This year the CDC released data showing that drug overdose deaths reached new heights in 2017, claiming the lives of more than 72,000 Americans. In response to the growing epidemic, the Trump administration has carefully planned out its all encompassing response in the form of sweeping legislation.
In late October, president Donald Trump signed the SUPPORT for Patients and Communities Act into law, purporting it be the “single largest bill to combat the drug crisis in the history of our country.” Called the SUPPORT (Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment) for Patients and Communities Act, it flew through the House and Senate in an uncharacteristic showing of mass bipartisan support.
The new piece of legislation funnels money through multiple grant programs to address the growing opioid crisis. Some of the major issues the the bill hopes to deal with include:
- Increased monitoring and detection of fentanyl and other synthetic opioids
- Preventing addiction for susceptible seniors
- Increase access to Medicaid funding for substance abuse treatment
- Help pregnant women and new mothers receive treatment for opioid use disorder
- Expanding oversight of opioid prescriptions and payment
- Raising awareness about the influence that synthetic drugs can have
- Increased data sharing in regards to opioid abuse
- Developing protocols to prevent overdoses in emergency rooms
- Crackdown on the counterfeit drug industry
- Combat opioid-related infectious diseases such as Hepatitis C
- Curtail illegal drug importation
The allocated funding from this bill, along with that provided by the 21st Century Cures Act, provides more than $500 million per year for the states to address their own addiction crises. However, experts argue that even this amount may not be enough to fully address the scope of the issue. States will need to take a careful look at what kinds of policies and measures are most effective in addressing addiction, which they can do by following case studies, listening to research, and broadening their approach. Here are some of the most effective ways that states can use federal funding to support drug and alcohol recovery.
Enforce Parity Laws For Health Insurance and Behavioral Health Care Providers
In short: Conduct continual analyses into insurance provider compliance with mental health and SUD parity laws, as well as network adequacy in addressing these issues. This includes enforcement actions for non-compliant companies, re-examinations, and follow-up to ensure that proper steps are taken.
Mental health and SUD parity laws prevent group health plans and health insurance issuers that provide mental health or substance use disorder (MH/SUD) benefits from imposing less favorable benefit limitations on those benefits than on medical/surgical benefits. In other words, to provide the same level of benefits for mental and/or substance use treatment and services that providers do for medical/surgical care.
In Pennsylvania, as part of a statewide, coordinated effort to address the opioid epidemic, the PID (Pennsylvania Insurance Department) has actively been combing through benefit packages, prior authorization policies, and cost sharing obligations in order to ensure that marketplace providers are properly following mental health and parity laws. Since they began auditing, they have found several significant parity violations and are in the process of correcting these instances and mandating exams for all leading insurers to pass.
SUD treatment is an essential health benefit under the Affordable Care Act applying to individual and small group (1-50) coverage, and in Pennsylvania, the PID are digging into the all biggest insurance providers in the state to develop new templates and tools to uncover parity violations and enforce standards. The process works as follows: The PID conducts an examination to determine whether the company is in violation of parity standards. If so, the company must agree to a corrective action plan and in some cases pay a civil penalty.
As the PID moves forward, it continues issuing re-examinations to make sure companies have taken the corrective actions. In some cases, insurance providers could also be unable to provide adequate coverage for patients in need. By conducting continuous analyses on insurance providers with a special eye for substance use disorder treatment, the state will be able to provide stricter oversight and better coverage options.
Expand MAT Support
In short: Reduce cost sharing as much as possible for MAT and eliminate prior authorizations for time sensitive access to vital medications. Expand access to treatment providers that provide behavioral health, MAT, and SUD treatment.
Although MAT, Medication Assisted Treatment is one of the National Principles of Care for Substance Abuse and endorsed by all major government health agencies and experts in the field, it is still widely stigmatized and underused in the medical profession. A Blue Cross Blue Shield study found that while the rate of patients diagnosed with an opioid use disorder between 2010 and 2016 increased, the rate of those receiving MAT did not grow at a comparable rate.
A comprehensive 2012 study on MAT found that treatment of opioid abuse with MAT was associated with increased retention rates, reduced mortality, improved social function, and decreased drug use and improved quality of life.
Despite strong evidence that MAT is one of the most effective forms of treatment for patients with SUDs, there are still strong barriers to MAT that persist such as: stigma, inadequate provider networks, high cost sharing, and prior authorization requirements.
In Pennsylvania, the state government has taken several steps to increase MAT access and efficacy. They have brokered agreements with commercial insurers and Medicaid managed plans to eliminate prior authorization for MAT. They have also encouraged and in some cases required SUD providers to offer MAT treatment in order to receive funding from the city.
In Vermont, the development of a more robust care system incorporating MAT has proven to be effective in reversing the overdose rate. In the early 2000s, the state didn’t have any MAT programs to speak of, but now the state’s primary addiction treatment network is built on MAT, with the understanding that addiction, just like any other disease, may require medications to treat it.
Vermont offers what it calls MAT teams. These teams are made of one nurse and one behavioralist to handle the extra workload that comes with an addiction patient, while the primary doctor or nurse practitioner focuses on treating the condition itself. MAT teams can provide an extra level of accountability for patients, ensuring that they are seeing a therapist, staying sober, and submitting pill counts.
Part of Vermont’s MAT support also comes in the form of efforts to get more providers to prescribe medications for opioid addiction. The state has partnered with the University of Vermont Medical Center to train more providers so they know how and when to prescribe buprenorphine.
According to figures from the Centers for Disease Control and Prevention (CDC), the drug overdose death rate in New England was about 30 per 100,000 people, whilst Vermont is below the regional average at only 23.
Increase Naloxone Availability
In short: increasing access to Naloxone for healthcare providers, first responder, and community organizers in order to significantly reduce overdoses.
Massachusetts and many other states have established a standing order for naloxone. In Massachusetts, the number of opioid related overdose deaths among residents as already leveled off significantly. More than half of the 50 U.S. states now have naloxone standing order programs. These programs have gone a long way to increasing distribution of naloxone and saving lives from overdose. For example, in North Carolina, prior to using a standing order model, in 2012, outreach workers for the North Carolina Harm Reduction Coalition (NCHRC) distributed 201 vials of naloxone and recorded 30 reversals. In 2015, under a doctor’s standing order, they distributed 15,879 naloxone doses and recorded 1,547 overdose rescues. You can see NCHRC’s standing order document here.
Pennsylvania has issued a statewide standing order to increase naloxone access and increase public support for initiatives that place more naloxone in the hands that need it. According to the Centers for Disease Control and Prevention, nearly 5,400 Pennsylvanians died of a drug overdose in 2017, making it the nation's leader in total fatal overdoses. “Stop Overdoses in PA: Get Help Now Week” is part of a new statewide effort to help reverse this trend and is using $5 million in state budget funding to provide free naloxone kits at over 80 locations in the state. In addition, the state has eliminated restrictions on the number of naloxone prescriptions that a consumer can fill in both Medicaid and commercial products. They have also required Medicaid managed care plans to work with providers to prescribe naloxone when they prescribe opioids.
In short: Expand efforts in emergency departments and within law enforcement to coordinate patient referrals to treatment providers.
Emergency departments and first responders often encounter patients who have overdosed or need medical services related to drug addiction. Working in tandem with several agencies, the Pennsylvania Department of Drug and Alcohol Programs has created “warm handoff” protocols for emergency department doctors. Instead of simply providing overdose victims with lists of resources, they now actively contact drug and alcohol counselors to meet with individuals while they are still within the ED and direct them to treatment.
Similarly, law enforcement can act as referral sources for individuals in need. The Angel Initiative is a program started by the Kentucky State Police in 2016 with one goal in mind: to save lives. Under this initiative, anyone battling addiction in Kentucky can come to Kentucky State Police Stations and get help finding a treatment center, no questions asked. Individuals can call ahead or arrive at one of 16 KSP posts across the Commonwealth and meet with an “Angel” who will help refer them to treatment centers and health professionals.
Invest in Alternative Pain Management
In short: improve insurance coverage and patient accessibility to alternative pain management options.
One possible answer to the dilemma of responsible pain management and withdrawal could be neuromodulation, also known neurostimulation. This type of technology works by sending electrical currents that interrupt pain signals in the brain, effectively relieving pain.
The Neuro-Stim has been used by rehab clinics in 30 states to help people with withdrawal symptoms associated with opioids. The Neuro Stim Bridge is attached directly to the skin behind a person’s ear and sends electrical pulses that disrupt pain signals being sent through the brain. For recovering addicts, detox from substances like opioids, benzodiazepines, and alcohol can be a significant barrier to getting sober. In one clinical study on patients undergoing opioid withdrawal, subjects experienced a pain reduction of more than 30% within 30 minutes of using the device. After using the device for a period of five days, 88% of patients successfully transitioned to the next phase of their program.
Alternative medications options can also prove useful for mitigating and relieving pain. When evaluating the efficacy of alternative pain management strategies, many pain treatments, including acetaminophen, NSAIDs, tricyclic antidepressants, and massage therapy, are associated with lower mean and median annual costs compared with opioid therapy. COX-2 inhibitors, SNRIs, anticonvulsants, topical analgesics, physical therapy, and CBT are also associated with lower median annual costs compared with opioid therapy. Pennsylvania’s Medicaid program reviews Medicaid coverage policies in the state to ensure that alternative pain treatments are available.
Enhanced Prescription Drug Monitoring Programs
In short: Fund robust prescription drug monitoring programs to ensure that doctors are not over prescribing painkillers.
PDMP or the Prescription Drug Monitoring Program is a tool that states can use to address prescription drug diversion and abuse. Each program differs from state to state, but the general idea is that you have a database tracking prescriptions to potentially identify patients who may be doctor shopping, doctors who may be over prescribing medications, and patients who could be being co-prescribed medications. If a state requires all its operating physicians to consult the PDMP before prescribing medication, it could potentially reduce the risk of abuse and dangerous co-prescriptions.
Studies on states that implement PDMP’s show that they have reduced opioid prescription rates by 8% and opioid overdose deaths by 12%. Data from the CDC looked at prescription rates nationally and reported that opioid prescriptions rose 10% from 2006 to 2010, and decreased by more than 13% from 2012 to 2015. Examinations of prescription lengths showed that patients were at risk for abuse after using them daily for more than five days, and were more unlikely to discontinue after using for more than 90 days.
There are 29 states currently using PDPM strategies to reduce the risk associated with prescription drug abuse. Over the past decade, more states have succeeded in implementing Prescription Drug Monitoring Programs, which may have played a part in the reduction of opioids prescribed since 2010 which is down to 640 MME’s (morphine milligram equivalents per capita) from 782. While this shows that the tide has been halted, it’s still a far cry from reducing the nearly triple sized number of opioid prescriptions we have now compared to 1999. Another sobering statistic to remind us of the severity of this problem is that the United States opioid prescription rate is nearly four times higher than the amount distributed in Europe.
Currently, opioid prescriptions vary widely across the country, with the highest prescribing locations doling out opioids at nearly six times the rate of other areas. The highest associated risk factors associated with higher prescriptions rates are a more significant percentage of non-Hispanic whites, a higher prevalence of diabetes and arthritis, higher unemployment, and higher Medicaid enrollment.
Reduce Opioid Prescriptions Without Cutting Off Patients
In short: While it’s important to limit the amount of pills in the marketplace, it’s also important to ensure that patients are carefully tapered down from high dosages of medication.
Currently, the United States is the leading nation in the world when it comes to opioid prescriptions. Although we have just 4% of the world’s population, we account for roughly 27% of the world’s drug overdose deaths and over 3% of our population has misused an opioid painkiller at some point, more than twice the rate of any other country. We also consume roughly 30% of the world’s opioid supply.
While rates of prescriptions have been curved downwards since 2010, there still hasn’t been a significant change in overdose rates or in American’s reported levels of pain. Research even suggests that opioids may cause more harm than good in the long term, with people developing tolerance rather quickly and facing the negative health consequences of severe dependency. As pain relieving effects grow more diminished, the odds of addiction and overdose increase.
One comprehensive study on the long term effects of opioids on pain outcomes found that patients on these drugs did not have better pain outcomes than those who avoided opioids. The study lasted for over a year and followed individual patients closely, something that typical trials conducted by opioid manufacturers neglected to conduct.
Another study published in JAMA found that roughly 40 to 70% of opioid tablets given to surgical patients wind up going unused. Published in 2017, this study shows how lots of extra pills can wind up in the hands of friends and family members, whether through being sold, stolen, or given. Cutting back opioid prescriptions for surgical patients and other individuals who may wind up with unused pills is a first step towards reducing pill diversion.
Even now, lawmakers are passing legislative measures that put caps on the number of days that opioids can be prescribed for, limiting prescriptions to within certain time frames and requiring recurring face-to-face meetings in order to refill on prescriptions. My creating an extra hurdle to get opioids, this will hopefully cut down on excess medications and discourage individuals attempting to take advantage of opportunities.
Andrew Kolodny, an opioid policy expert at Brandeis University, believes that laws must tread a careful line when it comes to restricting prescriptions: “The idea is not to constrain decision making, but to make it a little harder for doctors to casually over-prescribe.
Some of the highest risk individuals for opioid addiction are those who have just run out of prescription medication and those who still suffer from chronic or debilitating pain. This is why doctors should never abruptly cut off patients who are on opioids. These individuals would be left with crippling pain and withdrawal symptoms that may push them towards acquiring cheaper, illicit drugs.
Patients may not even be addicted a first. They may just be dependent on these opioids because they had been prescribed them for so long. In the case of addicts, the solution is straightforward: get them into treatment. But for the average patient who becomes dependent on these drugs, the line may not be so clear. They could even start turning to street drugs because they see it as continuing treatment for their pain.
Some low dose patients on opioids may be fine staying within their current prescription limits, but anyone given a high dosage is at risk for potentially dangerous consequences. That risk goes up when they are suddenly cut off from their supply. This is why tapering may be a safer and better option. According to Dr. Anna Lembke from Stanford Medicine however, doctors don’t have any experience with this part of treatment.
A forced taper may be difficult for a patient to undergo, but history has shown that it can ultimately be for the best. Lembke points out that patients usually report less pain after the period they have tapered off opioids, likely due to the fact they are no longer experiencing withdrawals but also because of diminished opioid-related hyperalgesia, where opioid use heightens the user’s sensitivity to pain.
There are numerous evidence based policies that can help curb drug addiction within the United States. The federal funding provided by the comprehensive opioid legislation passed this year can serve as the foundation for stronger and more effective efforts at stemming the tide of addiction. However, it will take decisive action to begin implementing plans on the scale needed to fully address this crisis. Stay tuned to the Landmark blog for more stories on the latest trends in drug treatment as well as informational resources for the disease of addiction.