Overdose Epidemic

Opioid epidemic: 6 key steps that states should take now

Andis Robeznieks , Senior News Writer

The AMA has released a national policy road map based on in-depth analysis of the response to the opioid epidemic by four states: Colorado, Mississippi, North Carolina and Pennsylvania. The report, “National Roadmap on State-Level Efforts to End the Opioid Epidemic; Leading-edge Practices and Next Steps,” analyzes successful strategies used and lessons learned to guide policymakers and others in the months ahead.

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The report was produced by the AMA and Manatt Health Strategies, which identified best practices developed by state Medicaid directors, insurance commissioners and other officials. Among other things, they have helped increase access to high-quality, evidence-based treatment for patients with substance-use disorders (SUDs), widened availability for the opioid-overdose antidote naloxone and opened paths to comprehensive pain care.

“We are at a crossroads in our nation’s efforts to end the opioid epidemic, and states are being creative on how they respond,” said AMA President Patrice A. Harris, MD, MA, also chair of the AMA Opioid Task Force. “It is time to end delays and barriers to treatment; time for payers, PBMs [pharmacy benefit managers] and pharmacy chains to revise policies that restrict opioid therapy to patients based on arbitrary thresholds; and time to help all patients access evidence-based care for pain and substance use disorders.

“Physicians must continue to demonstrate leadership, but unless and until these actions occur, the progress we are making will not stop patients from dying,” she said.

The report’s “recommendations may not be easy to implement, but they are necessary to help end the epidemic,” the AMA document states, adding that the Association is ready to assist all stakeholders in their efforts to make critical state policy changes.

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The AMA report details these six specific actions states can take.

Improve access to medication-assisted treatment (MAT). Remove barriers such as prior authorization for the Food and Drug Administration-approved SUD treatments methadone, buprenorphine, naltrexone and buprenorphine-naloxone combination products. Ensure that MAT is affordable.

North Carolina and Pennsylvania removed prior-authorization requirements for their Medicaid programs. Pennsylvania Gov. Tom Wolf forged an agreement with his state’s top seven commercial insurers to eliminate prior-authorization requirements for MAT.

Increase mental-health parity enforcement. States must increase oversight and enforcement of mental-health parity laws. Colorado created an ombudsman office to help residents access behavioral health care and required its insurance department to report on compliance with parity laws.

The Mississippi Insurance Department is reviewing its procedures for evaluating health insurance issuer policy forms, summary plan descriptions, certificates of coverage, and other plan documents to assess compliance with the federal Mental Health Parity and Addiction Equity Act.

Enforce network-adequacy laws while measuring and building network capacity. Pennsylvania tapped state behavioral health and Medicaid funds to cut coverage gaps by building a hub-and-spoke network of 45 opioid-use disorder treatment centers of excellence. The centers support primary care and other community-based providers with a team of professionals, including certified recovery peer specialists.

Improve access to comprehensive pain care. “As policymakers and prescribers continue to decrease access to opioid analgesics to treat pain, it is vital to expand access to nonopioid pain-management strategies,” the report states, adding that there is “a pressing need” to ensure that insurance formularies and benefit designs support comprehensive, multimodal, multidisciplinary pain care.

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Colorado’s Medicaid program, for example, covers non-opioid options including local anesthetics such as lidocaine patches. It also covers physical and occupational therapy, cognitive behavioral therapy and other medical, physical and mental health services.

Improve access to naloxone. Actions, such as enabling patients to obtain naloxone directly from a pharmacist without a patient-specific prescription, save lives. North Carolina purchased 40,000 units of nasal naloxone that it distributed to opioid-treatment providers, emergency medical service agencies and other community partners.

Evaluate programs and policies. Few states have initiated the comprehensive evaluation of programs that the opioid epidemic warrants. As states implement policies aimed at saving lives, improving patients’ pain outcomes and reducing opioid-related harm, it is imperative that they conduct timely, practical evaluations to ensure that resources are being used effectively and efficiently.

“These recommendations are already proving effective in leading states,” said Joel Ario, managing partner, Manatt Health Strategies, and former insurance commissioner in Oregon and Pennsylvania. “If state policymakers want to have a tangible impact on improving patient care, these are the policies that are showing real promise. This is not hypothetical—this is what is needed to end the epidemic.”

Those specific steps emerge from these key themes, as detailed in the AMA report. 

States already have key tools, but they must be willing to use them. Regulators already have considerable authority to pursue policies that can cut barriers and improve patient care.

Medicaid leads the way. These federal-state insurance programs often provide more comprehensive care for SUDs than commercial insurers, and opportunities exist to extend Medicaid successes to commercial health plans. Medicaid expansion is identified as a key step in addressing the epidemic.

Grants help, but long-term sustainable funding is necessary. Without a reliable funding source, “programs that help save lives will simply go away,” the road map states.

Evaluate programs and policies to see if they work. Comprehensive analysis is needed to focus resources on successful interventions. Policies that create unintended negative consequences must be revised or rescinded.

Learn more, and find educational offerings geared to your state or medical specialty at the AMA’s End the Epidemic website.