CARA: Almost “Comprehensive” Enough



by John R. Cichy, MSW

As one of the two addiction treatment professionals in the state of Missouri who is a member of the American Society of Addiction Medicine (ASAM) I thought it would be useful to share some perspective pertaining to the recent victory achieved for individuals suffering from substance use disorder (SUD) through the July 13th passing of the Comprehensive Addiction and Recovery Act (CARA).

Also passed by the House of Representatives on July 8th, CARA (S. 524) is designed to expand access to addiction treatment services and overdose reversal medications, primarily crafted to address the growing opiate addiction epidemic that is impacting every state in the nation. Sponsored by C0-Chairman of the Senate Appropriations Committee Senator Roy Blunt of Missouri, CARA achieves some tangible benefits in expanding access to much needed medically-assisted treatment and increases funding for federally qualified health centers (FQHCs).

It takes a careful reading of the bill to find a troubling oversight that could cost the United States taxpayers literally billions of dollars in additional treatment costs. My point of contention centers around two provisions of the bill that at first glance appear like wonderful achievements, but when taken into context and understood with the perspective of a front-line battler of this horrible disease, there is much cause for concern.

The first provision of concern is Section 107: Improving Access to Overdose Treatment. The wording of this provision is as follows:

This section authorizes the Secretary of the Department of Health and Human Services (HHS) to award grants of up to $200,000 per year to federally qualified health centers (FQHCs), opioid treatment programs (OTPs), or any practitioner waivered to prescribe buprenorphine to establish a naloxone co-prescription program, train health care providers on naloxone co-prescribing, purchase naloxone, offset co-payments for naloxone, or establish protocols to connect patients who have experienced an overdose with appropriate treatment.

For those not familiar with medically-assisted treatment for opiate addiction, the two most powerful tools to combat this epidemic are naloxone and buprenorphine, marketed by Big Pharma in this case as Narcan and Suboxone, respectively. Naloxone, in the form of Narcan (Section 107), is the first-responders tool that is literally a life-saver and indispensable in saving overdose victims. An emergency injectable, Narcan is just one of the formulations utilized in the treatment community that contains naloxone. Of even more importance are two other versions: Naltrexone and Vivitrol.

Naltrexone is an opiate “antagonist”, which means that the synthetic opiate molecule (naloxone) forces the opiate molecules out of the opiate receptors in the brain, saving overdose victims, and if taken in daily pill form, making it impossible for people suffering from opiate addiction to use their drug of choice. Vivitrol is an injectable form of naloxone whose effects last for up to one month, taking the responsibility for taking a daily pill (Naltrexone) out of the hands of the opiate addict and greatly reducing the chance for relapse.

Suboxone, on the other hand, is what is known in the industry as a “partial agonist”. Also a synthetic opiate, similar to Methadone, a partial agonist works by being formulated to simultaneously stimulate the reward pathway, which eases withdrawal symptoms, at the same time as it partially blocks the euphoric effects of opiate use.

Proponents of Suboxone praise its use as the addicted user benefits by not having to put their life at risk to obtain the synthetic opiate and Suboxone is formulated to provide an even stimulation to the reward pathway, eliminating the extreme highs and lows of opiate addiction. Perpetual use of Suboxone thereby eliminates the possibility of death by relapse overdose and allows the addicted individual to return to productivity but it never allows the client’s brain to return to homeostasis, or balance of the brain’s chemical mix.

Now that the reader has an understanding of how naloxone/Naltrexone and buprenorphine/Suboxone are used to treat opiate addiction in the field, let’s take a look at the other provision which raises concern; Section 303. Medication-Assisted Treatment for Recovery from Addiction.

This section makes several changes to the law regarding office-based opioid addiction treatment with buprenorphine and the part of concern reads as follows:

Expands prescribing privileges to nurse practitioners (NPs) and physician assistants (PAs) for five years (until October 1, 2021). NPs and PAs must complete 24 hours of training to be eligible for a waiver to prescribe and must by supervised by or work in collaboration with a qualifying physician if required by state law. The HHS Secretary has 18 months to issue updated regulations governing office-based opioid addiction treatment to include NPs and PAs.

Why is this provision of concern? One of the primary claims of the Comprehensive Addiction and Recovery Act is that it expands access to addiction treatment services. Section 303 does just that by allowing nurse practitioners (NPs) and physician assistants (Pas) the ability to prescribe buprenorphine (Suboxone), without the oversight of a licensed psychiatrist. Without this provision, boutique treatment centers (Non-profits, 12-step, and faith-based recovery centers) would be challenged to afford the services of a licensed psychiatrist and access to medically-assisted treatment would be denied to their clients.

However, Section 303 has one glaring omission that makes it less than comprehensive. Where is the waiver for Naltrexone and Vivitrol prescriptions? As written this provision declares a winner in the currently debated issue of the preferred treatment protocol for opiate addiction. The opening salvo of this battle was declared by Big Pharma back in 2011 in a study out of Canada that touted Suboxone alone as superior to a progression from Suboxone to Naltrexone and then homeostasis. The main advantage claimed in this study was no lives lost to relapse overdose as medication is continued indefinitely.

The problem is that this opportunistic logic, if applied as written in the bill, leaves the U.S. taxpayer on the hook for a lifetime prescription to Suboxone for every opiate-addicted citizen treated. The Affordable Care Act came out in 2011 and appointed medically-assisted treatment the preferred protocol for addiction treatment provided by Medicaid (Buck, 2011). Combined with the concept of “federally qualified health centers (FQHCs)” being the only ones eligible to receive grants or waivers for training and co-prescription programs, the vast majority of “boutique” or specialized addiction treatment centers would only be able to provide Suboxone to their client. Without the additional overhead of hiring the expensive and increasingly overworked services of a psychiatrist, specialty treatment centers would be forced to provide substandard services. The only benefactor of this oversight is the maker of Suboxone, who I suspect had a hand in the crafting of this bill.

I have already written both of my senators, the Hon. Roy Blunt and Hon. Clair McCaskill and asked them to amend Section 303 of CARA to allow NP’s and PA’s to prescribe Naltrexone and Vivitrol before it goes before President Obama to be signed. I urge you all to contact your state representatives and do the same as it will literally save all of us billions of dollars in prescription costs in the important battle against opiate addiction.


Buck, J. A. (2011). The Looming Expansion And Transformation of Public Substance Abuse Treatment. Health Affairs , 1402-1410.


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