Editor’s Note: The American Medical Association (AMA) and Manatt Health released a national roadmap in September 2019 to guide policymakers in taking action to help end the nation’s opioid epidemic.i Based largely on in-depth analyses of the responses to the opioid epidemic in Colorado, Mississippi, North Carolina and Pennsylvania, the 2019 roadmap identified numerous promising strategies as well as areas where more work and innovation clearly were required. Our expanded 2020 roadmap, summarized below, starts with our 2019 policy recommendations and an assessment of progress made. It also highlights areas where there are opportunities for improvement, as well as provides best practices and tangible recommendations for states to effectively address the drug overdose epidemic moving forward.
As companion pieces to the roadmap, the AMA and Manatt are cohosting a series of webinars with deep dives into the key topics spotlighted in the paper. Our next program—“Improving Access to Substance Use Disorder Treatment in Justice-Involved Settings”—is scheduled for April 20 and features presenters from the AMA, the American Civil Liberties Union, Johns Hopkins School of Medicine and the North Carolina Department of Health and Human Services. Click here to register free.
Progress Made on 2019 Policy Recommendations
When we look at the progress made since our 2019 paper, we see that the results across states are mixed, with the COVID-19 pandemic creating new challenges but also opening up new opportunities. For example, the important national focus on addressing racial inequities in health care has exposed huge disparities in how different populations fare with respect to substance use disorders (SUDs), but also generated new support for addressing those disparities. One thing that has not changed is that the 2020 roadmap is organized around the same six essential policy goals as the 2019 version. (See Exhibit 1.)
| Exhibit 1. Progress update on AMA–Manatt Health 2019 policy recommendations |
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Evidence-based treatment for opioid use disorder. Provide the full continuum of care, including medications to help treat opioid use disorder (MOUD) that are provided equitably across the health care system.
- Results are mixed. The COVID-19 pandemic has brought new challenges and increased mortality from illicit fentanyl and methamphetamine. More states have enacted laws prohibiting health insurers from using prior authorization for MOUD, but more than half of the nation’s states still allow it.
Parity enforcement. Increase oversight and enforcement of mental health and substance use disorder parity laws, including prospective evaluation of payer compliance.
- Results are mixed. Some states have enacted meaningful laws, and 30 states have joined a new National Association of Insurance Commissioners (NAIC) work group to refine regulatory tools that can hold insurers accountable. Yet state and federal oversight remains limited, as exemplified by the regular parity violations that are found when states conduct compliance exams.
Network adequacy/workforce enhancement. Ensure adequate networks that allow for timely access to addiction medicine, psychiatry and other physicians trained to treat addiction and mental illness; support payment reforms, collaborative care models, and other efforts to bolster and support the nation’s substance use disorder treatment workforce.
- Much more work remains. Innovative payment models continue to be explored, and some states are working hard to increase access to care, but millions of Americans with an SUD remain without treatment.
Pain management. Enhance access to comprehensive, multidisciplinary, multimodal pain care, including nonopioid and nonpharmacologic pain care options; remove arbitrary restrictions on opioid therapy for patients with pain.
- Much more work remains. While policymakers continue to rely on arbitrary restrictions for opioid analgesics, states and insurers have done relatively little to increase access to evidence-based alternatives to opioids and other medications and treatments that have proved cost effective in treating pain.
Harm reduction. Reduce harm by expanding access to naloxone, supporting sterile needle and syringe exchange programs, and coordinating care for patients in crisis.
- Progress continues. If not for naloxone, it is likely that tens of thousands more Americans would have died in 2019–2020. Some states have taken steps to increase access to sterile needles and syringes, and emergency departments are showing great promise in helping coordinate care for patients who experience an overdose event.
Data surveillance and evaluation. Support standardized data collection and surveillance efforts, and evaluate policies and outcomes to identify effective policies and clinical interventions so as to build on the most successful efforts, and also to identify policies and programs that may need to be revised or rescinded.
- Much more work remains. States are taking action to gather more information, but they need to take the next step to turn that data into effective overdose prevention, treatment and targeted interventions. Few states have evaluated whether current policies are increasing access to care or reducing opioid- and drug-related harms. There remains a lack of standardized data collection efforts across states, and data collection to address racial, ethnic and gender-related inequities also is limited at best.
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Our 2020 roadmap highlights the areas where there is opportunity for improvement, and builds on the progress that has been made by providing actionable recommendations and identifying best practices for lowering barriers and improving access to evidence-based care for an SUD; supporting multidisciplinary, multimodal treatment for patients with pain; and expanding the use of proven and promising harm reduction strategies. With respect to COVID-19, which has contributed to the again-rising overdose death rate, the roadmap spotlights the way provider networks have been decimated, but also highlights the accelerated use of telehealth and other policy changes that could become part of short- and long-term strategies to improve overdose prevention and treatment strategies. Especially as the opioid epidemic continues to evolve into a more deadly and complicated polypharmacy and illicit drug overdose epidemic, there is a significant need for policymakers to ensure continued evaluation of the effectiveness of their policies and pivot when needed. Additionally, removing the stigma for those who receive treatment for an SUD, for patients with pain, and for people who use drugs remains a long-overdue need across all domains.
The 2020 roadmap also highlights the need to more directly address the harsh disparities and long-standing inequities in access to SUD treatment for black Americans and other racial and ethnic groups, including an emphasis on ensuring that policy and clinical interventions directly confront those inequities. One study found that for every appointment where a black American received a prescription for buprenorphine, white patients had 35 such appointments.ii These inequities translate directly into differing mortality rates across racial and ethnic groups. In 2018, when the nation was beginning to see a decline in overdose deaths, it was due entirely to gains among white Americans. The rate of drug-induced deaths for American Indians, Asians, black Americans and Latinos actually increased and appears to have continued to increase in 2019 at a rate higher than among white Americans.
Addressing the Implications of COVID-19 for the Drug Overdose Epidemic
COVID-19 has exacerbated the nation’s drug overdose epidemic, impacting people with substance use disorders and the physicians and other health care professionals who serve them.iii National, state and local media reports indicate that these strains are sharply pushing up overdose rates.iv Although not enough to overcome rising overdose rates, providers and government agencies moved quickly to enable new flexibilities to provide care options for patients with an SUD and for patients with pain.
Drivers of increases in overdose. The COVID-19 pandemic has created a challenging environment for many, including patients with pain and patients with a substance use disorder/opioid use disorder (SUD/OUD) due to:
- More financial instability, stress and anxiety. The stress of contracting COVID-19 or facing the loss of family members and friends, coupled with job loss and job insecurity, has contributed to high levels of stress and anxiety.
- Social isolation. The COVID-19 pandemic has increased social isolation, a particular challenge for people with an SUD who rely on social connections as part of their treatment and recovery. While some peer recovery services and groups moved online, these online forums do not always work as well for many people with an SUD.
- Disruptions in access to treatment options and harm reduction services. Physicians and other health care professionals who provide addiction medicine and behavioral health care are being further squeezed as states face budget shortfalls, prompting shutdowns or reductions in service options. Potential patients may also face more limited in-person options, requirements to pass COVID-19 tests prior to securing treatment, and changes in where and when they can secure help. While the shift to telehealth has opened up important options in MOUD access, lack of technology access among some people with an SUD has disrupted treatment. Harm reduction services that provide primary overdose prevention may have become limited, altered hours, or become more difficult to reach during COVID-19.
Policy innovations. In response to the COVID-19 pandemic, certain flexibilities were enabled to ensure providers and patients with acute or chronic pain had continued access to necessary care and treatment options. These include:
- Expanded use of telehealth. In March 2020, the federal government offered increased flexibility to allow for the initiation of buprenorphine via telehealth, including through telephone-only services, which has proved particularly critical for many people with an SUD and/or chronic pain.v An AMA survey of pain medicine physicians found that 80 percent of physician respondents said that the flexibilities provided by the DEA during the COVID-19 pandemic have been either very helpful or somewhat helpful for treating patients with pain.vi
- Easing access to medications. The federal government gave states the flexibility to allow opioid treatment programs (OTPs) to support take-home doses of methadone for up to 28 days at a provider’s clinical discretion. States also offered extended supplies of medications and, in some instances, eliminated prior authorization requirements, as recommended by last year’s AMA–Manatt roadmap, for medication for opioid use disorder.vii
- Easing counseling requirements. Even prior to COVID-19, organizations such as the National Academy of Sciences and the American Society for Addiction Medicine were recommending that government agencies and providers allow people to receive MOUD even if they cannot or do not opt to participate in recommended counseling and therapy. In response to COVID-19, states such as West Virginia temporarily suspended counseling requirements for the duration of the public health emergency, making it easier for people to secure MOUD.viii
Fixing the Broader Structural and Systemic Barriers to Treatment
Beyond the specific challenges raised by COVID-19, access to evidence-based care remains a barrier to many seeking treatment for an SUD due to ongoing structural and systemic challenges. We once again emphasize:
- States must be willing to use their oversight and enforcement authority. State regulators have differing degrees of authority to pursue policies and changes that can have a significant impact on reducing barriers and improving patient care, but the extent to which they use these tools to increase access to evidence-based treatment or hold payers and others accountable for impeded access varies considerably.
- Medicaid often leads the way. Medicaid is a major payer for SUD treatment, serving four in ten individuals with an OUD in the United States. It often provides more comprehensive SUD care than the commercial insurance market and, in all states, has been a driving force for greater use of MOUD.ix During the COVID-19 pandemic, many states have used their Medicaid flexibility to provide additional funding to SUD providers facing declining revenue and new COVID-19–related costs, as well as to dramatically expand use of telehealth for SUD treatment.x
- Grants are helpful, but long-term implementation needs long-term, sustainable funding. Many best practices that are helping save lives are currently grant funded and need long-term, sustainable funding to continue benefiting individuals with an SUD. Without reliable funding streams, programs that help save lives may simply stop. This issue has become even more important with the large influx of federal dollars during the COVID-19 pandemic and the potential that termination of these emergency funds will leave gaping holes that will be exceptionally hard to fill for states facing significant budget pressures.
- Evaluation must include both policy outcomes and surveillance data to address prevention. Few states have undertaken efforts to evaluate current laws, policies and programs to determine whether those policies, programs and laws are working to increase access to evidence-based care and reduce harm. If they have not had their intended outcomes, it is imperative to critically examine why and address policy shortcomings. Similarly, state-level surveillance efforts must develop and grow in multiple ways. Not only must data collection and surveillance efforts include nonfatal overdose as well as mortality to ensure resources are used to support overdose prevention and treatment, but increased emphasis must be placed on data collection and surveillance that is disaggregated to highlight differences by race, ethnicity, age, gender and other factors critical to confronting health inequities. In designing evaluation studies, it will be critical to go beyond narrow cost-benefit analyses to measure outcomes in broad social terms.
Conclusion
Work remains for states to ensure access to evidence-based treatment, to ensure harm reduction efforts are advanced, to address long-standing health inequities, and ultimately, to ensure progress is made in addressing the broader drug overdose epidemic.
- Policy enactment has been extensive. The epidemic has led to the passage of hundreds of new laws, regulations, clinical guidelines and national recommendations. Some are evidence-based, such as increasing access to MOUD, enforcing mental health and substance use disorder parity laws, and enhancing access to harm reduction services, including continued emphasis on access to naloxone to help save lives from opioid-related overdose.
- Policy implementation remains elusive. Even as access to evidence-based treatment for OUD has been a major focus, much more work remains to ensure access to treatment for OUD. Putting policies into action requires additional steps, which is why the bulk of recommendations in the report focus on tangibly removing barriers to evidence-based treatment for OUD and enforcing state and federal parity laws. Health insurance companies and other payers must change their practices or patients will continue to be harmed.
- Policies must be examined and evaluated for effectiveness. The report highlights the need for thorough evaluation and commitment by states to further policies that work and to revise or rescind policies that are harmful to patients. This includes ensuring that policy evaluation and data collection directly address long-standing health inequities.
- There are many examples to learn from. The AMA–Manatt analyses reveal multiple areas in which there have been positive outcomes and promising results. This includes the development of hub-and-spoke models of care, community-based naloxone access efforts, and reforms in state Medicaid agencies to improve access to multidisciplinary, multimodal pain care. The 2020 roadmap identifies many initiatives that all states can learn from and potentially adopt. This includes providing MOUD to those in justice-involved settings, removing stigma for OUD and pain, and using data to meaningfully reduce long-standing health inequities.
- Demonstrating program success is a work in progress. The report identifies many areas in which additional work can be done to further increase access to evidence-based care, including pilot projects being done by emergency departments to assess and refer patients to treatment for OUD. Because many successful pilot programs are dependent on grant funding, we urge greater attention to program evaluation to help illuminate which pilot programs that may be helping hundreds of people today can be scaled up as national models that could help hundreds of thousands tomorrow.
- All stakeholders can take action. The national roadmap provides recommendations that may not be easy to implement, but they are necessary to help end the epidemic. There are recommendations that can be applied by governors, state legislators, attorneys general, insurance commissioners, Medicaid officials and other policymakers. Many of the recommendations also could be implemented voluntarily by health insurance companies, PBMs and other stakeholders if they were so inclined or encouraged to do so. Patients with an SUD and patients with pain need help. The overdose epidemic is more deadly than ever. Physicians and other health care professionals must continue to take action.
i This report discusses in detail the need to change terminology from “opioid epidemic” to “drug overdose epidemic.” There are several reasons for doing so, including the fact that what may have begun a decade ago as an epidemic of opioid misuse, overdose and death related to prescription opioids has now become a much more complicated and deadly epidemic due to illicitly manufactured fentanyl, methamphetamine, cocaine and heroin. Harm related to prescriptions has decreased slightly but remains far too high. The terminology is critical to ensure that policy interventions focus on the larger epidemic rather than primarily prescription “opioids.”
ii Lagisetty PA, Ross R, Bohnert A, Clay M, Maust DT. Buprenorphine Treatment Divide by Race/Ethnicity and Payment. JAMA Psychiatry. 2019;76(9):979–981. doi:10.1001/jamapsychiatry.2019.0876.
iii According to a recent American Academy of Addiction Psychiatry (AAAP) COVID-19 Buprenorphine Provider Survey Report, 70% of providers were concerned that patients were experiencing mental health distress during the pandemic, and almost half of providers who responded were concerned that their patients faced significant barriers to using telephones or unstable housing during this time, impeding the providers’ ability to provide medications during the pandemic for their patients with opiate use disorder (OUD). Source: www.aaap.org/wp-content/uploads/2020/10/COVID-29-Survey-Results-First-Glance_EW-10.15.pdf. Accessed October 20, 2020.
iv American Medical Association (AMA). Issue Brief: Reports of Increases in Opioid- and Other Drug-Related Overdose and Other Concerns during COVID Pandemic. American Medical Association, Advocacy Resource Center; 2020:17. www.ama-assn.org/system/files/2020-10/issue-brief-increases-in-opioid-related-overdose.pdf. Accessed October 28, 2020.
v Substance Abuse and Mental Health Services Administration (SAMHSA). FAQs: Provision of Methadone and Buprenorphine for the Treatment of Opioid Use Disorder in the COVID-19 Emergency. SAMHSA; 2020:4. www.samhsa.gov/sites/default/files/faqs-for-oud-prescribing-and-dispensing.pdf, 2020.
vi An issue brief describing the key findings from the survey is available here: https://end-overdose-epidemic.org/wp-content/uploads/2020/11/Issue-Brief-AMA-Survey-of-Pain-Management-Physicians-During-COVID-19-FINAL.pdf.
vii Substance Abuse and Mental Health Services Administration (SAMHSA). Opioid Treatment Program (otp) Guidance. 2020. www.samhsa.gov/sites/default/files/otp-guidance-20200316.pdf. Updated on March 19, 2020. Accessed October 22, 2020.
viii State of West Virginia Department of Health and Human Resources, Bureau for Medical Services. Memorandum to West Virginia Medical Providers Regarding Medication Assisted Treatment Services Counseling/Therapy Requirements. 2020. https://dhhr.wv.gov/bms/Documents/MAT%20Therapy%20Suspension%20MAY2020%20Update.pdf. Updated May 20, 2020. Accessed October 4, 2020.
ix One of the most successful programs can be found in Virginia. See, for example, An Evaluation Report Prepared for the Virginia Department of Medical Assistance Services, Addiction and Recovery Treatment Services, Access and Utilization During the Second Year (April 2018–March 2019). Virginia Commonwealth University. Available at www.dmas.virginia.gov/files/links/5218/ARTS%202%20year%20report.Feb2020%20FINAL.pdf. Accessed October 20, 2020.
x State Strategies to Support Access to Substance Use Disorder Treatment Services through the COVID-19 Pandemic. National Governor’s Association; 2020:16. www.nga.org/wp-content/uploads/2020/07/NGA-Issue-Brief-SUD-Treatment-Access-COVID-19.pdf. Accessed October 30, 2020.