On, October 26, 2017, President Trump declared the opioid epidemic a public health emergency. I wanted to know, what does that mean exactly? I was surprised to find little about the implications. In brief, more money will be available, additional personnel can be directed toward the crisis, various insurance requirements can be waived or adjusted, grant deadlines and requirements can be waived or extended, some drugs may become more accessible, and telemedicine can be modified.
Regarding the issuance of a public health emergency, I wonder where the personnel and money will come from and what services will be reduced in exchange. I recently heard a quote, “only the government can cut off 2 inches from the top of a piece of material and sew it onto the bottom and be convinced it makes it longer!” I am extremely happy that solutions are being investigated, but the devil IS in the details.
The final commission recommendations
The final commission recommendations were released with 56 specific items. So what has already been addressed and what has not based on the preliminary recommendations? The following occurred prior to the final recommendations:
- Increased access to treatment at centers with more than 16 beds by allowing a Center for Medicare and Medicaid Services (CMS) waiver (each state Governor must apply)
- All federally employed prescribers have been directed to receive special training to provide medication-assisted treatment
- Measures have been implemented to decrease the flow of illicit drugs into the country via the postal service
- NIH has partnered with pharmaceutical companies to develop non-addictive painkillers and new treatments for addiction and overdose
One would hope that these measures will increase access to treatment, decrease the availability of illicit drugs, and expand efforts to find alternative medications for pain and for treating addiction.
Recommendations that have not yet been followed include:
- More data sharing among state prescription drug monitoring programs and relaxing patient privacy regulations to allow improved ability to treat patients with substance use disorder (SUD)
- Full enforcement of Mental Health Parity and Addiction Equity Act to increase benefits for mental health and substance use diagnoses
Both of these actions should have positive effects on the identification and treatment of those with opioid use disorder. Privacy laws sometimes limit important information that a clinician needs to appropriately address the disease and incorporating families and caregivers (who may not be permitted to contribute to a patient’s care with existing regulations) into the plan likely increases success. The Mental Health Parity and Addiction Equity Act (MHPAEA) is crucial in combatting this epidemic. Addiction is a disease and should be afforded the same financial provisions of other diseases, like heart disease and cancer. Financial barriers fuel the denial of someone with SUD, often preventing them from seeking treatment.
In general, the focus of the final recommendations can be divided into several sections. I won’t comment on every recommendation, just some that I find interesting and worthy of attention.
Related articles: Here is a link to Dr. Dye’s two previous commentaries on the preliminary recommendations from Trump’s opioid commission.
Federal funding and programs
To improve the delivery of federal funding to states, the commission urged Congress and the administration to block grant federal funding for opioid- and SUD- related activities to the states. Block granting allows a large sum of money from the federal government to be spent with limited provisions on how. Evidence-based programs would be funded through these grants. The commission also acknowledges the need for better data analysis and accountability to ensure that the dollars are spent on the most effective solutions. One of the big problems with government spending is that so much money goes into the bureaucracy and not enough makes it to the heart of the problem. Maybe, in this case, it will be different.
Opioid addiction prevention
Many don’t know that prescribing opioids is often the cheapest way to “address” acute and chronic pain. The commission identified a disturbing trend in federal healthcare reimbursement policies that incentivize the prescribing of opioids and limit access to non-addictive treatments for pain.
Unfortunately, opioids are relatively inexpensive, so insurance companies are often happy to cover them. In some cases, non-addictive pain management, addiction treatment, and medication-assisted treatment are bundled into federal reimbursement policies so that hospitals and doctors are essentially discouraged from providing alternatives to opioids and from offering treatment for opioid use disorder. Physical therapy and non-opioid medication should be easily accessible and affordable and addiction treatment should be encouraged. This is something the government can affect—it may help turn the tide on the crisis while providing adequate relief for those in pain.
Thankfully, the commission recognizes the unintended consequences of the infamous pain scale and making pain the “fifth vital sign”! One would think that requiring hospitals and doctors to identify and treat pain quickly could only be a good thing. However, many medical professionals, including me, believe this is a core cause of the culture of overprescribing that contributed to the crisis.
The U.S. Department of Health and Human Services (HHS) previously included pain question responses from discharged patients in calculations to determine incentive payment. In other words, if patients didn’t get the pain treatment they thought they deserved, (which often was a prescription for opioids), the payment to hospitals and doctors was reduced! Addressing a possible SUD takes a great deal of time and specialized expertise, which many doctors do not have. It is much easier to just prescribe an opioid and “satisfy” patients and not risk a reduction in pay. The commission recommends that CMS remove pain questions entirely from patient satisfaction surveys so providers are not encouraged to prescribe opioids to make patients happy. This is long overdue.
Among the recommendations of the commission, there is also a focus on prescribing guidelines, regulation, and education. There are several detailed suggestions, including education of prescribers, residents, and medical students. But what about others in the hospital, like nurses and allied health, who tend to spend more time with the patients? If all personnel are educated in the recognition of SUD, the diagnosis will be more frequently considered and treatment may be extended to more people. Thankfully, more educational resources are becoming available not only to physicians on the front lines but also for the general public. In fact, Elsevier launched its free Opioid Epidemic Resource Center which provides continually updated resources from healthcare experts on multiple topics related to opioid use and addiction.
Opioid addiction treatment, overdose reversal, and recovery
HHS/CMS, the Indian Health Service, Tricare, and the VA still have reimbursement barriers to substance abuse treatment, including limiting access to certain FDA-approved medication-assisted treatment, counseling, and inpatient/residential treatment. It’s imperative that federal treatment providers lead the way by treating addiction as a disease and removing these barriers. Primary care providers employed by these federal health systems should screen for SUDs and, directly or through referral, provide treatment within 24-48 hours. Each physician employee should be able to prescribe buprenorphine (if that is the most appropriate treatment for the patient) in primary care settings. For individuals with a SUD, ensuring life-saving access to affordable healthcare benefits is an essential tool in fighting the opioid epidemic.
Relaxation of telemedicine regulations can also aid in access to treatment and is addressed in the commission’s report. Many areas, rural and non-rural, in the U.S. have no provider available who is certified to prescribe medication-assisted treatment. If telemedicine allows qualified providers to treat patients without having to be physically present, access to treatment can increase significantly. Patients who are willing to pursue medication-assisted treatment will no longer have to sometimes travel long distances for monthly visits when they can do virtual visits.
The commission also recommends that drug courts be established in all 93 federal district courts and that they embrace the use of medication-assisted treatment. Drug court offers the option of treatment and probation rather than incarceration. Eligibility requires very strict criteria be met before this option is offered. Not only does this increase the chances that many will receive appropriate treatment, it may decrease the prison population. There is data to support that drug courts are more effective than incarceration, yet 44% of U.S. counties do not offer it. Medication-assisted treatment can lead to lasting recovery when abstinence-only may not.
The issue of opposition to the concept of drug court brings up a very important aspect of addiction. The untrue belief that acknowledging SUD as a disease means that those affected should not have consequences for their behavior, is a huge barrier to progress and contributes to the stigma of addiction. While SUD is a disease, it is not an excuse. Offering strict treatment through drug court to a very specific group does not let them off the hook. Once a person acknowledges they have the disease, it is that person’s responsibility to treat it and not use it as a crutch. Drug court may offer the only opportunity for someone to finally recognize what “is wrong with them”. The additional education and treatment may be the only hope for long-term sobriety and an end to a lifetime of crime to obtain more drugs.
Unfortunately, my local county in Ohio, reports that many of those offered drug court reject it because going to jail for a few months is easier than the strict 18-month treatment pathway. Perhaps, we should start treating patients in the prison system. Their room and board are already provided and they are a captive audience. Why not provide treatment without having to build a new structure?
The bottom line
The commission’s final report is very extensive and has many recommendations. It is not surprising that the major themes are prevention and increasing access to treatment. Education is such a huge part of the solution and is addressed in the report. Those with opioid use disorder continue to use because they don’t believe they have a choice. For someone without the disease, it is very difficult to conceive.
In the grip of the disease, an addict’s brain is wired to seek drugs, like he or she seeks food when hungry, just to feel “normal”. It is no longer about getting high; it is about survival.
Fortunately, there are solutions. Even if the success rate is low, most of us believe that saving lives is important. We don’t give up on a cure for a rare, fatal cancer. Opioid addiction is the cancer of our generation—it is progressive and often rapidly fatal. Why should we give up on it?