AMA Advocacy Insights webinar series: Strategies to address the drug overdose and death epidemic

Webinar (series)
Strategies to address the nation’s worsening drug overdose and death epidemic
Dec 12, 2023
Virtual

The 2023 AMA Overdose Epidemic Report (PDF) finds that—despite positive actions from physicians, growth in harm reduction services and policy advancements—the nation’s drug overdose and death epidemic is deadlier than ever. The annual report details many of the reasons the epidemic persists, largely due to illicitly manufactured fentanyl and the continued lack of meaningful implementation and enforcement of policies that support affordable, accessible and evidence-based care for patients with substance use disorders or pain.  

Learn more in this webinar about policy actions that need to be taken, harm reduction strategies that should be implemented more broadly, and efforts by physicians and the AMA Substance Use and Pain Care Task Force to end the epidemic. 

Moderator

  • Jesse M. Ehrenfeld, MD, MPH, president, American Medical Association 

Speakers

  • Bobby Mukkamala, MD, chair, AMA Substance Use and Pain Care Task Force 
  • Daniel Blaney-Koen, JD, senior attorney, Advocacy Resource Center, AMA 
  • Jennie Jarrett, PharmD, director, science and drug policy, AMA

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Dr. Ehrenfeld: Thank you for joining us this afternoon for our latest in the AMA Advocacy Insights webinar series. I'm Dr. Jesse Ehrenfeld, president of the American Medical Association. I'm also an anesthesiologist in Milwaukee, Wisconsin. And it is my pleasure to be your host today for this important discussion about the nation's drug overdose and death epidemic.

Now, much of our attention has been focused over the pandemic, the last three years. And so many of our friends and colleagues answered that call. And while our nation continues to be plagued by a serious drug overdose epidemic that is destroying communities and families. In fact, the drug-related overdose epidemic today is deadlier than it has ever been in America. And that's why a webinar like this one is so important, well, our continued advocacy is so critical, and why the AMA and physician advocacy is essential to providing evidence-based solutions that are going to improve outcomes and save lives.

Our 2023 AMA Overdose Epidemic Report, released just last month in November, details many of the reasons why this epidemic persists. While opioid prescriptions have decreased for the 13th consecutive year, overdose and death related to illicitly manufactured fentanyl, methamphetamine and cocaine have only increased.

Xylazine and other toxic synthetic adulterants present new challenges. In 2022, more than 107,000 people died from a drug-related overdose in the United States. And data shows that the epidemic is increasingly impacting young people and those who are pregnant, as well as Black and Brown communities.

The report highlights that the physician community is working on multiple fronts to remove barriers to providing evidence-based care for patients with substance use disorders and pain. Progress in reducing deaths, however, has been incredibly difficult due to a combination of factors, including the increasingly dangerous illicit drug supply contaminated with fentanyl and other toxic substances. The continued stigma faced by individuals with a substance use disorder and the fact that health insurers year after year continue dragging their feet and are just not stepping up to help patients access evidence-based care.

There have been some signs of progress this past year, notably community-based distribution of naloxone by leading harm reduction supporters and an important approval by the U.S. Food and Drug Administration of over-the-counter naloxone, which the AMA has long championed. Naloxone dispensing has increased more than 200% since 2018. And access to opioid overdose reversal medications continue to save tens of thousands of lives.

Now, we're at a point in our country where naloxone needs to be available as easily as a first aid kit or a defibrillator in public spaces. And while we continue to study and address the underlying factors that contribute to substance use disorders, policymakers must look at additional evidence-based, harm-reduction strategies to combat the skyrocketing number of overdoses. If it wasn't for naloxone, it is likely that tens of thousands of additional sons, daughters, husbands, wives, friends, neighbors and colleagues would die each year.

But we need more than just naloxone. Without action on the policy recommendations in the AMA report, the epidemic will continue to harm and kill Americans. Today, our expert panel will provide additional data, AMA efforts and state policies, but also talk about the gaps that hinder us from making meaningful and sustained progress. I want to make sure we leave some time for questions and get to all these important issues, so let's go ahead and dive in.

I'm so honored to introduce our panel of experts. I've got Dr. Bobby Mukkamala, an otolaryngologist, head and neck surgeon in Flint, Michigan, former chair of the American Medical Association Board of Trustees. He is current chair of the AMA Substance Use and Pain Care Task Force, former chair of the AMA Council on Science and Public Health, and former chair and former president of the Michigan State Medical Society board of directors.

Dr. Mukkamala is a passionate advocate on a range of public health issues, including the city of Flint's nationally publicized struggles with high levels of lead in their water. There, he chaired the Community Foundation of Greater Flint, and he is also a recipient of the AMA Foundation's Excellence in Medicine Leadership Award. Welcome, Bobby.

We also have Daniel Blaney-Koen. He is a senior attorney with the American Medical Association Advocacy Resource Center. In this capacity, he works with state and specialty medical societies on state legislative, regulatory and policy advocacy work. Currently, he focuses on state legislation and policy concerning the nation's overdose epidemic, with a particular emphasis on overdose prevention and treatment. Daniel works on issues to support physicians and other health care professionals seeking care for mental health and wellness, and he covers other pharmaceutical issues and related insurance market reforms. Welcome, Daniel.

We also have Jennie Jarrett. She's the director of Science and Drug Policy at the American Medical Association. She's a clinical pharmacist and research assistant professor in the Department of Pharmacy Practice at the University of Illinois Chicago College of Pharmacy. After years as a family medicine clinician and physician educator, her current work focuses on workforce development and health policy, specifically to maximize interprofessional primary care teams to improve patient care for vulnerable underserved populations with substance use disorders. Welcome, Jennie.

So let me drive into the panel, and I want to start with Dr. Mukkamala. I mentioned the recently-released 2023 AMA Overdose Epidemic Report in my opening remarks. Before we go into some of the details, can you tell us about the overall findings of the report this year and the importance of this yearly report?

Dr. Mukkamala: Absolutely. Thanks, Dr. Ehrenfeld, for that fantastic introduction and where we are today with it. So this report is the latest in a series that seeks to update the medical community and, frankly, the country at large on the opioid epidemic. And so overall, as you stated, we're not in a great place. The epidemic is deadlier than ever, and this is despite more than a decade of decreases in prescription opioids. And that's because this isn't happening in our patient care spaces. And it's not with our prescription pads. But it's in our communities, as you said.

So the driver of this currently isn't what's coming from the pharmacy. It's illicit fentanyl. It's heroin. It's cocaine. It's xylazine in this ever—I don't like to use the word evolving—I would say devolving state of this. And so the yearly report that you referenced is important because it details the current status of this epidemic and the changing nature of it.

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And so, just looking back at what's the output of this report and where we are today, when physicians needed to be thoughtful about opioid prescribing, that's where we focused. We went from the time that you and I remember well, where there were smiley faces in the ICU. And the frowning face was for a patient in pain, and the smiley face was for somebody whose pain was well controlled. Pain as the fifth vital sign, that era, to being more thoughtful about prescribing pain medication.

I, as an otolaryngologist, perform one of the more painful procedures of tonsillectomy. And there was a time not long ago that we would routinely prescribe patients for two weeks or longer of a narcotic pain medication just because that's what we were trained. And we became introspective about those habits, and what do patients really need? How much do they really use so there's not some sitting at home unused that could be diverted.

And so my own adjustment, after years of routine opioid prescribing, is something that a lot of physicians did when we were called upon to do that. But when illicit drugs became the concern, our focus was added to—I wouldn't say shifted because we continue to focus on what comes from our prescription pad and our pharmacies. But we added to that what's happening in our communities. When it became fentanyl-laced drugs or xylazine, the recommendations of our group changed to make sure that our focus was what was around the corner, so to speak, as opposed to what was in our rearview mirror.

And when harm reduction became—or is becoming another strategy, our focus evolved again. And naloxone access, needle exchange, so someone with a substance use disorder isn't also going to end up with hepatitis or HIV. Test strips to see what's actually in what's being used. When we know what the right treatment is but things like the red tape of prior authorization make doing the right thing difficult, that's when our advocacy arm ramps up to shine a bright light on the hurdles that we have to face.

When mental health disparity is a barrier is a barrier because our parity laws are just written but not followed, we call attention to that with statistics that show that 90% of people with a substance use disorder don't get treatment for it, right? And 50% of those with mental health issues in general don't get treatment. And so we need to eliminate those barriers, things that make it hard to do the right thing. Parity shouldn't just be a checkbox that a plan has and says, yep, we've got parity. Let's move on, right? It needs to be something that's demonstrated, and it's really not.

Dr. Ehrenfeld: That's really, really helpful context, and appreciate those statistics. What are some of the physician actions detailed in the report this year? And in that same vein, how does the work of the AMA Substance Use in Pain Care Task Force that you chair get folded into the report?

Dr. Mukkamala: Yep, yep, so physicians actions thus far have been very important, again, with that 50% reduction in opioid prescribing, a 60% reduction in morphine mill equivalents that are being prescribed, that's a dramatic difference. A 200% increase in PDMP use just in the past four years and a concomitant 200% increase in naloxone being dispensed, these are things that are physician driven. Increased training to prescribe buprenorphine, for example, advocacy to eliminate the X-Waiver, which we were able to accomplish.

And so this report and others from our task force, in combination with groups like Manatt Health, highlight what can and is being done in various communities. And there's really no need to reinvent the wheel—I've said that a lot—just because we can emulate the work that's being done across the country because there's plenty to emulate. Just one example, emergency departments that are not just saving lives anymore with Narcan but are immediately set up to help patients with the next critical step of being connected to treatment in their community to prevent the next close call, not just save the life.

And clearly, what we've done is great, but there's more to do. We've got to get comfortable as a physician community addressing substance use disorder. And just like—it used to be that when people had depression there was a generation of physicians that weren't comfortable treating that. But now, routinely, physicians are comfortable starting patients on treatment for depression. We need to get there when it comes to patients with substance use disorder.

Dr. Ehrenfeld: Makes a lot of sense. Jennie, let me bring you in here. So what are some of the key findings in the report related to public health specifically?

Jarrett: Thanks so much for having me. I think one of the first components of the report that are really critical to highlight here is just the harm reduction approaches that are being utilized or not being utilized well enough in our community. So harm reduction is a key component to saving lives and improving patient outcomes overwhelmingly. And that's not just through reducing opioid prescribing. That's not what saving lives is what we can see from the data in the report.

Number one, naloxone saves lives. We've been saying that from the AMA perspective and overwhelmingly in the medical community for years and decades. But I think it needs to be said again. Even with the 200% increase in the naloxone dispensing between 2018 and 2022, it's still just not enough. We need to go beyond the simply co-prescribing. Even though we're seeing increases in that co-prescribing, we need to go beyond that for a broader access across our communities to naloxone.

We should be prescribing naloxone to anyone at risk for an overdose, whether or not they're being prescribed opioids or not. There may be other risk factors that we can consider for prescribing naloxone. We need to be educating our patients that you can get naloxone over the counter. And having it is really useful in any setting. It's easy to use. It doesn't take a lot of education to use it. And so having it is really important. I think it's also important to have naloxone accessible in the community and even to have potentially students with it in school where we know there's high-risk patients who may need the naloxone.

I think secondarily from a harm reduction perspective is we need to be utilizing medications for opiate use disorder at a higher rate, or MOUD. That includes methadone and buprenorphine because we know those medications save lives. It's important that we would be utilizing these medications is just as critical as if we use an antihypertensive agent in a patient with high blood pressure. It's a chronic disease to have opiate use disorder. And so these medications need to be utilized at a higher rate.

I think we've seen challenges with the segregation of access of these medications, specifically with methadone from opioid treatment programs or OTPs. And that increases challenges for accessing these critical medications for our patients. Even though we are seeing and reporting here in our report that there's increased numbers of OTPs, which is helpful, there continues to be long wait times for some of the patients to access methadone through some of these programs.

I think innovative models are also ways that we're seeing critical access to these medications, specifically low threshold buprenorphine models. And that really has promise for increasing access to care. However, in this report, you can see, since 2020, we've really been stagnant at prescribing buprenorphine for patients and providing that access to them. So there's more to be done there.

I think we're seeing unique models of care that have potential for great opportunities, particularly with the new DEA regulations for mobile OTP programs, where you can access methadone and buprenorphine in the community by bringing it to the patients where they are.

I think number three, one of the critical components here is the safe use supplies that are important to reduce infectious disease and, importantly, overdose risk for our patients. Drug-drug checking supplies are an important component to reduce the risk of this overdose.

So fentanyl test strips, as well as newly emerging xylazine test strips are really important for people to understand better the potency of their products so that they can reduce their risk, whether that's using with someone or letting someone know or having naloxone on hand if they're using some type of opioid product. It's also critical for all the states to decriminalize these drug checking supplies so that patients can have access to these things to reduce their risk. I think that's really important.

I think, finally, syringe service programs are also a critical component for harm reduction. And these are more than just needle exchange programs. They're critical for the reduction of infectious disease risks. We know it reduces the risk of HIV, hepatitis C by more than two-thirds. That's incredible for our patients, as well as their trusted programs for non-judgmental support and resources. And they can also be a great bridge to some of these broader MOUD resources. So naloxone saves lives. Increased access to MOUD products. And finally, safe use supplies are really important harm reduction. That's highlighted in the report.

Dr. Ehrenfeld: Thanks for walking us through that, Jennie. Daniel, what are some of the policy considerations and recommendations that you think are worth noting from the report?

Blaney-Koen: Yeah, thanks, Dr. Ehrenfeld. I want to—some of the policy recommendations go back to what Dr. Mukkamala said. Part of the action that a state takes, it might be innovative for that state or it might be unique to that state, but somebody else has already done it. So for example, removing barriers to medications for opioid use disorder.

It's important that we have a policy in place, legislative and otherwise, to end prior authorization for medications for opioid use disorder. But it's equally important that state regulators and your department of insurance and, to the extent necessary, your state attorney general enforces that law. Payers say all the time that they've removed these policies, but physicians and patients tell us all the time that's not the case. So the policy is there, but we need to enforce the policy.

For example, we want to increase—go back to what Jennie said—we want to increase access to MOUD everywhere and new models. But one of the old models is that patients need to be able to pick up a prescription in a pharmacy. But as many as half of pharmacies don't even stock naloxone for a variety of reasons, including stigma. So pharmacy chains need to step up and actually stock this lifesaving medication.

We talked about removing barriers to medications for opioid use disorder. One of these also is in the law. Not all policies have to be legislative, as I mentioned for pharmacy stocking. But some do need to be legislative. So let's allow addiction medicine physicians and addiction medicine specialists prescribe methadone in the community. And there's a federal bill that would enable us to do that.

Other policies, we also need to protect patients with pain. Dr. Mukkamala mentioned the significant, some might say, dramatic decreases in access to opioid analgesics. In 2016, the CDC issued a recommendation with arbitrary thresholds. This is the total amount that a patient should be able to receive for pain. And physicians answered that call, surgeons of all types, family medicine physicians, internal medicine physicians have taken a second look and a third look at their prescribing practices.

But on top of that, patients who benefit from opioid therapy also have seen dramatic reductions, non-consensual tapering policies, or cut off altogether. So in 2022, with the AMA support and support of patient advocates across the country, CDC revised those guidelines and removed all of those thresholds. And this is really important to emphasize.

Almost 40 states have policies on the books that use the 2016 guideline. Today, the AMA has urged all of those states to remove those policies. The CDC changed because patients were being harmed. Now, we need states to follow suit. Only two have, Colorado and Minnesota. And the state toolkit that Dr. Mukkamala referenced, that I put into the chat, has examples of some of those policies.

Also, the policy that can really help, states are awash in millions of dollars in opioid litigation funds. Let's go ahead and spend that on evidence-based opportunities. We know what happened with tobacco litigation funds. Money was not spent on public health activities. With the opioid litigation funds, let's work to actually spend those on public health initiatives.

Let me give you a couple of examples. If we want to increase access to addiction medicine services, we need to train the next generation of addiction medicine physicians. One way to do that is for universities to hire core faculty in addiction medicine and/or addiction psychiatry. We can't train the future generation of physicians if there aren't physicians to train them in those specialties. Opioid litigation funds can hire addiction medicine and addiction psychiatry physicians.

And this isn't in the report, but there are great examples of physicians who are building outpatient clinics through hospitals and health systems. That needs the commitment of hospitals and health systems to build those outpatient clinics. And you can't build those outpatient clinics if you don't have addiction medicine and addiction psychiatry physicians on staff, as well as numerous support staff, such as pharmacists, peer counselors, social workers, nurses.

So it's a team-based approach that can be done. And I want to emphasize again, states don't have to figure all of this out on their own. They can use these resources that are in the report and that are in other AMA resources to provide those best practices. The AMA didn't come up with them. We're just analyzing what's happening around the country to be able to share that with everyone.

Dr. Ehrenfeld: So Dr. Mukkamala, let me come back to you. Do you think there's anything that's being oversimplified or something maybe that's misunderstood about the epidemic, either in the media or in the eyes of the public?

Dr. Mukkamala: Yeah, it's a great question, Dr. Ehrenfeld. And I guess one thing that comes to mind when I hear that question is somewhat the assumed automatic nature of knowing what the right thing to do is when a patient comes in with a substance use disorder and being able to do it because that's not what happens, right?

If the understanding is, OK, when somebody comes in and says, I'm ready for treatment. Let's do it. The reality is, the answer is, OK, I'm so glad you've come to me in this moment. Let me go ahead and apply for prior authorization for you to address your pain issues. And I'll call you back in a couple of weeks, and we'll get you started, right? That is just a terrible situation to be in given what it takes for somebody with a substance use order to get to that moment, right? It's just—it's an opportunity lost.

And then the other thing that comes to mind with that question is there just remains a wide spectrum of perception and understanding of substance use disorder and how to manage it. And that wide spectrum means that, when we are in conversations about how to address it, the nature of that conversation is going to vary. When we're in a group of physicians, as we are today, talking to health care workers that are seeing patients with substance use disorder daily, it's a very different conversation than the one we have when we're talking to lawmakers and law enforcement about how best to handle this issue.

And one misunderstanding that impedes progress in this is that many still think that this is a bad choice, right, that this is something that—that using illicit substances is a moral failure. But we need to get past that. I talk a lot about looking forward to the day when treatment of a substance use disorder is readily available just like it is for the treatment of diabetes and cancer.

And so this is, I think, where we need to get. And so there's still a misunderstanding, in the general public for sure, but even within the diaspora of the million physicians in this country about how to approach these patients.

Dr. Ehrenfeld: Makes a lot of sense. Jennie, Daniel, what do you all see as next in terms of advancing policy, next steps on this issue?

Jarrett: Yeah, think it's critical to build on that discussion of we have to know where we are before we can move forward. And how we're approaching patients is a really critical component of that. And as we're thinking, as Daniel mentioned, about training the next generation, we have to understand that there were potential missteps in how we were trained initially and that we have to, first of all, train ourselves to make sure that we're ready to support these patients but also meet the patients where they are, and recognizing that there is a broad spectrum of treatment goals for these patients.

Historically, it looked at abstinence as the only treatment goal for a patient with a substance use disorder. But we recognize that abstinence is not the only treatment goal. And by focusing only on abstinence as the treatment goal for our patients with substance use disorder or opiate use disorder, we actually can cause harm in those patients potentially.

We know that if patients are reducing their use and having safer use, they have improved outcomes. And so again, thinking about the spectrum of our treatment goals and, as we approach patients, letting them understand where their goal is as how we want to support them to help them have better outcomes and save their life is really important.

So physicians and the health care team can provide support to patients by continuing to care for patients even if they're using substances. Oftentimes, we're finding many health care entities out there won't necessarily take patients who are continuing to use substances. And they need to be abstinent. And so growing that spectrum of treatment goals and still providing support for patients, even if they continue to use, that potentially might be a part of their goal. And so making sure that we're continuing to see those patients.

Dr. Ehrenfeld: Thanks for those comments on harm reduction. Let me just ask because I think there's a lot of misunderstanding. Is there good evidence for overdose prevention sites? Is there good evidence for the efficacy of a needle and syringe exchange program?

Jarrett: I think that's a great question, Dr. Ehrenfeld. I think the evidence for overdose prevention sites is growing. We know that not a single person has died at an overdose prevention site, and I think that's a positive outcome that we're seeing. There's also no evidence of increasing crime with overdose prevention sites. And I think that's a positive benefit of those sites.

We also know that an overdose prevention site can increase access to these harm-reduction supplies that we know save lives, including syringes and test strips. And finally, they're really highly regulated entities to ensure the public safety and public health more broadly. This is a great opportunity, I think, as we're learning more about overdose prevention sites, to get more information and potentially expand to determine what the best practices are.

Dr. Ehrenfeld: Right. So Daniel, let me come to you. What's next steps? How do we advance policy? What policies do we need to accomplish some of these public health solutions that Jennie and others have talked about?

Blaney-Koen: Thanks, Dr. Ehrenfeld. Yeah, one is let's recognize that some of these policies might make us uncomfortable. But we want to try to stop people from going to so many funerals. I think that those also make us uncomfortable. So overdose prevention sites, for example, there are states that are considering them. And they're having really detailed discussions. There are two that are operating in New York. There's one that's operating, or about to start operating, in Rhode Island. Let's have some further study to identify the public health benefits that we think that we're going to see from them.

At the same time, physicians find uncomfortable things all the time. You take your patients how they are. So for example, it makes people uncomfortable that if someone who is pregnant and they use substances. That is not a comfortable situation for anybody. But the medical and public health perspective is let's treat that individual. Let's accept the fact that we want to ensure a healthy pregnancy and a healthy baby. And so then let's take the evidence-based, there's good medicine and good medical practice to do that. Stigma should not enter that equation.

There are, for example, receiving medications for opioid use disorder is a constitutional right if somebody is in jail or prison. We're thankful that there are many in law enforcement who agree with that. We're thankful that the Department of Justice—which gets a bad rap on a lot of this—but the Department of Justice is enforcing those constitutional protections. And that's a fabulous thing.

We need state attorneys general to enforce those constitutional protections at the state level. Some are doing it. Some could do that a little bit more. So in terms of policy, we have lots of legislative opportunities. But policy and advocacy doesn't have to happen just at the legislative level.

Dr. Ehrenfeld: Well, thanks for that. We are starting to get a flood of questions coming in through the Q&A. So let me encourage folks who are dialed in to put your questions in. And I think we're going to turn to those now because we've got a bunch of good ones, and I want to make sure that we get through as many as we can.

The first question I've got, let me send this to Dr. Mukkamala. How do we fight opioid overprescribing while not harassing pain doctors for their prescribing? As in, how do we monitor the amount of opioids in circulation while making sure that pain doctors can prescribe patients the medications that they genuinely need?

Dr. Mukkamala: It's such a great question because the nature of my practice is going to be different than the person that's across the street from me. It's going to be dramatically different from somebody that's in the practice of managing patients' pain. And so having a threshold that says, OK, if you have this many prescriptions, if you have this many morphine milliequivalents that you're prescribing, it's going to alert and then prompt an investigation is just a very inappropriate way to assess them.

And so it should be an apples-to-apples comparison. It shouldn't be my morphine milliequivalents prescribed relative to somebody across the street that's a pain management specialist that's taking care of patients that frankly need that care so that they're not looking for solutions to their pain elsewhere. And that's what we have to improve on because what we see in the headlines is going to dissuade people from doing what's absolutely necessary here, as Daniel mentioned, which is taking care of patients with pain.

If the headline is that such and such a physician is being investigated because they are a standard deviation above the mean, but then the outcome of that investigation is, well, actually they're seeing patients from a 50-mile radius around Flint, Michigan, where I am, to take care of patients with pain, well, fine. Then there's not going to be a punishment. But just the scrutiny itself dissuades people from taking on that task which is so needed right now. So I think that's how we fight that is making sure it's an apples-to-apples comparison.

Dr. Ehrenfeld: Let me ask this next question to Daniel. We've heard about prior authorization, and somebody who's dialed in asks, is prior authorization a problem for medications for opioid use disorder? And what can be done to address this?

Blaney-Koen: Thanks, Dr. Ehrenfeld. It is a problem, and we know it's a problem because state and federal mental health parity and addiction market conduct exams—it's a fancy word for an investigative report. And those investigative reports detail over and over and over that health insurance companies use prior authorization to limit access to medications for opioid use disorder.

We wish they didn't. These are life-saving medications that have very little potential for abuse. And so the only reason that somebody would have prior authorization is to limit access. When somebody goes to the pharmacy and they face a prior authorization and that prior authorization requires a call to the physician, but if the physician can't be reached or if it's on a weekend and there's nobody to answer the phone, the patient then has to leave the pharmacy without access to the medication.

We would never do that for insulin. We would never do that for a medication to help prevent a heart attack. But for some reason, we accept the fact that health insurance companies continue to do this for people with a substance use disorder. And it has to be stopped. When somebody experiences that, whether it's a physician who has to fulfill a prior authorization or a patient who experiences it, the last thing they're going to do is to call the department of insurance. They want to find care. They want to find care.

And what happens, unfortunately, is that some people return to use. And they return to use of illicit substances. And there are too many examples of people who overdose as a result of that return to use. And that's the effect of this kind of prior authorization policy. So what can we do to stop it? We need enforcement.

One, we need health insurance companies to end the policies. They can do that on their own. We support state legislation to prohibit the policy. But if health insurance companies continue to violate the law, the only thing that's left is for departments of insurance and attorneys general to enforce the law. And that's where we are. And the general public needs to step up and say, this is not OK that we continue to allow this to happen. Laws are only as effective as they are enforced and followed by those that they're supposed to regulate.

Dr. Ehrenfeld: Thanks. Jennie, you had talked earlier about trying to take care to where patients are, meeting patients in their communities. This next question says, what can street medicine teams do to help with this problem?

Jarrett: That's a great question about street medicine teams. I think we have tons of evidence that there are definite pockets within our country of health care and pharmacy deserts where it's challenging for patients to access health care and medications more broadly. Street medicine teams are an excellent opportunity to come to patients and minimize that gap in distance for care. And specifically with those mobile opiate treatment programs, they can provide medications for patients right where they are.

I think, additionally, many street medicine teams will have peer recovery support, where patients—or an Indigenous person's model where they understand the community and some of the broader challenges that that community might be facing in accessing this type of care.

Dr. Ehrenfeld: Makes a lot of sense. This next question, let me start with Dr. Mukkamala, and then I'll go to Daniel. Thoughts on the recent spike in overdoses of pregnant women. What's going on? What do we need to be doing?

Dr. Mukkamala: Yeah, it's such a critical question because it's what's happening right now. The fact that overdose mortality has tripled over the course of the past few years in pregnant women highlights the importance of this question. And we have to do something about it. And as far as the root cause, again, I think it gets back to stigma, right? The fact that there's a lot of focus on punishment of the substance use disorder in somebody that happens to be pregnant, right?

That's not going to solve that problem, right? That's a medical condition, right? We don't punish somebody that ends up in diabetic ketoacidosis because the medical condition led to that crisis moment. We shouldn't punish somebody that has a consequence of a substance use disorder. That patient needs treatment.

But because of the stigma as it relates to pregnant women there's almost a fear of seeking that treatment. And so what happens? Overdoses and death. And so I think that's the root cause of the problem is having a separate standard to treat this medical condition of substance use disorder than we have for anything else, like cancer and diabetes. That needs to all be approached the same way. When a patient has a condition, whether that's diabetes, whether that's cancer, whether that's a substance use disorder, treatment is what's necessary for that condition.

Dr. Ehrenfeld: Daniel?

Blaney-Koen: Yeah, and Dr. Ehrenfeld, this is one area where some legislative change is going to be necessary in some states. In some states, if a pregnant individual uses substances, that is, by law, considered abuse and/or neglect. And those laws drive people who are pregnant to not seek treatment because they're afraid that they're going to be reported to child welfare services, that their children will be taken away from them. Or they're afraid that, even if they're using buprenorphine, that if they have a positive test for buprenorphine, child welfare services will initiate an investigation and take their children away.

Whether or not that's justified, the fear is real, and the fear drives pregnant individuals to not seek treatment. So state laws need to change to remove those penalties of automatic charges. Rather, what we support is let's put the decisions in the health care team. The health care team can treat individuals. Let's stop treating a substance use disorder as a de facto crime. And so help ensure that if somebody is pregnant and they use substances they can receive treatment. That's one thing.

The second thing is that—and we were very proud to do this. States can step up, and they can not prosecute individuals who use substances if they are pregnant. And that happens in states. And so rather than prosecute an individual for being pregnant and using substances, let's do all we can to encourage those individuals to receive treatment in a nonpunitive manner.

Dr. Ehrenfeld: Makes a lot of sense. So that question around stigma enshrined in state law is such an important one. Bobby, let me give you this next question, which is on that same theme. What can physicians do to help remove stigma around substance use disorder and treatment?

Dr. Mukkamala: Yeah, I think we can do a lot. And it starts amongst ourselves, right? I mentioned the diaspora of the million physicians in this country and where we are and the variable nature of where we are in helping patients with a substance use disorder. So one is just raising the level of understanding about the nature of substance use disorder that is something that needs treatment to eliminate that double standard that I referred to earlier.

But as we get more and more physicians that are understanding the nature of substance use disorder, we shouldn't have it compartmentalized where you need to have fellowship training in addiction medicine to do it, right? It needs to become more normal, where in medical school we are exposing students to patients that have a substance use disorder so we can improve the workforce's ability to deal with it.

And then we can go beyond the workforce and put ourselves in those conversations where stigma still exists in a big time way, law enforcement, the legal community, the communities in general to address the stigma there. So first, it comes with our own training amongst ourselves, and then taking that training into our communities to raise the level of understanding about what it means to have a substance use disorder. I think that's how we deal with the stigma.

Dr. Ehrenfeld: OK, and Dr. Mukkamala, I've got one more question. This is a two-parter. It's a long one, so bear with me. What's being done about doctors being prosecuted for prescribing FDA-approved opioids that are prescribed within the scope of their knowledge? And then it says also, what is being done for the chronic pain patient community who have been tapered significantly or taken off of medication altogether that in many cases allow them some function of their life?

Dr. Mukkamala: Yeah, so two pretty different questions there. I guess the first one about prosecution of physicians that are prescribing. Again, to make a blanket comment about all of those prosecutions is inappropriate because there's details that are missing from that question. But I think it might be trying to get to the point of physicians that are doing what they've been trained to do, which is to manage somebody's pain, but are being prosecuted because they are an outlier, as I mentioned, a standard deviation above the mean.

What's being done about that? It's frankly conversations like this so that we can understand what it means to take care of patients with pain, what the nature of a practice is that's doing it, right? So if I'm two standard deviations above the mean as an otolaryngologist for prescribing opioids, sure, maybe that needs some scrutiny, right? But if I'm a standard deviation or two above the mean of physicians in general but I'm a pain medicine specialist and I'm the only one around for 50 mile radius of where I live and patients are coming to see me to manage that pain and that's why I'm an outlier, well, that's a very different story.

And that's what we are, we're advocating for the defense of those physicians to do what they do best, which is to practice medicine. When they're under the scrutiny of law enforcement, whether that's the FDA or local law enforcement, that's what we need to say is, look at it for what's being practiced. Is it the practice of medicine that's reasonable? And defend that practice of medicine.

Dr. Ehrenfeld: Makes sense. Next question is for Daniel. What public health funding is available to curb the overdose epidemic?

Blaney-Koen: Thanks, Dr. Ehrenfeld. First of all, states always have annual appropriations. So these are for existing state programs, and that's a matter of political decisions in the states for the annual appropriations of programs and services. But I mentioned the opioid litigation fund, so let me give you five examples of where additional funding can help.

First, Jennie mentioned mobile units. And there are a growing number of good examples of mobile units, buses, vans, that can deliver buprenorphine and syringe exchange services directly into communities. So that is something that states could do and support now through the opioid litigation funds.

The second, more naloxone in public situations. As some products are over the counter and there are laws in states that allow for physician distribution, hospitals and health systems can purchase large quantities of naloxone using opioid litigation funds to distribute directly from emergency departments. That's the second thing.

The third thing, one of the big barriers for patients to get to opioid treatment programs for methadone for opioid use disorder is transportation. States could go ahead and fund transportation programs to alleviate some of those burdens, those transportation burdens, those childcare burdens on individuals who need to get to a methadone clinic on a daily basis. But they don't have the childcare fund, they don't have the childcare resources or they don't have the transportation resources to go there. So that's the third thing, transportation and childcare resources using opioid litigation funds to fund that.

The third thing, or the fourth thing, and I'll say this again. Hospitals and health systems can hire core faculty in addiction medicine and addiction psychiatry and pain medicine. We can't have effective programs if there aren't core faculty. They're out there. Hire them. Build that workforce. Help build that workforce.

And then the fifth thing, nonopioid pain care alternatives. These are more expensive. Physical therapy is more expensive than some pharmacologic therapies, and some pharmacologic therapies are expensive. So there are states that are building into budgets financial support for nonopioid pain care alternatives. These are areas that can be supported by states. Strongly encourage states to consider—those are just five. There are a lot of other options, evidence-based options that can help patients with pain, help patients with substance use disorders, and help reduce the burdens of harm reduction.

Dr. Ehrenfeld: All right, Jennie, so less than 10% of emergency departments today in the U.S. are prescribing naloxone or initiating therapy for patients with opioid overdoses. What steps as a system can we take to step it up in treating patients with substance use disorder who show up in emergency departments?

Jarrett: This is such an important question. We know that a patient who dies of an opioid overdose, on average, interacts with the emergency department six times before their death. There's six opportunities for their life to be saved by prescribing naloxone or prescribing medications for opiate use disorder.

We know when patients come into the hospital for a heart attack, it's protocolized. We know that patients are going to leave the hospital with aspirin, with a statin, with an ACE inhibitor. And that's a part of the protocol. Why are we not protocolizing this critical medication for a chronic disease that's a high-risk opportunity, I think, that this is a very large opportunity? And I think that health systems need to incorporate this in order to help to save lives.

Dr. Ehrenfeld: And then I've got a question for Dr. Mukkamala. Will the AMA be pushing back against the idea that physicians are primarily responsible for this problem and epidemic?

Dr. Mukkamala: Absolutely. As I mentioned in my opening comments, there was a time, based on our training, that we prescribed in a certain way, right, just like I talked about prescribing for two weeks of pain medication for people post tonsillectomy. That's something that we were introspective because it was called for to look at what we were trained to do, how we were trained and why that needed to change.

But that's yesterday's newspaper. That's five years ago's newspaper. That's not what's driving this issue now. And so I wouldn't say it's pushing back on the idea. But what I'm saying is that that's old news, right? What's driving this isn't what's coming from my exam room. It's not what's coming from our operating rooms. It's not what's coming from our health care systems. It's what's in our neighborhoods.

And so when somebody says that—when somebody is looking at my prescribing habits post sinus surgery and saying that has a lot to do with what's going on out there today, I'd say absolutely not, man. You're reading the newspaper from years ago. And what you need to be doing is listening to these conversations and seeing that it's not what's happening within the health care system. It's what's happening in our communities that needs attention.

Dr. Ehrenfeld: Makes a lot of sense. So let me throw this out to the group. How do we remove the responsibility from the patient to learn how to navigate this complex health care system as a prerequisite to accessing treatment? So the example given by the person asking the question is, I still see programs requiring patients to find an outpatient buprenorphine provider, make their own follow-up appointments, face weaning of medications prior to discharge. We wouldn't expect an emergency department patient to find their own specialist prior to discharge or an inpatient to find their own PC before leaving the hospital.

Dr. Mukkamala: I think that the metaphor is exactly on point, right? I say all the time that when somebody comes into the hospital with a broken bone, it's minutes to figure out, OK, who's going to address it? When's it going to be addressed? Putting them on the schedule, getting to take care of. God forbid they come in with something associated with a substance use disorder and then need treatment afterwards, right? People are waiting for days or weeks to find that sort of treatment.

And so that's obviously what needs attention. So how can we remove that responsibility from the patient to say, "Hey, look, here's a list of people. Go ahead and call them when we discharge you, and see if you can get plugged into treatment." That's not going to fly. That can't be the way we deal with this, right? We don't deal with any other medical condition like that.

And so I think it gets back to Daniel's point of using the resources that we have and the funding that we have to have the health care system be able to do more than just say to the patient, here's a list of numbers, and good luck, right? We need to have that warm handoff or that hot handoff, so to speak, so that people leave the hospital system, that inpatient setting, with a very defined plan to get treatment.

Jarrett: There's great opportunities at the state level that some states are doing. I know here in the state of Illinois, there's a 24/7 hotline that the state actually is funding to help support patients. They can call at any time and get access across the state of Illinois to get support. And so I think other states are using some of their opioid litigation funds for some of these great services. And with the changes in regulation and ability to use telehealth, it's an excellent opportunity to provide access immediately for patients, even if they're not just located right in your clinic.

Blaney-Koen: Yeah, let me build on that a little bit. And there are some hospitals and health systems in the country who use peer counselors or social workers or others to connect somebody to treatment, to have them in that facility. Sometimes, oftentimes, that requires the hospital administration to support having additional social work staff to be able to do that work. And that's a decision of the institution to make that financial commitment to have those individuals there.

The other thing here is that the responsibility—here, it's a wonky term, but network adequacy. And we talk about network adequacy. Every health plan in the country is required to have an adequate network of addiction medicine physicians for situations like this. But if they're not held to the standard of the law, and we know that they're not, then that's why it's so difficult to be able to access somebody upon treatment.

We would never expect somebody who has a heart attack, who presents in the emergency room with a heart attack, if they get treatment in the facility, we don't say, we don't give them a list of three cardiologists in the state and say, good luck finding somebody. No, there are connections to care. But we tolerate, for some reason, we tolerate that for somebody with a substance use disorder.

Dr. Ehrenfeld: Well, thanks for those comments. Before I close this out, let me just ask my panelists if you have any other closing thoughts, key takeaways, any other message that you'd like to leave with our listeners. And I'll start with Dr. Mukkamala.

Dr. Mukkamala: Yeah, thanks, Dr. Ehrenfeld. I guess, just again, looking at where we are with this, it's a moving target. And now it's moved to our communities. And it's driven by illicit drugs, like fentanyl, like xylazine. So we need to, one, make sure that we keep our eye on the ball and raise our level of understanding. And when you see a headline about xylazine, especially when you're in the medical community as a physician, we need to investigate what that is, right? We need to be curious about it because that is where this is going. And we need to raise that level of understanding.

And I would encourage our physician community to start having those conversations with patients. It's not enough just to check the PDMP and make sure that it's not a prescription-driven issue. But instead, ask the next follow-up question about illicit drug use. That should just be part of our normal conversation just like we ask about smoking.

When that becomes the normal way to take care of our patients, that's when we start to identify and then can be their advocate in dealing with things like prior authorization, like the criminal nature of this and pregnant women. So that's when we can become their advocate. It makes us a better physician when we can raise our level of understanding and then be that advocate for our patients.

Dr. Ehrenfeld: Thanks for that. Daniel.

Blaney-Koen: I hope people will leave here thinking, OK, I heard a lot of policies. I heard a lot of clinical ideas. I heard a lot of practical things we can do. I hope people leave with a commitment to do one of them, at least one of them. There are a lot of positive things that can be done.

The epidemic currently is terrible. It's wreaking just an unbelievably terrible toll on the country in communities everywhere. Everyone knows someone, if not yourself, who has been affected by this. But everyone can do at least one thing. And the AMA would absolutely be your willing partner to do that in any state legislature or any advocacy arena.

Dr. Ehrenfeld: Perfect. Great, and Jennie.

Jarrett: Thanks. I think that if the group leaves here with anything from me today it is that we should be meeting patients where they are. And there's lots of opportunities for harm reduction. And like Daniel said, commit to maybe learning about or implementing one of those things. And we know that that's going to save lives, and we know that's going to improve patient outcomes in the long run.

Dr. Ehrenfeld: Well, thank you all so much. Thank you to the audience for some great questions. And thank you so much to my colleagues for sharing solutions. As I think about what we've been hearing and talking about today with this epidemic, it's clear that this is happening in the context of a larger health care system. And the challenges that we have around navigating prior authorization, around getting patients the care that we know is evidence-based are only made harder because of stigma. And there certainly are things that all of us can do, regardless if you're a physician, a clinician, a health care team or just somebody who is in the advocacy space to make this easier.

I had an experience. Two weeks ago, I went to an anesthesia CME review course where I was asked to make some comments about policy issues. And I went to a session on managing patients who are on buprenorphine, who are on some of the medication-assisted therapy for opioid use disorder. And the presenter had an audience poll at the beginning of the session. And it was really, really interesting.

First of all, they asked some questions about perceptions around patients who have opioid use disorder. And it was clear that there's a lot of stigma in our ranks around taking care of these patients. And then the audience answered some questions about how hard it is to manage patients who are being treated for an opioid disorder. And there was a lot of concern about 'I have to manage these medications.' This was an anesthesia meeting intraoperatively, and the receptors are blocked. And what does it mean when someone's on buprenorphine?

And by the end of a 30-minute session, it was amazing how enlightened the entire audience was. And you saw this in the follow-up polling, that actually these patients are actually straightforward to manage when it comes to understanding how to take care of them, how to be an effective advocate and how to deal with any drug-drug interactions that come up in your particular area of practice. And that was really illuminating for me as somebody who spends a lot of time thinking about how we can make sure that our patients are getting the care that they need.

So the solutions that we seek aren't going to be found in any one session. But I'm so grateful for everybody who dialed in today because together we're going to continue working to make sure that we do our part to ensure that we reduce the challenge, the deaths and the scale of this epidemic. The AMA is committed to our advocacy in this space and we hope that you are too. Thank you all so much for dialing in, and thank you for your time and your support of our patients.


Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.

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