AMA Unveils Toolkit to Help States ‘End’ the Overdose Epidemic

With drug overdose deaths continuing to rise, policymakers must help people with substance use disorders access evidence-based care and treatment, said leaders from the American Medical Association (AMA) and Manatt Health during a webinar on Monday.

In unveiling their “State Toolkit to End the Nation’s Drug Overdose Epidemic” — which includes proposals ranging from scrapping prior authorization requirements, to incentivizing positive behavior change, to enforcing parity laws — the groups highlighted that 28 states have witnessed a 30% increase in overdose deaths in 2020 over the year prior.

“The point is that these policies must not just exist on paper,” said Bobby Mukkamala, MD, of the AMA Task Force on the Overdose Epidemic. “Our toolkit provides the tools and it’s up to all of us to ensure that they’re implemented and enforced.”

Overdose deaths during the 12 months ending in April 2021 are projected to exceed 100,000 for the first time ever, according to the CDC. From April 2019-April 2020, young people ages 15 to 24 saw the largest percentage increase in drug overdose deaths, at 49%.

The toolkit from AMA and Manatt Health identifies key barriers to evidence-based care, and pairs those problems with examples from states that are leading the way in eliminating a particular barrier.

For example, clinicians in many states are required to obtain prior authorization before dispensing treatment for substance use disorders, but the District of Columbia and New York state have both enacted policies that eliminate this and other utilization management barriers.

The groups’ document provides 24 recommendations across six major policy areas:

1. Expanding access to evidence-based treatments
2. Ensuring access to addiction medicine, psychiatry professionals, and other trained physicians
3. Enforcing mental health and substance use disorder parity laws
4. Increasing access to alternative options for patients with pain
5. Broadening harm reduction efforts to reduce the number of overdose deaths and disease
6. Monitoring and evaluating substance use disorder programs

One action every state can take is to expand access and coverage for medications for opioid use disorder (OUD) under Medicaid — as required by federal law — and among commercial insurers, noted authors of the toolkit.

In addition to jettisoning prior authorization requirements, the toolkit encourages insurers and pharmacy benefit managers to put medications for OUD on the lowest cost-sharing tiers of a formulary and to base coverage decisions on standards developed by medical experts such as the American Society of Addiction Medicine.

Panelists at Monday’s webinar also highlighted the importance of equitable access to treatment for justice-involved individuals as well as pregnant, parenting, and post-partum individuals.

Mukkamala asked stakeholders to reflect on whether their own states are supporting pregnant women with substance use disorders or whether their states’ policies are punitive. He noted the examples set by New Mexico and Montana as a “starting point” in providing evidence-based care for this population — Montana no longer penalizes pregnant, parenting, and post-partum women who use medications for OUD.

Kelly Pfeifer, MD, deputy director of Mental Health and Substance Use Disorder Services for the California Department of Health Care Services, highlighted her state’s MAT Expansion Project, which ensures that two out of three FDA approved medications for OUD are available in jails, prisons, primary care settings, mental health clinics, emergency departments, and hospitals.

The state also launched a technical assistance learning collaborative to help those receiving treatment maintain it and for others who needed treatment to get started. More than half of the county jails in the state participated, she noted.

Also in 2022, California will launch a first-in-the-nation contingency management program for people with stimulant use disorder, a new benefit of the Medicaid program born from a 1115 waiver. The program lasts for 6 months and involves twice weekly visits, she noted. Participants will be rewarded for “positive behavioral change” — for example, a negative urine test — with gift card equivalents to encourage better “day-to-day decision-making” and drug avoidance.

In addition to expanding access to treatment, every state can increase access to providers by developing network adequacy standards and reporting requirements that help to identify gaps in coverage, the toolkit noted.

States can also leverage “hub-and-spoke,” emergency department interventions, and other protocols for connecting patients with substance use disorders to the appropriate medical professionals and treatment.

Another key principle highlighted by panelists at the webinar centered around mental health parity laws, which have been in place for roughly 15 years, noted Mukkamala.

Yet a report to Congress, issued by HHS and the Department of Labor late last month, cited violations “across the board” related to insurers failing to deliver on mental health and substance use disorder benefits, Mukkamala said.

“It’s no secret to anyone that health insurers violate state and federal parity laws,” he said. “So please use the toolkit for the tools that you need to hold them accountable.”

The toolkit also identifies possible funding streams and funding opportunities, including federal funding and possible opioid-related legal settlements, which can be used to help finance evidence-based programs and help prevent more overdose deaths in the future.