How Policymakers Can Confront the Opioid Crisis: A Wisconsin Lawmaker’s View

After his election in 2006, Wisconsin State Representative John Nygren thought his legislative focus would be on taxes. But substance use disorder—especially involving opioids—would soon become a critical component of his work. In 2017, The Pew Charitable Trusts started working with Wisconsin officials, including Rep. Nygren, as they grappled with the worsening problem.

In this Q&A, the Republican from Marinette reflects on how the opioid crisis has hit his district in northeastern Wisconsin and his own home, and on the range of policies that states can pursue to improve their treatment systems.

Q: When did you realize that the Wisconsin State Assembly needed to do something about opioid use disorder?

A: It began when my small town of Marinette was named a “heroin town” by some major newspapers, due to the amount of overdose deaths and crime activity. That was tough enough to hear as a legislator, but drug use also affected my own daughter, starting when she was in high school. Since then, she’s gone to treatment several times and relapsed every time. She had an overdose event in 2010 and has spent time in prison. This brought the issue not only to my community, but my family’s living room.

Initially, we dealt with it privately. Drug use, in general, was not publicly talked about at that time. It was thought to be a law enforcement issue, ­and there was not pressure at the legislative level yet.

Then I began to see obituaries two or three times a week about young people who had died at home, or died unexpectedly. My friend was a funeral director and could hear the whispers. Talking with law enforcement and medical professionals, it became clear we needed to act. We thought our community was unique, but it was foretelling what was to come across the country.

With the encouragement of my daughter and my staff, we began working on the Heroin, Opiate Prevention and Education (HOPE) Agenda. Five years later, the legislation and work has continued.

Q: What new laws have been part of the HOPE Agenda?

A: Our first round of bills in 2013 and 2014 was really about harm reduction. At that point, we thought it was about people dying in small towns of heroin overdoses. We didn’t realize the big role of prescription opioids.

In 2014, we passed the “911 Good Samaritan” law, which gives a person immunity from prosecution if they call to report an overdose. We expanded naloxone availability for first responders so they could reverse overdoses. We expanded access to treatment in rural areas and improved our drug disposal operation.

For the next round of bills, we identified that prescription drugs were the entry point for most people developing opioid use disorder. We passed improvements to our prescription drug monitoring program, which I think is really the best tool, because it gives doctors all the information in front of them.

We’ve also continued to expand access to medication-assisted treatment (MAT) in more nuanced ways. We lowered barriers to licensure for prescribing MAT drugs, which we learned other states didn’t have, and increased our number of social workers and drug counselors.

This past legislative session, 29 out of the 30 bills passed unanimously, and the other one got only two “no” votes. This shows, first, that the issue is not partisan in any way, shape, or form. Both parties have brought ideas. Second, it’s not just about my part of the state—it’s everywhere.

Q: What successes are you seeing on the ground? Where does progress still need to be made?

A: Doctor shopping [the practice of visiting multiple physicians to obtain the same or similar drugs in a short time span] is now down 32 percent since 2015. Prescriptions are down about 30 percent as well, but emergency room visits are up. That tells me that health care providers are probably reducing the supply of prescription painkillers to their patients, but illicit fentanyl has come into greater use and changed the game.

It also tells me that providers are not always referring their patients to treatment. That’s why treatment is the number one focus for us, and why the hub and spoke model—which treats patients at the “hub” and continues care through their local primary care doctors—is going to be very important for us.

But one of the biggest successes is not any one bill that’s passed, but the amount of attention the opioid crisis has gotten. People have come up to me and said that their son tore up his knee, and when the doctor offered him a prescription opioid, they asked for alternatives. That’s great to hear.

Q: What do you wish policymakers and the public better understood about opioid use disorder?

A: Stigma is still a big problem. Many people still don’t understand that about 80 percent of people with opioid use disorder started with prescription drugs, many times legally prescribed. I can see how somebody would take that prescription and think it wasn’t dangerous.

So I do think some of my colleagues still see opioid use disorder as a moral failing rather than a medical condition. But they’re coming along; we all are.

Another issue is the ripple effect that opioid use disorder has on communities. Many children have been left behind. The number of children in foster care has spiked 20 percent in Wisconsin over the last few years, mostly attributed to the opioid crisis. That’s something we didn’t realize would happen at the outset.

Q: How do you respond to concerns that opioid laws will keep chronic pain patients from receiving treatment?

A: We take great pride in the fact that Wisconsin has seen a reduction in opioid prescriptions without any law that limits prescribing. There is misinformation out there that we “cut off” medication for pain patients, but we have been careful not to do that.

In my opinion, it’s a danger that some people believe that. Public perception of what we’ve done is just as important as what we’ve actually done, because if the public doesn’t accept it, we may not be able to move the ball forward.

Ultimately, we want doctors and patients to make the decisions that are right for them. But we also want to understand why a pill is prescribed versus other forms of treatment—maybe insurance covers it or it’s cheap. So right now we’re looking at Medicaid and private insurance coverage for physical therapy, acupuncture, chiropractic care, and other nonaddictive forms of treatment.

Studies even show that opioids aren’t effective long-term. If that’s what science is saying, then there has to be some other form of treatment for pain patients. We can’t just say, “Live with it.”

Q: Where should future legislative efforts focus?

A: We need to keep expanding access to treatment, including by connecting people to treatment that already exists. Technology can play an important role, such as a bed tracker system that will allow doctors to find where treatment is available in real time. Such a thing already exists for mental health, but we should have the same for substance use disorder. We should engage primary care providers, as they are often the first people who can recommend treatment.

On that note, mental health treatment needs to be more easily accessible. Dual diagnosis for mental illness and substance use disorders is through the roof—it’s clear that some people use drugs and alcohol to treat mental pain they’re going through. Policymakers are slowly coming to grips with that and realizing that if we treat mental health, down the road, health care costs would be way lower.

Q: What advice would you give legislators in other states seeking to address the opioid crisis?

A: One thing we’ve learned is to build a treatment infrastructure and support system that can address opioids but also whatever drug crisis might be next.

Don’t presuppose that you know what’s happening. There is still a significant amount of underreporting of opioid deaths. Initially some Wisconsin counties said they didn’t have the problem; they did, and either didn’t identify it or nobody wanted to talk about it.

I would add that personal stories matter. I know they exist among legislators, but constituent stories about the straight-A valedictorian or state track champion that overdosed in college, those stories help personalize government.