Watch the AMA's daily COVID-19 update, with insights from AMA leaders and experts about the pandemic.

COVID-19 August 7, 2020 update

AMA Chief Experience Officer Todd Unger talks with AMA experts and external health professionals about the nation's drug overdose epidemic and COVID-19.

Find out how the AMA is working with physicians to end the opioid epidemic in the U.S.

Learn more at the AMA COVID-19 resource center.

Speakers

  • Patrice A. Harris, MD, MA, immediate past president, AMA
  • Stephen M. Taylor, MD, MPH, ex-officio member, board of directors, American Society of Addiction Medicine 
  • Charles Reznikoff, MD, addiction medicine, Hennepin Healthcare

AMA COVID-19 Daily Video Update

AMA’s video collection features experts and physician leaders discussing the latest on the pandemic.


Unger: Hello, this is the American Medical Association's COVID-19 update. Today we'll be discussing the nation's drug overdose epidemic, and COVID-19. I'm joined today by Dr. Patrice Harris, AMA's immediate past president as well as a psychiatrist and former public health director in Atlanta. Dr. Harris is also the chair of the AMA Opioid Task Force.

Dr. Charles Reznikoff, who works in addiction medicine and internal medicine at Hennepin Healthcare and is an associate professor of medicine at the University of Minnesota in Minneapolis. Dr. Reznikoff also represents the American College of Physicians on the AMA Pain Care Task Force.

And Dr. Stephen Taylor, ex officio member on the board of directors of the American Society of Addiction Medicine, or ASAM, as well as an ASAM delegate to the AMA House of Delegates. Dr. Taylor is also the Medical Director of the Players Assistance and Anti-Drug Program of the National Basketball Association and the National Basketball Players Association, as well as Chief Medical Officer of the Behavioral Health Division of Pathway Healthcare in Birmingham, Alabama. I'm Todd Unger, AMA's Chief Experience Officer in Chicago.

Dr. Harris, the AMA Opioid Task Force recently published its 2020 Drug Overdose Report. What does the report tell us about the current state of the nation's drug overdose epidemic?

Dr. Harris: Well, Todd, I think the most critical and top line message is that the epidemic has grown more deadly. The overdoses and deaths are now fueled by illicitly manufactured fentanyl, methamphetamine, cocaine, and heroin. And I think it's also important to note that the number of opioid prescriptions has decreased 37%, in fact, from 2014 to 2019. So we really need to broaden our focus when it comes to overdoses and not just focus on opioids because we see them driven by other substances now.

Unger: Dr. Reznikoff?

Dr. Reznikoff: Yeah, it was quite interesting information in that report. And I think we all really saw that the rise of opioid prescriptions was linked to the rise of opioid addictions and death, but it doesn't necessarily follow that lowering opioid prescription reverses all the damage that was done. So an addiction once formed isn't cured by lowering the opioid prescription. And in fact, some ways, people are having their opioids discontinued abruptly might even put them at risk of harm. So the lowering opioids is a good thing, but it's not enough to treat the people affected by opioid addiction.

Unger: Dr. Taylor?

Dr. Taylor: And in fact, I think the point that, that leads us to understand is that the issue isn't so much an opioid epidemic as really an epidemic of the disease of addiction, which is not a drug-specific disease. And hence we see that there's not just a problem with opioids, but in fact, right on the heels of that, we see a problem with methamphetamine and a resurgence of cocaine use.

And, of course, those aren't happening in a vacuum either. And so we're seeing now that the overdose deaths are very often happening with people who've been using methamphetamine and then have had their drug that has been laced with fentanyl. And it's the synthetic opioids like fentanyl and its analogs that are causing many of the deaths. So what that tells us is that what we really need to focus on is, how do we get people treatment for addiction, for the disease of addiction in an ongoing way, treating this chronic potentially relapsing disease according to the model that is necessary for providing adequate treatment for people who have that disease?

Unger: Dr. Harris, what have physicians been doing to decrease drug-related deaths and are those efforts working?

Dr. Harris: Well, Todd, they are. And I hope the viewers recall that the AMA board of trustees convened the opioid task force in 2014 to first of all amplify efforts already underway by the physician community to address the opioid epidemic, but also to further coordinate and collaborate our efforts. And based on our initial recommendations, physicians have registered for PDMPs, those state database programs. Physicians have increased and enhanced our education around pain and around substance use disorders. And physicians have been working in partnership with others to reduce the stigma, not only around the diagnosis of a substance use disorder, but also help-seeking treatment. And I could not agree more. Again, we convened this task force for a specific focus, but it is absolutely critical for us to look at the issue of substance use disorders in total and not, and I mean the royal "we", not just physicians, and not just focus on one particular substance or drug.

Unger: Dr. Taylor?

Dr. Taylor: I'll piggyback on that because when we think of the AMA and the others with whom the AMA has worked, we in ASAM are among those others. I mean, we are also physicians, of course, but we've been very proud to partner with the AMA working on programs that have provided substance use treatment and some of the related social supports and teaching physicians and actually reimbursing physicians for providing the kinds of social supports that are needed to, to take care properly of patients who have substance use disorder. We have to remember that addiction is a sort of a multifocal disease. It's clearly a medical disease but it's impacted by so many factors in society that are contributing to this condition, including unfair access to housing and inadequate access to quality education and to jobs.

And all of that is part of what leads to people having difficulties that will very often contribute to substance use disorder. And if I may, I'll go on and say, given the time that we're in, it's worth noting that race comes into play here as well, because these very same factors that contribute to people of any color or any ethnicity developing a substance use disorder are also the factors that we see that disproportionately affect people in the African American community. And so the fact that we are working together with the AMA to help physicians to have an impact on these various factors and on patients affected by these various factors, I think is very important.

Dr. Harris: Yeah, sorry about that. I do have to also thank ASAM for their partnership and something that we probably haven't talked about enough, but the AMA and ASAM worked on a new payment model for these services. You know, if we are going to address globally, treatments and making sure that treatments are available for those who have substance use disorder, we are going to have to address the problem from soup to nuts, if you will. And part of that is addressing head-on issues around physician reimbursement and reimbursement for other services that may be required as part of treatment for substance use disorder.

Dr. Reznikoff: I really appreciate that. And AMA's advocacy around reimbursement reform has been critical and I think has been really important. I think we're, especially now with COVID-19, every health care institution in the country is under financial stress and every health care institution in the country is looking at what they need to cut, what they can cut, how they can make the budget work, and addiction programs are being cut. And it feels a little, I'm from Minnesota so I'll use an analogy, it feels like taking your snow tires off as winter approaches. I'm really worried about addiction services being cut. But we need payment reform, and we need our healthcare institutions in state and federal level to commit to this because COVID-19, believe it or not, will end someday. But complex pain and addiction, those will exist as long as human beings walk on this earth.

Dr. Reznikoff: And so we need to have a long-term commitment to treating those diseases. The one other thing I would say is the AMA Overdose Report showed 70,000 overdose deaths last year, which sounds awful. But there are 2.5 million Americans living with opioid addiction, and that's just opioid addiction. That means only 3% died last year. There's 97% are still walking around untreated, needing treatment, needing care. And we really need to mobilize to give best care to that 97% of people who still lived. Still living. 2.5 million Americans need help. And so we got a lot of work to do.

Unger: Dr. Reznikoff, can you talk a little bit about naloxone's role in that rate that you just mentioned?

Dr. Reznikoff: Yeah. Well, I mean it, to dovetail to the last point, the report showed 1 million naloxone kits were administered last year, which is amazing, but there are 2.5 million Americans at risk of overdose death.

And so we've come a long way with naloxone, but we need to keep going and extend that. If a provider gives 10 naloxone kits out to people with addiction, one of them is used to save a life. So that's a number needed to treat of 10. That is excellent by medical standards. So this is a very effective tool at saving a life. But it doesn't treat the addiction and it doesn't prevent the next overdose.

So it's a bridge to buy time, to get the person into proper treatment. So that said, naloxone has been a great advance for us, but it's not enough, and it's only a bridge. So it's a good thing. I don't want to diminish its benefit, but it's only the start.

Dr. Taylor: You know, another way to look at naloxone is that it is a type of tertiary prevention in a sense. Once the person's already had, or once the person already has the illness of addiction, what we then use naloxone to do is to prevent the most awful outcome of addiction, namely potentially deadly overdose. And I think that when we're looking at preventing overdose, one of the things that we also need to focus on is the population of folks who are incarcerated, because we know that a person who is returning to the community after having been incarcerated is 129 times more likely to suffer an overdose than the general population. So when we talk about uses of naloxone and how that can be used effectively, one of the key populations that you would want to target are those folks who are leaving incarceration, coming back into the community, because we know that's a high risk population.

And with any prevention intervention, you want to target those people who are at greatest risk. And so I feel as though that's something we need to focus on is those folks who are involved in the criminal justice system, not just when they are departing the criminal justice system, but also while they're in treatment.

It's also a very important thing to focus on to, to increase the access of patients who are incarcerated to be able to access physicians and to access care and to be treated while they are still in treatment. We know that that will decrease the chances of recidivism, the chances of relapse, after they return to the community.

Dr. Reznikoff: It is such a good point, and above that, it's just a human right to receive treatment for a medical condition, whether you're incarcerated or not. And we will look back on these days where we incarcerated people and then denied them treatment for an addiction as a real failing of our system and a real abrogation of their civil rights.

Unger: Dr. Harris, based on the report, what else needs to be done to end this epidemic?

Dr. Harris: Well, certainly we need all partners engaged and involved, and the AMA has been urging that the payer community engage in this. And certainly we want to make sure that all arbitrary barriers, all barriers are eliminated to evidence-based pain care. And we know one of those barriers is prior authorization. We've seen some movement on that in this stage, but we need all insurers in all states to look at whether or not there are these barriers of prior authorization. The other issue is around parity, and we urge all payers, all of the insurers, to do an internal audit. We certainly want the insurance commissioners at the state to do one as well, but the payers can start by doing an internal audit to make sure that they are complying with any federal or state parity laws. And I would say meaningfully comply, right? Because we have so often sometimes compliance, I call checkbox compliance. It's the bare minimum. And it ultimately doesn't get the best care to patients so they could have the best outcomes. So we really want that compliance to be meaningful.

Dr. Taylor: And yet another way that, I just can't miss this opportunity to point out, yet another way in which we at ASAM have been privileged and pleased to partner with the AMA is around this whole issue of third party payers. Because in fact, we have been able to work with the AMA to, and I'll give the specific case in the state of Colorado, to get the insurers there to adopt the ASAM criteria for assessing the patients' medical necessity and the level of care that patients require.

And we know, if left to their own devices to do that, third party payers, insurers will very often just do what works best for the bottom line, but because we've been able to work with the AMA in Colorado to get a law passed that requires most third party payers to use the ASAM criteria, we've now got a system in place there, at least in that state, and this is certainly something that can be replicated elsewhere, wherein patients' needs are what determines the level of care that they receive when they are getting addiction treatment. So that's an example of a very specific way in which we've been able to work well with the AMA to get insurers to do what's really going to benefit patients in terms of getting them treatment for this disease.

Dr. Reznikoff: Yeah, Dr. Harris made a reference to pain treatment as well. And I just wanted to call that out. The AMA has been really out front advocating for multidisciplinary pain teams and that's really the future of treating pain. Unfortunately, I worry that with the financial stress that the healthcare system is under, they're looking at "Who do we furlough, the cardiologist or the acupuncturist?" And they're making these false choices where really important members of the multidisciplinary pain team and safe, appropriate treatment of pain is being cut for financial reasons. So I worry that just as we're starting to establish our multidisciplinary pain teams, they're going to be cored out by the financial stresses we're facing.

So I do think it's important to double down on the multidisciplinary, not just opioids; every treatment we can offer patients who are suffering in pain, to get them feeling better, living better, functioning better. We got to keep our focus on that because we were just sort of getting some momentum. And I think that's a really integral part of this as well.

Unger: Well, thank you so much, Dr. Harris, Dr. Reznikoff, and Dr. Taylor for being here today, for sharing your perspectives, and for all of your important work. That's it for today's COVID-19 update. We'll be back on Monday with another segment. For additional information on the AMA Opioid Task Force 2020 Drug Overdose Report, visit end-overdose-epidemic.org. For updated resources on COVID-19 go to ama-assn.org/covid-19. Thanks for joining us today and please take care.


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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