When it comes
to solutions to the opioid epidemic - talk is cheap. The last 20 years
everybody has “the solution”. The AMA came up with a new version of theirs entitled “AMA Opioid Task
Force Recommendations for Policymakers.”
Inspection of this page shows that it is basically a rehash of
everything we have known over the past 10 years or longer. The only new message
is that the AMA is now suggesting that policymakers should follow these
recommendations. In this era of patient empowerment, direct advice to patients
is completely missing.
Drug
legalization advocates have apparently vilified the Reagan era “Just Say No”
campaign to the point that attempts at primary prevention of substance use are
now politically incorrect and forbidden. How can you possibly stop opioid and
methamphetamine epidemics when there is a large and vocal advocacy for
legalizing all drugs emboldened by the cannabis campaign? There are few reasonable voices out there saying “You know you can really live a better life
without drugs or alcohol”.
It should
probably come as no surprise that real action on the drug epidemic cannot be
expected from a government that is unable to end a decades long streak of mass
shootings. We hear the familiar refrain that people were “in the wrong place at
the wrong time” or that they are “fallen heroes” and that “now is the time to
move on”. A real adaptive response to mass shooting like even slightly tougher
gun laws would make a difference. Despite hearing that “this is the last time
that our children can be victimized” the mass shooting saga drags on - courtesy
of local and federal governments.
The resolution
of the opioid epidemic is another example of how our government doesn’t
work on serious public health issues. The epidemic has been in place for
the past 20 years. Using deaths by
overdose as a proxy measure suggests that things may be improving the last
couple of years, but the epidemic is far from resolved. The more recent problem has been that people
who started using prescription opioids have changed to heroin or fentanyl – the
supplies of both are plentiful and less expensive than the street value of typically
prescribed opioid pain tablets.
A few words about the points the AMA has in their graphic:
1. MAT -
medication assisted treatment for opioid use disorder is considered a major
advance in treatment. That applies both to methadone maintenance treatment and
more recently buprenorphine maintenance with various preparations.
Sustained-release naltrexone injections are also an option but they are more
controversial due to the longer induction and wait time until the patient is
safely covered by opioid receptor antagonism. The current AMA position is to
remove prior authorization from these treatments so that they are more readily
available. Some treatments are more cost-effective than others. It is not clear
from the statement how the AMA hopes to remove these barriers particularly
since they have not been effective in removing them for the past 30 years of
utilization management or prior authorization. They may be counting on
political leverage in this case but I don’t see it happening. Regulators and
politicians could easily make this an exception to the current utilization
management and prior authorization statutes that they have on the books but it
should be apparent from that statement that they are the problem in the first
place.
2. Mental
health - the document cites the well-known correlation between mental illness
and substance use. The document also cites the Mental Health Parity
Addiction and Equity Act (MHPAEA) as meaningful but the only way this law
gets enforced is if civil action is brought against healthcare companies. These
healthcare companies are protected by legislation and they basically do
whatever they want. The AMA Task Force suggests that healthcare company should
be “held accountable” but that hasn’t happened in the 10 years since the MHPAEA
has been passed. The document suggests
that a number of addiction specialists should be in the networks of these
healthcare providers, but for 20 years politicians have been rationing mental
health services to the point that county jails are currently our largest
psychiatric institutions. The mental health suggestion in this document seems
like another wish.
3. Comprehensive pain care and
rehabilitation access - I would really like to see the numbers on this one. If
anything there has been a tremendous proliferation of freestanding or chains of
pain clinics over the past 20 years. That proliferation correlates directly
with increasing opioid prescriptions. As far as I can tell there has been no
movement at all in terms of determining what constitutes a quality pain clinic
versus something else. This may have to do with the politics that wrung the
word “quality” out of the healthcare system 30 years ago. There is also an
access problem. In other words there has always been “non-opioid alternatives”
like physical therapy but healthcare systems ration their utilization. This might be another area where education is
important and convincing people that a course of physical therapy even if their healthcare company makes them pay for it is potentially more beneficial than
taking opioids and getting deconditioned for a period of time.
4. Maternal and child health - there is no doubt
that punishment-based paradigms can intrude on the parental relationships with
children and result in destabilization of families. This usually occurs on a
county by county basis and there are no statewide standards and no specific
treatment facilities. The problem is compounded by the fact that most states
consider social services to be as expendable as mental health services and it
takes more than a suggestion to reverse that 20-year trend. Recently, the child protection issue as a result of substance use has become so bad that additional tax legislation is needed just to cover this problem.
5. Civil and
criminal justice reforms - the most significant reform suggested in this
section is that MAT is continued when a person is incarcerated and after they
are released. This is a tall order considering how difficult it is for anyone
to access MAT in an outpatient setting. Jails and prisons have the absolute
worst record. The evidence for that is people who are acutely taken off of
methadone, buprenorphine, or other psychiatric medications at the time of
incarceration. That can lead to weeks of opioid withdrawal symptoms and intense
physical symptoms. Despite many county
jails considering themselves to be psychiatric hospitals very few of these
places are equipped to assess and treat psychiatric disorders or do medication
assisted treatment of substance use disorders.
That is the AMA
WishList and all of its deficiencies. I have not seen a realistic assessment of
the problem and how to reverse it in spite of the fact that there are two
documented opioid epidemics in the medical literature and suggestions about how
they were resolved. I never heard anyone referencing them. Medication assisted
treatment was one component but there are other significant factors that no one
seems to be talking about at this time.
Working in a
residential treatment facility provides me with unique perspective on the
problem. The continuum of care ranging from residential treatment to intensive
outpatient treatment to date treatment to self-help groups like Alcoholics
Anonymous and Narcotics Anonymous depends on a number of factors to make it
work. First and foremost is a competent staff in the facility with reasonable
boundaries and a supportive environment. Most medical facilities do not have
this because of significant bias against people with substance use disorders.
There are some treatment facilities that have similar biases and they should
not be allowed to admit people until that problem is resolved. The measures
recommended by the AMA Task Force are medically weighted and that means that
treatment facilities need to have medical staff. If the facility needs
histories and physicals done medical staff need to provide that function as
well as comprehensive detoxification, treating associated medical problems, and
providing psychiatric care and MAT. There is no point in having residential or
outpatient treatment programs in a network if they cannot provide that level of
care. People who need MAT should not be treated in facilities where they cannot
get medical assessment and treatment.
That basic fact
seems to be missing from the AMA Task Force guidelines, state regulations, and
any discussion at the federal level about what kind of treatment is needed for
people with active opioid use disorders.
The AMA could
be of more service referring people to appropriately staffed treatment programs
and advising the public on the source of all of these obstacles of care. As I
have been writing here for years now those obstacles are a product of pro-business
government policy at both the state and federal level and how those rationing
businesses are able to operate. Until that basic flaw is corrected - I do not
anticipate any increase in access to treatment (at least effective treatment),
increased access to appropriate social services, or sudden revision of county
jails to suddenly make them functional psychiatric units.
There are some changes that would make an immediate difference in the opioid epidemic instead of the continued evidence-based platitudes. If there are any policy makers or politicians out here that are serious about making some changes - here they are:
1: Hold physicians harmless for providing MAT:
The suggestion that more physicians should be providing MAT for opioid use disorder has gone from a suggestion to more of a demand. Just this weekend there have been debates about why Emergency Department Physicians aren't providing MAT for every person with OUD that they see. My first thought when I saw that was: "Are they serious?" People are not presenting to EDs with casual use. They are not people coming into clinic intentionally in withdrawal to start buprenorphine induction. They are generally people with very serious use problems who end up in EDs because of a different problem. Many of them are polysubstance users with multiple drugs on board and in many cases drugs that are typically flagged as having potentially serious interactions with buprenorphine. Add to that the dearth of buprenorphine prescribers that will accept referrals from an ED and it makes perfect sense that Emergency Medicine physicians do not want to send people out with buprenorphine.
The physicians are not the problem, the practice environment is. The solutions seem obvious to me. The first is to indemnify the physicians for providing care that is harm reduction to patients with high risk. This already happens in state statutes that cover Good Samaritan provisions, mandatory reporting of child and adult protection concerns, and civil commitment and guardianship proceedings that hold the petitioners harmless for good faith activity. MAT is a very similar endeavor. But I would not just stop at a vague statutory requirement. I would tie it in with abbreviated training for MAT. When I took that training, at least half of the patient case examples were high risk with limited resources, psychiatric comorbidity, and they were using high levels of multiple substances. The answer in each of these scenarios was to prescribe buprenorphine as a way to assist the patient with the OUD aspect of the problem.
2: Open up addiction clinics:
The idea that primary care physicians are all going to start seeing large volumes of these patients will not materialize as long as there is a problem with cross coverage. I have seen it happen many times. A well intended physician starts prescribing buprenorphine and even in a mutli-specialty clinic has nobody else to assist and is on-call 24/7 for years until they burn out. There has to be a structure in place where there are clinics that can handle large volumes of patients including the referrals from all of the local EDs and correctional facilities and provide adequate cross coverage for the physicians prescribing buprenorphine.
3: Decrease the training requirement:
Unlike others - I don't think it can be eliminated for the reason I cited above. The physicians and other prescribers need to know the high risk scenarios that they can treat. I think it could probably be done in two hours with a case book of treatment scenarios. The case can be made for collaborative care/mentoring arrangements with experienced physicians, but the funding of those scenarios should be seriously considered.
4: Provide temporary housing programs to take people directly from the ED and crisis appointments:
As a former acute care psychiatrist - I know the uneasy feeling of providing brief opioid detox services and discharging patients with OUD to the street with medications that have street value. There is no surer path to immediate relapse. If we are really serious about helping people get established on MAT, they need a stable environment where it can happen.
5: States need to license substance use programs only if they provide medical services and MAT:
If we are all serious about the effects of MAT in OUD it is time to start acting like it. There is no longer an excuse or reason for not offering MAT to all patients in residential, extended care, or outpatient treatment programs. There are no religious or ideological grounds that justify not offering these services and the license of all treatment facilities should depend on it.
These are my ideas about stopping the opioid epidemic that stop all of the platitudes in their tracks. There is a rational way to proceed that does not depend on physicians sacrificing to keep the irrational system afloat. The rational way will cost money, but it will also save money but not in the way politicians usually talk about healthcare savings. It will save money and resources by saving lives, not investing in inadequate treatment, and finally putting a dent in the large circulating pool of opioid and polysubstance users that are circulating between emergency departments, inpatient units, drug treatment programs without MAT, detox units, shelters, and jails.
George Dawson, MD, DFAPA
