, August 2022. https://aspe.hhs.gov/sites/default/files/documents/8d26dfc6c859795bf2307ae6a845b7f5/ASPE-brief-covid-flexibilities-aug-2022.pdf.

[14] CBS San Francisco, “New California law allows mobile pharmacies to serve vulnerable populations,” CBS News Bay Area, Aug. 30, 2022. https://www.cbsnews.com/sanfrancisco/news/sb872-mobile-pharamcies-new-california-law-sen-bill-dodd