The importance of removing barriers to evidenced-based treatment has taken on further importance as the deadly drug overdose epidemic worsens and evolves.

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These barriers include cost, time-wasting prior-authorization requirements for medications proven to effectively treat substance-use disorders (SUDs), and vastly insufficient insurance coverage for nonopioid treatments for pain management, says a new report developed by the AMA and Manatt Health consultants.

After flattening out and even slightly declining in 2018, U.S. drug overdose deaths are once again rising. There were 79,251 overdose deaths for the 12-month period ending this May (the most recent period available), compared with 67,821 for the 12 month-period ending in May 2019, according to the Centers for Disease Control and Prevention (CDC).

Deaths involving prescription opioids peaked in July 2017 and have steadily declined. But heroin-related overdose deaths rose 31% between 2015 and 2019 according to the CDC, and deaths caused by other substances have risen exponentially during the same period. This includes overdose deaths related to:

● Cocaine, up 192%.
● Simulants such as methamphetamine, up 271%.
● Illicitly manufactured fentanyl and fentanyl analogs, up 537%.

The COVID-19 pandemic exposed treatment gaps and has made things worse for patients with an SUD, for patients with pain and for patients who benefit from harm reduction services.

“Sadly, the drug overdose epidemic continues, and it has become more complicated during the COVID-19 pandemic,” said AMA Past President Patrice A. Harris, MD, MA, chair of the AMA Opioid Task Force. “It is long past due for all stakeholders to remove barriers to care and address systemic inequities that have been brought to light during this pandemic.”

The pandemic has created more stress and anxiety caused by financial instability, social isolation and disruption in access to treatment options and harm-reduction services that has contributed to a national spike in drug overdose deaths. Read about how the overdose epidemic has gotten worse during COVID-19.

Opportunities for action identified

The road map highlights six key areas where regulators, policymakers and other stakeholders can act.

● Improve access to evidence-based treatment for opioid-use disorder (OUD). Remove prior authorization and address other barriers, including affordability, to medications for treating OUD.
● Enforce mental health and SUD parity laws. Increase meaningful oversight and enforcement of parity laws, including requiring payers to demonstrate compliance prospectively as part of the product approval process.
● Address network adequacy and enhancing workforce. Ensure access to addiction medicine physicians, psychiatrists, and other health care professionals.
● Expand pain-management options. Enhance access to comprehensive pain care, including multidisciplinary, multimodal treatment.
● Improve harm-reduction efforts. Expand access to the overdose-reversing drug naloxone and coordinating care for patients in crisis. Harm reduction also must include increased access to sterile needle and syringe services.
● Enhance monitoring and evaluation. Implement programs that monitor and evaluate policies and outcomes to identify what is working, and then build on those successes.

The road map expands on the 2019 report with best practices from more than 25 states and additional research to support its recommendations.

Progress has been mixed. For example, 21 states and the District of Columbia have enacted laws limiting public and private insurers from imposing prior authorization requirements on an SUD service or medication, but that leaves 30 that haven’t done so.

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The road map notes that considerable time, energy and resources have been spent enacting extensive policies aimed at ending the overdose epidemic. Policy implementation, however, remains “elusive,” and much more needs to be done to ensure access to OUD treatment.

Inequities exposed by COVID-19

“We have an unprecedented public health challenge today, as the COVID-19 pandemic has strained our health care system, exacerbated the drug overdose epidemic, and highlighted preexisting, systemic barriers to care facing vulnerable and underrepresented populations,” said Joel Ario, Manatt Health’s managing director.

The road map discusses how the pandemic and the national focus on addressing racial inequities in care has “exposed huge disparities” in the SUD treatment different populations receive. For example, it cites a JAMA Psychiatry study that found for every appointment where a Black American received a buprenorphine prescription, white patients had 35 such appointments.

“These inequities translate directly into differing mortality rates across racial and ethnic groups,” the road map states.

Patients helped by policy innovation

Positive developments include flexibilities authorized by the federal government allowing the use of telehealth to initiate buprenorphine prescribing and other SUD treatment, allowed opioid-treatment programs to support take-home doses of methadone for up to 28 days, and implementation of a new funding mechanism in which the CDC supports local targeted, data-driven overdose prevention interventions.

“The bulk of recommendations in this report focus on tangibly removing barriers to evidence-based treatment for OUD and enforcing state and federal parity laws,” the road map states. “Health insurance companies and other payers must change their practices or patients will continue to be harmed.”

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

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