Bobby Mukkamala, MD, reviews the 2021 Overdose Epidemic Report

AMA's Moving Medicine video series amplifies physician voices and highlights developments and achievements throughout medicine.

In today’s episode of Moving Medicine, a discussion with the details of—and numbers from the 2021 Overdose Epidemic Report with Dr. Bobby Mukkamala, chair of the AMA Board of Trustees and the AMA task force working to prevent deaths and improve patient outcomes.

Speaker

• Bobby Mukkamala, MD, chair, AMA Board of Trustees 

Unger: Hello, this is the American Medical Association's Moving Medicine video and podcast. Today we're talking with Dr. Bobby Mukkamala, an otolaryngologist from Flint, Michigan about the AMAs newly released 2021 overdose epidemic report. Dr. Mukkamala is the chair of the AMA Board of Trustees and chair of the AMA Substance Use and Pain Care Task Force. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Mukkamala thanks again for joining us today. The AMA just released its 2021 overdose epidemic report. First off, can you give us a little bit of background about the primary goal of this report?

Dr. Mukkamala: Absolutely. Thanks for having me Todd for this important conversation. So, this report captures physicians' actions thus far to help end the nation's drug-related overdose and death epidemic. And also importantly talks about the work that still needs to be done to emerge from this epidemic. Our AMA's primary goal with this work is to reduce the number of people dying from a drug-related overdose and improve the outcomes for patients with pain, with a mental illness or a substance use disorder.

Unger: Now just as background for viewers out there, I notice there is a shift in terminology away from kind of the opioid epidemic report and to the overdose epidemic report. What's behind that shift?

Dr. Mukkamala: Well the reality is is that when it was something that was being prescribed, most of that was opioids. But now that the bulk of people that are sort of suffering with this are seeking illicit drugs, some of those are not opioids, right? Some of those are sedatives, barbiturates, benzodiazepines, other categories of medications that are non-opioid but still very problematic to the public health.

Unger: And I think would you say that's behind what we're seeing, which is this kind of countervailing set of trends in terms of the number of prescriptions versus deaths?

Dr. Mukkamala: Yeah, absolutely. I mean today's epidemic has evolved or I should say devolved significantly. Illegally manufactured fentanyl, fentanyl analogs are extremely lethal, very widespread and are often packaged to look just like prescription medications. So, people think they're safe when they're anything but. And yet, while this epidemic has changed, the response to it is still lagging behind. That's why even though policies aimed at reducing the number of prescriptions of these opioid analgesics have cut the number of prescriptions almost in half, there are still more drug-related overdose deaths than ever. And we worked hard to make progress on this one issue but others have emerged in its wake.

Unger: The increased use of state prescription drug monitoring programs or PDMPs, has this had an impact on these efforts?

Dr. Mukkamala: Yeah, it has. I mean between 2014 and 2020, we did see the use of these state PDMPs increase from 61.5 million to more than 910 million uses. So, as a physician I see the value in the PDMP as a tool to help me learn information but the PDMP doesn't treat pain or substance use disorder, right? So, mandating me to use it a certain number of time a year might be helpful to identify patients who may need help with a possible opioid use disorder or better coordination of care but a PDMP isn't going to make it any easier for them to find that help. It's not going to help that patient get into see a pain management physician or an addiction medicine specialist and it doesn't help connect the patient with treatment. So, and keep in mind also that there are more than 106,000 physicians and other professionals have an X waiver to prescribe buprenorphine in the office, which is a very important medication and treatment. But 80 to 90% of patients with a substance use disorder still don't receive treatment. So, a huge disconnect between sort of supply and man for those resources and services.

Unger: Why that disconnect?

Dr. Mukkamala: I think it's still not enough, right? When you look at, okay, we have 106,000 physicians with an X waiver, some of them use it. I have my X waiver, I did that because I wanted to learn about it. But as an otolaryngologist, I just don't have that much opportunity to have patients that I'm taking or for the long term to use it. So, just like me there are a lot of people that have the waiver as part of a desire to educate themselves but we shouldn't fool ourselves into thinking that there's a hundred thousand physicians out there that are ready to take a hundred patients each to deal with this problem. And so, a huge disconnect between supply and demand. And so, I think we need to make it part of medical education actually, so that a new generation of physicians feels much more comfortable taking care of patients with substance use disorder.

Unger: Well let's talk a little bit more then about the way forward because we're in a different situation now where the use of the illicit drugs is really made this a much more difficult situation. How do we have to change how we approach this and how we think about this problem?

Dr. Mukkamala: The main thing that I see is lack of access to treatment. And so, what this epidemic would really benefit from is increased access to evidence-based treatment rather than only mandates for physicians to do this or to do that or to get three hours of CME on pain management or something like that. That's not going to get it done. We need to shift our thinking to harm reduction, increasing access to care and reducing deaths, not just sort of saying, okay we have a hundred thousand physicians that did X problem solved because clearly it's not solved.

Unger: What do you mean when you talk about harm reduction, reducing harm? Can you give us more details about that change in thinking?

Dr. Mukkamala: Yeah. Yeah. So, when it comes harm reduction or substance use disorder, harm reduction commonly is thought to be focused on naloxone, right? This lifesaving opioid overdose related drug that saves tens of thousands of lives and the AMA encourages physicians to prescribe it and to learn about its use. But harm reduction though is much more than that. It also includes access to things like needle and syringe exchange services to reduce the spread of bloodborne infectious disease. And that includes making sure that the laws help pregnant women, and parenting women and families get treatment for substance use disorder, rather than threaten them with punishment and sort of separating families and adding to the stress.

It also includes ensuring that medications for treating substance use disorder and care for mental illness is provided to those who need it in jails and prison, right? So, all these sort of subsets of the population that are very high risk but right now have a hard time getting treatment. And finally it includes harm reduction centers for safe drug, use as well as distributing fentanyl test strips. So, the fentanyl that comes in off the street has such a wide variety in dosing that sometimes what you think you're taking is something that will kill. And so, just simply test strips to find out the potency of what it is that's there minimizes the deaths from it.

Unger: So, it really is, it is a different way of thinking and that's an excellent way to clarify that aspect of harm reduction. You also mentioned increasing access to care. We hear stories of patients that go to pharmacies with a prescription but the insurance company requires prior authorization and the pharmacist can't reach the physician. What happens in a scenario like that?

Dr. Mukkamala: Yeah, well unfortunately what happens there's multiple press reports about patients winding up having to leave that pharmacy without that prescription that they need so badly. And some patients have returned to using because of this lack of access. And of course, then they can die of an overdose. So, there's no medical or moral reason to delay or deny a patient access to that lifesaving medication. And that's why every state has to prohibit prior authorization for medications from being a barrier to adequate treatment of opioid use disorder. And that's just the first step but such a basic step. Don't disconnect patients with the treatment they need by a bureaucratic process that delays them, getting the medication at the counter at that pharmacy.

Unger: And speaking of disconnect at pharmacy, we also hear about patients who they've been on a stable of opioid therapy for years only to go to a pharmacy and have the pharmacist tell them it's against the law to continue at the dosage that they were prescribed. Again, what's the outcome there with patients?

Dr. Mukkamala: Yeah, I mean these arbitrary reductions of care, just like what you just described cause incredible physical suffering and mental anguish. These laws and policies by health insurance companies and pharmacy chains have been linked to hundreds of suicides as well. I mean just the desperation that happens in that moment and it's time for policy makers to remove these arbitrary and sometimes counterproductive laws. Patients with pain have suffered a lot because of these laws and policies based on the 2016 CDC Opioid Prescribing Guidelines. And so, those guidelines were used as sort of lines in the sand, meaning you cannot get more than X and that's just not how medicine works. That's not how patient care works. So, the CDC is now considering chain changes to that and we urge them to adopt the AMA's recommendations to restore balance and put compassion back into taking care of patients with pain.

Unger: Dr. Mukkamala, I talked to many different physicians about many different topics. One thing is the same, the pandemic has made everything worse. Is this situation with the over overdose epidemic another one of those things?

Dr. Mukkamala: Absolutely. I mean there's no question that the pandemic has exacerbated the nation's drug overdose and death epidemic. On top of that structural racism, health inequities have made the pandemic even worse for the marginalized and minoritized communities. And the same is true when in the context of the opioid overdose of epidemic. So, research and data from the NIH and SAMHSA and the CDC, all of which show rising mortality rates for these historically minoritized and marginalized populations. So, absolutely just one more bad thing that's come from COVID.

Unger: So, as a chair of the task force, how do you and the rest of the task force attempted to really address these are big challenges.

Dr. Mukkamala: Absolutely. Yes. So, we've really tried to support the federal government and using telemedicine to increase access to care. I mean this is a perfect situation for telemedicine. It's not physical exam intensive, it's more conversation intensive, perfect for what we're doing right now talking on the screen to each other. We've supported the DEA in its roll out of new options for mobile treatment units to sort of bring evidence based care to rural areas and underserved areas where patients don't necessarily have the ability to drive 20 miles to get somewhere. And the pandemic made the drug overdose epidemic worse but certain we're not giving up on treating.

Unger: Dr. Mukkamala, what do you think the key takeaways are from this report for policy makers and other key stakeholders out there?

Dr. Mukkamala: Yeah. I mean key takeaways I would say that policy makers and these other stakeholders have a choice of whether to pursue evidence based strategies to support patients and their access to this life saving and life affirming care. So, every effort it has to be made to remove the health inequities and these barriers for patients with substance use disorder, mental illness, patient suffering and pain. Remove the barriers that stop them from getting the care that they need. More of our loved ones will suffer and die if these barriers remain. And physicians are going to continue every effort we can to help our patients and we are willing and eager to work with these stakeholders to stop people from dying and improve these outcomes and change this trajectory. So, we've made some progress with reducing prescriptions but obviously the target has shifted and we have to continue our focus because we still have a long way to go.

Unger: Dr. Mukkamala, thank you to you and the task force and our AMA advocacy team for all of the work going on to address this incredible challenge. To learn more about AMA's Overdose Epidemic Report, visit end-overdose-epidemic.org. We'll be back soon with another Moving Medicine video and podcast. You can join us for future episodes and podcasts of Moving Medicine by subscribing at ama-assn.org/podcasts. Thanks for joining us today. 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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