In December 2019, Congress authorized funding for the Alternatives to Opioids (ALTO) in the Emergency Department program—the final step in the legislative process needed to set the ALTO grant program in motion and another significant victory for ACEP’s federal advocacy efforts.

Background

The ALTO program was originally developed by ACEP President-Elect Mark Rosenberg, DO, MBA, FACEP, and Alexis LaPietra, DO, FACEP, and their team at St. Joseph’s University Medical Center in New Jersey in 2016. Intended to address issues of variation and overprescribing of opioids, ALTO is an evidence-based, multidisciplinary acute pain management program that helps treat painful conditions for patients in the emergency department without using opioids and also helps other patients who may have an opioid use disorder (OUD). In just one year after implementing the program, opioid prescriptions in the St. Joseph’s emergency department fell by 46 percent, and after two years, opioid prescriptions were down by 82 percent.

ACEP’s federal advocacy efforts to help expand the reach of the ALTO program began in 2017, and the path from introduction to authorization and appropriations was extraordinarily rapid by legislative standards. ACEP’s Washington, D.C., staff worked with Rep. Bill Pascrell (D-NJ) and Rep. David McKinley (R-WV), as well as Sen. Cory Booker (D-NJ), Sen. Shelley Moore Capito (R-WV), Sen. Michael Bennet (D-CO), and Sen. Cory Gardner (R-CO) to develop legislation that would establish a federal grant program to provide $10 million per year to help other emergency departments implement their own ALTO protocols.

On March 7, 2018, the Alternatives to Opioids in the Emergency Department Act was introduced in both the House and Senate (HR 5197/S 2516)—fortunately timed, as all of Congress’ attention was squarely focused on the nation’s opioid epidemic. ACEP received an invitation to testify about the ALTO program’s success before a House Committee on Energy & Commerce hearing on March 22, 2018, and Dr. Rosenberg testified on ACEP’s behalf. ACEP members advocated for ALTO during the annual Leadership & Advocacy Conference, and the bill was included among a number of other opioid-related bills that were marked up in the Energy & Commerce Health Subcommittee in April and the full committee in May. ALTO received a voice (unanimous) vote on the House floor in June, and it was then merged into the SUPPORT for Patients and Communities Act (HR 6), which was ultimately signed into law on Oct. 24, 2018. The ACEP-developed ALTO legislation went from introduction to enactment in a mere eight months.

Finding Funding

Securing funding for ALTO would prove to be a trickier prospect, however, as the annual congressional appropriations process has all but broken down in recent years. Due to bitter partisan battles and a variety of other factors, Congress has largely been unable to pass all 12 annual appropriations bills, instead relying on a patchwork of omnibus and “minibus” (ie, collection of a few bills) funding packages backfilled by a series of temporary stopgap measures known as continuing resolutions (CRs) to keep the government funded at existing levels. In fact, the process has broken down so severely that legislators have sometimes failed to pass even CRs to keep the government running, leading to several notable government shutdowns, including the longest shutdown in U.S. history (35 days) at the end of 2018 that bled into early 2019. A further challenge was that funding for the ALTO program was dependent on the success of the Labor, Health and Human Services, Education, and Related Agencies (L/HHS) appropriations bill, a package often subject to major partisan squabbles and “poison pill” amendments inserted to make a bill less effective and that stall progress.

ACEP continued working with legislators, including ALTO’s original sponsor Rep. Pascrell, to secure funding for the program in the L/HHS bill. In June 2019, Rep. Pascrell offered an amendment to the fiscal year (FY) 2020 L/HHS package on the House floor to fund ALTO at its full $10 million, and it passed with overwhelming bipartisan support in a 382-32 vote. In September 2019, the Senate L/HHS bill included funding for ALTO, albeit at a lower $4 million level. Despite the disparate funding levels, the inclusion of ALTO in both the House and Senate bills was a critical step to help provide momentum for its inclusion in any final appropriations package.

Unfortunately, the appropriations process once again ground to a halt in fall 2019. Negotiations fell apart over abortion-related amendments and President Donald Trump’s border wall budget requests; meanwhile, a potential veto threat from the president that would sink any potential compromise loomed over the negotiations. Even at the beginning of December, serious doubts that a spending package agreement was even possible remained, and the likelihood of another short-term CR (meaning flat funding levels and little chance for any new programs to be funded) appeared high.

Million-Dollar Miracle

However, appropriators tried to iron out their differences, and ACEP continued to advocate for ALTO’s inclusion in any possible year-end funding package. On Dec. 16, in what was nothing short of a congressional miracle, appropriators unveiled a $1.4 trillion spending agreement consisting of a four-bill minibus and a larger eight-bill package to provide stable government funding for all departments throughout FY 2020. Included in the package was another ACEP legislative advocacy win: $5 million in funding for the ALTO program in FY 2020. Though less than the $10 million originally authorized, this critical funding will help emergency departments throughout the country establish and implement their own ALTO protocols to continue the fight against the country’s opioid epidemic.

In January 2020, the Substance Abuse and Mental Health Services Administration announced the grant opportunity for the ALTO demonstration program, with an anticipated 10 awards to be distributed in the initial round. Applications are due March 17 and are available  here.

Work Continues

In just two years, ALTO went from legislative concept to reality, with strong ACEP advocacy involved every step of the way. Still, our work isn’t done. As of this writing, ACEP is already working with our legislative champions on the ALTO appropriations request for FY 2021 budget, with the hope of securing the full $10 million to help further extend the reach of this important program.

Mr. McBride is a senior congressional lobbyist in the public affairs department at ACEP.