Ending the Opioid Epidemic: Leading-Edge Responses and Next Steps

By Joel S. Ario, Managing Director, Manatt Health | Jessica Altman, Pennsylvania Insurance Commissioner | Patrice Harris, M.D., President-Elect, AMA | Susan Kansagra, M.D., Section Chief, Chronic Disease and Injury, North Carolina Division of Public Health

Editor’s Note: With the number of opioid deaths six times higher in 2017 than in 1999, the opioid epidemic is continuing its rampage across the country. What can be done to solve the epidemic? What steps have states taken that are showing meaningful progress? What needs to come next? To uncover the answers, Manatt Health and the American Medical Association (AMA) performed an in-depth “spotlight”analysis of how four hard-hit states—Pennsylvania, Colorado, Mississippi and North Carolina—are addressing the epidemic. We shared our findings in a recent webinar. In part 1 of our article summarizing the program, below, we look at the top-line findings from our state analyses and share a deep dive into how North Carolina is responding to the epidemic. Watch for part 2 of our summary in the May “Health Update,” providing insights into how Pennsylvania is dealing with the epidemic and a look ahead at next steps. Click here to view the webinar free, on demand—and here to download a free copy of the presentation, as well as the spotlight analyses for Pennsylvania and Colorado.

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Addressing the Nation’s Opioid Epidemic

The nation’s opioid epidemic started off being fueled by prescription opioids but has shifted into being driven by illicitly manufactured fentanyl and fentanyl analogues. Despite a 22% reduction in opioid prescriptions since 2013, the loss of life and emotional toll of the epidemic continue to climb. The AMA and Manatt Health examine the challenges states are facing and the ways that strong leadership can make a difference in our spotlight analysis series.

We began each state spotlight with an in-depth look at existing state policies, private initiatives and local activities underway to address the opioid epidemic. We then held extensive conversations with key regulators, physicians and other stakeholders about current challenges and opportunities. Next, we researched how each state measured success, as well as where gaps existed and what was being done to address them. Finally, we worked with medical societies and regulators to test our recommendations and ensure they were reasonable in the real world.

Key Findings From the State Spotlights: A National Roadmap

The spotlight analyses focus on moving the needle in three main areas:

1. Increasing access to high-quality, evidence-based care for substance use disorders;
2. Providing comprehensive care to patients with pain; and
3. Enhancing access to naloxone.

These three focus areas are the key recommendations from the AMA’s opioid task force. First convened in 2014 as the epidemic was rapidly escalating, the task force included members from 27 organizations who came together to develop recommendations for how physicians could take effective action. Today, due in part to the AMA and medical society advocacy, there are more than 62,000 physicians and healthcare professionals who can provide buprenorphine in their offices for the treatment of opioid use disorder (OUD). AMA advocacy also has been key to enacting laws in every state to increase access to naloxone.

There are five key findings from our state spotlight analyses that can serve as a national roadmap:

1. Remove prior authorization for medication-assisted treatment (MAT)—and ensure MAT is affordable.
2. Increase oversight and enforcement of mental health and substance use disorder (SUD) parity laws.
3. Ensure network adequacy for those needing treatment for opioid use disorder.
4. Enhance access to comprehensive, multidisciplinary, multimodal pain care.
5. Identify, learn from and continue best practices and pilot projects for increasing access to treatment and naloxone, as well as beginning efforts to use state-level data for targeting resources to the areas of greatest need.

A comprehensive public health focus underpins the work of the AMA opioid task force and the spotlights’ recommendations. Efforts to implement the five key recommendations may not always be easy, but they are necessary to end the nation’s opioid epidemic.

North Carolina’s Response to the Opioid Epidemic: A Six-Pronged Strategy

North Carolina has created a comprehensive opioid action plan involving multiple partners across its communities, including medical providers, health systems, law enforcement and the families impacted by the crisis. The state has created a six-pronged strategy for addressing the epidemic:

1. Reduce the oversupply of prescription drugs.
2. Reduce diversion and flow of illicit drugs, such as fentanyl and heroin, which are increasingly responsible for the rising death toll.
3. Improve community awareness around storing and disposing medications, speaking with doctors about alternatives to opioids, and preventing the cycle of addiction by supporting substance use prevention programs.
4. Increase the availability of naloxone.
5. Expand access to treatment and recovery support, recognizing that OUD is a chronic condition.
6. Measure the impact of each of these strategies.

Addressing the Opioid Epidemic Through North Carolina Medicaid

North Carolina has made proactive changes to its Medicaid program to promote safe opioid prescribing, non-opioid pain management and access to MAT. Changes include:

• Removing prior authorization for suboxone,
• Working with the General Assembly to consider non-opioid pain management, and
• Implementing formulary benefit changes to ensure consistency with Centers for Disease Control (CDC) guidelines and North Carolina’s STOP Act. (Signed into law on June 29, 2017, the STOP Act’s primary goal is to reduce excessive or inappropriate opioid prescribing by, among other approaches, imposing limits on how much opioid pain medication can be prescribed for acute pain. The limits do not apply to opioid prescriptions for chronic pain or for acute pain related to an underlying chronic condition, such as rheumatoid arthritis.)

North Carolina also has convened other payers across the state to develop a series of recommendations to support the judicious prescribing of opioids. The payers also focused on creating approaches to expanding access to opioid alternatives and improving the availability of treatment.

North Carolina’s Chronic Pain Self-Management Programs

North Carolina is working with communities on new approaches to dealing with chronic pain. Through the state’s Division of Aging and Adult Services, North Carolina is funding the implementation of chronic pain self-management programs focused on skill-building, exercise, and communication with family members and health providers. Delivered over six weeks in community-based settings, the programs have shown impressive results in reducing pain, improving mental health, increasing energy and enhancing quality of life.

Improving Naloxone Access, Treatment and Recovery

North Carolina has a standing order in place to ensure that anyone who is at risk of an overdose—or who has a family member or friend at risk of an overdose—can receive naloxone from a pharmacy. Under that standing order, more than 85% of retail pharmacies in the state are dispensing naloxone—and the goal is to get that number to 100%.

North Carolina also distributes naloxone through community distribution points. Established by the North Carolina Harm Reduction Coalition (NCHRC), the distribution points put naloxone directly into the hands of those at highest risk. Over the past five years, they have distributed more than 100,000 naloxone kits. In addition, by collecting information on how the naloxone kits have been used, the NCHRC has identified 1,400 reversals. (That number does not represent all reversals—only those reported to NCHRC.) Members of law enforcement agencies also are carrying naloxone, because in some areas of North Carolina, they are often on the scene before emergency medical services.

North Carolina has found that its syringe exchange program is another powerful avenue for distributing naloxone. There are currently 29 registered programs in the state, which often serve as entry points into treatment for people using illicit drugs who have no other access to care. The syringe exchange programs not only provide clean needles to decrease the risk of communicable diseases but also have referred thousands of people to treatment and recovery programs.

Federal opioid funding has been an additional important tool for helping North Carolina address the epidemic. In the first year of federal funding, the state expanded its treatment system to reach more than 5,000 individuals. It provided MAT to more than 2,000 people—and expects that number to double in the second year of federal funding. As a state that has not expanded Medicaid, North Carolina is using the federal dollars to bring treatment and recovery support to those who do not have insurance coverage.

In addition, the North Carolina Department of Health and Human Services (DHHS) is funding several important wrap-around services in a variety of settings to provide treatment, recovery and harm reduction supports:

• Peer support programs in emergency departments help people coming in for overdoses transition to treatment and recovery programs.
• The medical residency training initiative ensures that every resident graduating from the program is waiver trained. Fifteen residencies are already signed up to participate.
• Post-overdose response teams are trained by the state to offer help in counties hardest hit by the epidemic. The teams provide naloxone at the scene of the overdose, sometimes averting an emergency room visit. Team members then follow up in a few days to determine if the individual is willing to connect with harm reduction, treatment and recovery support.
• Justice-involved populations have high rates of substance abuse and overdose. North Carolina is focused on breaking the cycle of addiction by connecting people to treatment and recovery programs and supporting them in re-entering society.

The Results of North Carolina’s Strategy

North Carolina is seeing positive results from its comprehensive approach to battling the opioid epidemic:

• The number of opioid prescription claims and the percentage of all Medicaid prescription claims for opioids have declined.
• The number of individuals (both those uninsured and those with Medicaid) being served by treatment programs has almost doubled over the last five years. North Carolina anticipates continued progress, due both to federal funding and to state efforts to close the coverage gap.
• The number of overdoses being treated in emergency departments has started to decline. The trend began in 2018 and is holding in Q1 2019. There has been an 11% decline in emergency department visits for opioid overdose in the opening months of 2019 versus the same period last year.

Thanks to its multipronged strategy, North Carolina is making measurable progress in fighting the epidemic. The state is hoping that its comprehensive approach will continue to move the needle in the right direction.