A Paradigm Shift in Federal Policy

Over 20 years into the nation’s opioid crisis, the federal government passed its first major bill addressing substance use in decades [1]. Signed into law in 2016, the Comprehensive Addiction Recovery Act (CARA) was an attempt to make serious structural changes in the way Americans engage with substance use and addiction [1].

It marked a cultural shift away from treating substance use disorders (SUD) as a choice, and afflicted individuals as criminals, to a better understanding of use disorders as medical conditions. In other words, federal policy on drug addiction began to shift from the criminal justice domain to a public health concern.

CARA funneled $181 million each year into prevention, treatment, recovery, law enforcement and criminal justice reform, and overdose reversal [1,2].

The Three Waves of the Opioid Crisis

The 1990s had marked the first wave of the opioid crisis, fueled by addiction to prescription opioids like OxyContin, which was launched in 1996 [3]. Initially intended for use in end-of-life care for metastatic cancer patients, OxyContin was aggressively marketed to doctors by Purdue Pharma as a less potentially addictive pain killer [4]. In 2007, top executives pled guilty to criminal charges that they had misled regulators, doctors, and patients about the drug’s risk of addiction and its potential to be abused [4].

But when restrictions over prescription opioids grew stricter, already dependent individuals transitioned to heroin [3,5]. Heroin overdoses more than tripled between 2010 to 2014 — the second wave of the opioid crisis [5]. Fully synthetic opioids like fentanyl began being mixed into the heroin supply [3].

Extremely potent synthetic opioid use characterized the third wave of the opioid crisis, drastically increasing overdose deaths by 2013, and fueling the federal government’s urgency to implement CARA [3,6].

Overdose Prevention and Treatment Access

Overdose prevention was a major target of the bill, expanding access to opioid overdose reversal drugs and fentanyl test kits [2]. By 2023, almost 30,000 Naloxone kits and 95,000 doses were administered, and over 5,000 medical providers had been trained through CARA grants, according to SAMHSA [2].

The first-line treatment for opioid use disorder (OUD), buprenorphine has a high binding affinity to opioid receptors, blocking other opioids like heroin or fentanyl from attaching [7]. However, buprenorphine only partially activates the receptors, diminishing the opioid response, lowering the potential for misuse, and lowering overdose risk [7].

Recognizing the efficacy of medication assisted treatment, CARA dedicated a large portion of funding to expanding treatment access [1,2]. Formerly prescribed only by physicians, CARA allowed nurse practitioners and physician assistants to prescribe buprenorphine, as well [1,8].

Physician prescriptions increased by 1.63% per month following this policy change, and nurse practitioner prescribing increased by nearly 20% per month [8]. This had a particularly notable positive impact in rural populations, who experience more difficulty accessing treatment [9]. CARA also expanded MOUD and buprenorphine initiation in emergency services, and facilitated the continuation of MOUD for incarcerated individuals [2].

Supporting Women and Families

Between 2010-2017, maternal SUD and OUD rose significantly, and neonatal abstinence syndrome among newborns increased from 1.30 to 3.39 per 1000 hospital births between 2000 and 2009 [10]. Despite this, treatment services grew little.

As a response to this need, CARA put major focus onto improving addiction and treatment services for women and families [2]. Grant programs for pregnant and postpartum women and their children took a multifaceted approach, funding childcare services, outpatient OUD and SUD treatment, and behavioral health services [2].

However, some areas had limited resources for implementation [2]. According to Medicaid data, in New Mexico 40.3% of families of infants exposed to substances in utero did not receive a plan of safe care [11].

Pandemic Challenges and Innovative Solutions

Frequently mentioned in reviews of CARA’s implementation, the COVID-19 pandemic became a significant barrier to CARA programs, with its onset three years after the first grants began [2, 9].

COVID slowed the growth of MOUD access, but in response to rising opioid-related deaths during the pandemic, the Drug Enforcement Agency allowed healthcare providers to prescribe buprenorphine through telemedicine and removed barriers to training and education by waiving specific regulations [8]. To connect patients in rural areas to MOUD, certain grant recipients created a Mobile Community Response Team and operated through mobile clinics during the pandemic [2].

Conclusion

While it is difficult to measure all of the outcomes of CARA-funded projects, it is clear that CARA set a historical precedent for treating addiction as a public health concern worthy of federal resources, and continues to fund services today.