Opioids emergency declaration must be followed with smart action

Kevin B. O'Reilly , News Editor

President Donald Trump today directed the Department of Health and Human Services to declare the opioid epidemic a public health emergency. With the move, aimed at tackling the epidemic tied to hundreds of daily overdose deaths across the nation, the president also ordered other federal agency and department leaders to use any appropriate emergency authority they have to address the problem.

The president specifically announced a plan “to overcome a restrictive 1970s-era rule that prevents states from providing care at certain treatment facilities with more than 16 beds for those suffering from drug addiction.” He said several states had sought relief from this and other requirements and promised that “approvals to unlock treatment for people in need” would “come very fast, not like in the past."

Waiving Medicaid’s 16-bed federal limit to treat patients with a substance-use disorder was among the steps the AMA, in a September letter, recommended the president take in the context of an emergency declaration. The federal Institutes for Mental Diseases (IMD) exclusion within the Medicaid program limits bed capacity for patients needing effective, evidence-based treatment. Granting all 50 states waivers from the 16-bed IMD exclusion “is an important first step to increasing physicians’ ability to care for patients with an opioid use disorder,” the letter says.

In his speech today, the president also covered a variety of ongoing and upcoming federal activities on the opioids front in areas such as law enforcement, anti-drug advertising, and pharmaceutical research and development.

Patrice A. Harris, MD, chair of the AMA Opioid Task Force, said the president’s announcement will offer “needed flexibility and help direct attention to opioid-ravaged communities.”

However, she added, the presidential action—taken alone—“won’t solve a complicated problem.”

“Ending the epidemic will require physicians, insurers, drug manufacturers, and the government to follow through with resources, evidence-based treatment plans and smart public policies at the national and state levels,” Dr. Harris said.

“The number of prescription opioids in the country is declining while the numbers of people dying from heroin and illicit fentanyl are increasing at a staggering rate,” she said. “As it stands, it’s easier for patients to access heroin than to access evidence-based treatment and non-opioid pain care.”

It is estimated that only 10 percent of the nearly 2 million Americans with opioid-use disorder can access treatment.

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Dr. Harris noted that physicians are obliged to take a leadership role by “continuing to make judicious prescribing decisions, and by considering the full range of effective therapies for pain, including non-opioid and non-pharmacologic options, co-prescribing naloxone, helping patients access medication-assisted treatment (MAT) for opioid-use disorder, and removing stigma.”

A critical piece of the puzzle is meaningful insurance coverage for effective treatments, she said.

“Insurers must be willing to cover pain treatments beyond opioid analgesics, as well as long-term comprehensive treatment for opioid-use disorder to promote recovery,” Dr. Harris said.

The AMA has advised officials in Washington on how to best address the opioid epidemic. In the September letter, AMA Executive Vice President and CEO James L. Madara, MD, asked the president for his assistance in removing barriers to opioid-use disorder treatment.

“America’s patients need your leadership to encourage health insurance companies and pharmacy benefit managers to end the type of prior authorization, step therapy, and fail-first protocols that only serve as barriers to MAT and multimodal pain care,” Dr. Madara wrote. “When our patients have care delayed or denied due to insurance company policies, it could mean further harm or even death.”

Dr. Madara urged federal action on the IMD exclusion and two other key areas.

Suspend federal regulatory and other barriers to providing buprenorphine. The requirement that physicians and others seeking to prescribe buprenorphine to treat opioid-use disorder obtain a special federal waiver should be done away with. “Removing the federal waiver requirement will give many more patients new access to treatment from physicians and other qualified health care professionals,” Dr. Madara wrote, noting that MAT is safe, effective and well-established.

Direct the attorney general to enforce existing substance-use disorder parity laws. The federal Mental Health Parity and Addiction Equity Act should be enforced at the state and federal levels. Leadership is needed “to encourage health insurance companies and pharmacy benefit managers to end the type of prior authorization, step therapy, and fail-first protocols that only serve as barriers to MAT and multimodal pain care,” Dr. Madara wrote.

“Some payers already have taken positive steps to remove some barriers, but this epidemic requires all payers to work with us to ensure access to care,” he added.

The scale of the opioid epidemic demands a unified, evidence-based, compassionate response. One of the purposes of convening the AMA Opioid Task Force in 2014 was to coordinate various efforts that were going on around the nation.

The task force first issued recommendations in 2015. The recommendations of the task force are to:

  • Support physicians’ use of prescription drug-monitoring programs (PDMPs).
  • Enhance education on effective, evidence-based prescribing and treatment.
  • Support access to comprehensive, affordable, compassionate treatment.
  • Put an end to stigma.
  • Expand access to naloxone in the community and through co-prescribing.
  • Encourage safe storage and safe disposal of prescription medication.

The number of opioid prescriptions dropped more than 43 million between 2012 and 2016, a 17.9 percent decrease, according to research cited in an AMA Opioid Task Force report. Use of PDMPs by physicians and other health professionals has skyrocketed, with the number of clinicians registered rising by 180 percent to more than 1.3 million in 2016. Nearly 120,000 physicians completed courses administered by state and specialty societies on opioid prescribing, pain management, addiction and related areas in 2015–2016.

The AMA offers online CME to expand your understanding of the opioid epidemic. Explore educational content such as "A Primer on the Opioid Morbidity and Mortality Crisis: What Every Prescriber Should Know." This educational module was recently honored by the prestigious Brandon Hall Group’s Excellence Awards Program in the “citizenship” category, which is for organizations that “recognize the opportunity, and social responsibility, to go beyond training ... and are on the forefront of social change and merit recognition for positively impacting our world.”