When Susan Brooks was the U.S. district attorney for southern Indiana in the early 2000s, she prosecuted an Indianapolis doctor for overprescribing the painkiller oxycodone and an Evansville resident for injecting his ex-wife with a fatal dose of the same drug.
"Unless we do a lot more education about the problem, we’re going to see a lot more deaths," Brooks told the Evansville Courier and Press in 2004.
That year, 98 Indiana residents died from opioid overdoses, according to the Indiana State Department of Health. Over the next 10 years, more than 2,000 Hoosiers died from overdoses of opioids, a family of pain-relief drugs including fentanyl, heroin, hydrocodone, methadone and morphine.
More recently, Scott County attracted national attention because of an HIV outbreak linked to the sharing of needles by intravenous drug users. Their drug of choice was the prescription pain reliever oxymorphone.
Brooks today is a Republican member of the U.S. House from Carmel, fresh off election to her third term representing central Indiana’s 5th District. This year, she and nearly every other member of Congress voted in favor of the Comprehensive Addiction and Recovery Act, which President Barack Obama signed into law July 22.
Three years in the making, CARA aims to curb prescription opioid abuse and heroin use through prevention, treatment, recovery, education and law enforcement efforts. Lawmakers and advocates hailed it as an historic approach that regards drug addiction as a public health crisis rather than criminal activity.
"I think what we’ve learned over the decades is we cannot arrest our way out of this epidemic of addictions," Brooks, who grew up in Fort Wayne, said in a recent phone interview. "We have to remove the stigma of the addiction, allow families and people to seek help without being afraid of the stigma of having this kind of addiction."
When CARA is up and running, it is supposed to provide grants for communities to address drug crises, develop treatment alternatives to jail sentences, receive training in the use of the overdose-reversal drug naloxone and create disposal sites for unwanted prescription medicines.
Other grants will be available for law enforcement to investigate illegal drug activities, for high schools and colleges to support students recovering from substance abuse and for states to assist female drug offenders who are pregnant or caring for children.
The Department of Health and Human Services and the Justice Department are the main agencies to implement the programs.
All they need now is money.
Despite overwhelming bipartisan support in Congress for CARA – it passed the House 407-5 and the Senate 92-2 – lawmakers have been haggling all year over its funding.
Democrat Obama had asked the Republican-controlled Congress to spend $1.1 billion over two years to fight opioid addiction, an amount the White House said would have included up to $19 million for Indiana. Congress settled on about $900 million spread over five years, or $181 million a year, for CARA.
"This legislation includes some modest steps to address the opioid epidemic. Given the scope of the crisis, some action is better than none," Obama said when he signed the bill in July.
Lawmakers so far have appropriated just $7 million for CARA as part of a stop-gap government funding measure lasting from Oct. 1 through Dec. 9. Health and Human Services has received only $3.3 million.
"This appropriation will not allow us to implement most provisions of the bill and will not come close to providing the level of support necessary to make treatment for opioid use disorder available in every state," HHS said recently in an email statement to The Journal Gazette.
It appears that CARA might be on track to receive $37 million for all of fiscal 2017. But advocates on the left and the right have said that’s far from enough for the law to be effective.
Before Thanksgiving, four Democrats in the Senate, including Indiana Sen. Joe Donnelly, and 23 Democrats in the House sent letters to congressional leaders of both parties requesting money for CARA. The Senate Democrats recommended it be included in the 21st Century Cures Act, which would speed federal approval of drugs and medical devices and increase funding for the National Institutes of Health.
Sure enough, over Thanksgiving break, legislators negotiating the Cures Act agreed to devote $1 billion over the next two years to fight opioid abuse, about the same amount as Obama had sought last February. The House passed the revised bill by a 392-26 vote Wednesday, and the Senate is expected to approve the bill this week.
Michael Botticelli, director of National Drug Control Policy, said Wednesday in a conference call with reporters that much of the new money will be spent on "the opioid treatment gap."
"By substantially investing in treatment across the country, it will, I think, dramatically change the trajectory of this disease," Botticelli said.
The Cures Act will award grants to states according to their prevalence of opioid abuse, and the states will administer the grants. The legislation describes possible uses for the money, including prescription drug monitoring programs, training for health care workers and opioid abuse prevention activities.
But none of the money apparently will fund CARA, according to Botticelli.
"They are two different grant programs," he said.
Indeed, there is only one reference to CARA in the nearly 1,000-page Cures Act, and that is related to "savings in the Medicare improvement fund." Nowhere is there a mention of naloxone or the community-based coalition enhancement grants established by CARA.
Asked whether CARA will receive sufficient funding, Botticelli said, "That’s up to Congress to decide." He said the $7 million appropriated so far is "really insignificant either for Justice grant programs or for the health programs to get underway."
Donnelly said Wednesday in a conference call with reporters that he believes Cures Act money will go to CARA despite Botticelli’s contention. Brooks’ office said Thursday that although the Cures Act and CARA are separate, they may overlap.
For example, states might be able to tap Cures Act grants to fund addiction prevention and treatment programs offered through CARA.
The Cures Act "is certainly not a replacement for CARA but has a similar goal, which is to fund programs helping people struggling with heroin and opioid abuse," a Brooks spokeswoman said.
Donnelly, who like Brooks helped draft provisions of CARA, seemed satisfied with the $1 billion infusion regardless of where it ends up.
"By all common sense, it should be just a simple matter of providing the distribution," he said Wednesday.
Not long before the Cures Act bargain was struck, The Journal Gazette had asked Donnelly whether Congress was lacking the sense of urgency on opioid addiction that it displayed when debating, amending and approving CARA last summer.
"All my colleagues have to do is look at the problem in their state. If anything, the sense of urgency should be increased," he said.
"If you look at Kentucky or Ohio or West Virginia or Wisconsin; … it is killing people of all ages across the board every single day," he said about opioid overdoses.
Senate Majority Leader Mitch McConnell is from Kentucky, and House Speaker Paul Ryan is from Wisconsin. Kentucky ranked fourth nationally, behind West Virginia, New Mexico and New Hampshire, for drug overdose death rates in 2014, according to data from the Centers for Disease Control and Prevention. Ohio was fifth, and Indiana was 15th. The death rate is the number of deaths per 100,000 people.
The CDC has said more than 47,000 Americans died from drug overdoses in 2014, including 19,000 who died from prescription pain relievers.
"The alternate cost of the damage that this scourge is causing is much, much higher than that billion dollars – the cost of medical care, the cost of family damage, the cost of lost lives," Donnelly said.
He called opioid addiction "a wildfire."
Brooks said it will take time for opioid abuse grants to reach their destinations.
"Having been involved in the federal government, having been involved in the Justice Department, nothing moves that quickly. It takes a while to stand up new grant programs," she said.
The process could take longer if only because President-elect Donald Trump will appoint new leadership teams at the federal agencies that administer the drug grants, Brooks said.
State and local officials said they have received little information on available federal funding.
"Because details of how CARA funding will be implemented are still unclear, it’s impossible to predict how Indiana might be impacted," Jeni O’Malley, public affairs director for the Indiana State Department of Health, said in an email.
John Perlich, public information officer for the city of Fort Wayne, said in an email, "Grant eligibility rules, guidelines, etc. that would allow an informed decision about pursuing those grants are still unknown."
There have been other sources of federal money available for preventing and treating substance abuse. HHS spent $94 million this year in Affordable Care Act funds for 271 health centers to expand their delivery of substance abuse services. And the agency announced in August it would distribute $53 million to 44 states to fight opioid misuse.
Park Center Inc., a Fort Wayne nonprofit that provides addiction treatment services, is primarily funded by patients’ private insurance, Medicaid and self-payments, said Tom Allman, manager of addiction services.
"You can’t really provide services based on grants in a sustainable fashion, … because those grants run out. And when they run out, you’ve got nothing to fall back on," Allman said.
But Allman said he believes CARA is important because it represents the beginning of "a shift in thinking" about addiction by the federal government.
"I think CARA puts the treatment of the medical disease of addiction on the same playing field with other medical diseases, … so people will get the help they need," he said.
Brooks said federal legislation is only one component in the fight against opioid addiction.
"Just because we got a big bill passed or just because we put millions of dollars out there, that’s not going to solve this problem," she said. "It’s going to help, but we’ve got change the culture of the country in the way the country deals with pain, the education level of people who need to learn far more about prescription drugs and the hazards of long-term use of prescription drugs and particularly opioids."