Policy News Roundup: October 3, 2024

Opioid treatment gaps in high-need counties

A Department of Health and Human Services Office of the Inspector General (OIG) report found that hundreds of counties in high need of medications for opioid use disorder (MOUD) services lacked them in 2022.

• Even in counties where MOUD providers (office-based buprenorphine providers or opioid treatment programs, which provide methadone) did practice, they often did not treat Medicare or Medicaid enrollees.

The findings:

• 19% of U.S. counties did not have a single MOUD provider. An additional 21% had disproportionately few MOUD providers in comparison to other counties of a similar population size.
• More than one-quarter of high-need counties (those with disproportionately high overdose death rates) had few or no MOUD providers, including over 100 counties with no providers. Nearly half were also socially vulnerable (based on factors such as socioeconomic status, household characteristics, housing and transportation availability, etc.).
• Nearly one-third of U.S. counties (and nearly 1 in 5 high-need counties) did not have a single MOUD provider that treated any Medicare or Medicaid enrollees.
• Most opioid treatment programs (OTPs) treated Medicare and Medicaid enrollees, while most most office-based buprenorphine providers did not. There are far fewer OTPs, they are much less widespread across the country, and they pose many barriers that can make accessing care difficult.

Why: Factors that may influence MOUD providers’ ability and willingness to treat Medicare and Medicaid enrollees include:

• Medicare Advantage administrative burden and prior authorization requirements
• Low Medicaid reimbursement rates
• Inadequate public information about MOUD provider locations

Recommendations: OIG recommends that Centers for Medicare & Medicaid Services (CMS):

• Geographically target efforts to increase the number of MOUD providers that treat Medicare and Medicaid enrollees in high-need counties
• Work with states to assess whether their Medicaid reimbursement rates for MOUD are sufficient to recruit and retain enough providers
• Work with the Substance Abuse and Mental Health Services Administration to develop and maintain a list of active office-based buprenorphine providers

Source: Medicare and Medicaid Enrollees in Many High-Need Areas May Lack Access to Medications for Opioid Use Disorder (Department of Health and Human Services)

A National Institute on Drug Abuse study found that fewer than half of U.S. jails provide any MOUD.

The findings:

• Less than half (43.8%) of jails offered MOUD to at least some individuals.
• Only 12.8% offered MOUD to anyone with OUD.
• Of jails that offered MOUD, 69.9% provided buprenorphine, 54.4% naltrexone, and 46.6% methadone.
• Most jails (70.1%) did offer some type of SUD treatment or recovery support.

More details:

• The most common reason jails cited for not offering MOUD was lack of adequate licensed staff.
• Larger jails, those in counties with lower social vulnerability, and those with greater proximity to community-based MOUD providers were more likely to offer MOUD.
• Jails with direct or hybrid health care services were more likely to provide MOUD than those relying on external facilities with no onsite health care services.

Why it’s important:

• More than two-thirds of people incarcerated in U.S. jails have a substance use disorder.
• The risk for overdose is particularly high for people leaving incarceration.
• MOUD is the gold-standard treatment for OUD and can be lifesaving.
• This is a significant missed opportunity to provide effective OUD treatment in an environment where people in need of care can easily be reached.

Source: Fewer than half of U.S. jails provide life-saving medications for opioid use disorder (National Institute on Drug Abuse)

A National Institute on Drug Abuse (NIDA) study found that adults with opioid use disorder (OUD) who receive a higher daily dose of buprenorphine may have a lower risk of subsequent emergency department (ED) or inpatient behavioral health visits than those receiving the recommended dose.

Note: The recommended target dose for buprenorphine in Food and Drug Administration’s (FDA) approved labeling is 16 mg per day.

The findings: Within the first year of receiving treatment, compared to those receiving 8-16 mg per day:

• Those taking 16-24 mg took 20% longer to have a subsequent ED or inpatient health care visit related to behavioral health.
• Those taking more than 24 mg went 50% longer before having an emergency or inpatient visit.

Why it’s important: Higher buprenorphine doses could be more effective for managing OUD, especially for those who use fentanyl.

However: There are barriers to accessing higher doses — state laws, insurance policies, guidelines for recommended doses — that would need to be addressed.

Another thing: Another new study, with NIDA Director Nora Volkow as an author, found that semaglutide (e.g., Ozempic) was associated with a lower opioid overdose risk for patients with OUD and type 2 diabetes compared to other diabetes medications, presenting another possibility for expanding effective treatment.

• However: More research is still needed, and the medications’ high cost may pose a barrier to access.

Source: Higher doses of buprenorphine may improve treatment outcomes for people with opioid use disorder (National Institute on Drug Abuse); Ozempic linked to lower opioid overdose rate in those with diabetes, study shows (STAT)

A report from the National Academies of Sciences, Engineering, and Medicine (NASEM) says that the health care system for children is in crisis and in need of transformation to better meet the needs of children and families.

The findings:

• The report documents increases in chronic diseases (many with roots in early childhood), growing concerns with children’s behavioral health, and disparities among population groups.
• The report also highlights a lack of focus and leadership on children’s health. Children lack access to adequate preventive care despite the impact of early childhood on long-term health. Payment models often do not provide child health clinicians the flexibility or incentives to work with families and communities to address health and developmental needs.

Why it’s important:

• We know the importance of prevention, and it needs to be better supported by the health care system. But there are significant barriers built into the health care system that preclude kids from receiving prevention services.
• We know the importance of access to effective treatment and early intervention for behavioral health, which are also often lacking for youth.
• We know the importance of family involvement, but the health care system can make it difficult for clinicians to work with families.

Recommendations: The report provides recommendations to:

• Elevate the importance of child and adolescent health through continuous public focus and prioritizing children in policy at all levels of government. Coordination will be required across child-serving agencies with unified goals of improving child health.
• Finance health care systems for all children, emphasizing prevention and health promotion. Health care financing changes are needed to better reimburse for prevention efforts (and inclusion of families and communities), and increased funding is needed to support primary prevention in public health and schools.
• Strengthen community-level health promotion and disease prevention.
• Ensure co-creation and co-design of programs and structures with youth, family, and community voices and leadership. Including input from children, families and communities in health system redesign is critical to ensure it is equitable and linguistically/culturally competent.
• Implement and monitor impact and accountability measures to ensure children’s health and wellness needs are being met equitably.

Source: New Report Provides Road Map for Policy Changes to Transform Child Health Care and Meet the Challenges of the Youth Health Crisis (National Academies of Sciences, Engineering, and Medicine)

The National Academies of Sciences, Engineering, and Medicine (NASEM) also released a report on how marijuana policy impacts public health and health equity, proposing a public health approach.

The findings: The report found that:

• Alcohol and tobacco policy can provide examples of effective regulations for protecting public health, but such regulations are inconsistently applied and enforced across states for marijuana (see our marijuana report for more on this).
• State marijuana regulations often prioritize commerce over public health. There is strong industry influence and potential conflicts of interest (see more on this below).
• The legalization of hemp in the 2018 Farm Bill has led to the emergence of a new market for synthetic, hemp-derived intoxicating products (e.g., delta-8 THC), with little regulatory oversight.
• Perceived availability and use of marijuana have increased in the past decade. There has been a shift towards concentrates, edibles, and vape oils, which are often higher potency than dried flower products. More regulation and enforcement are needed to continue the decline in illegal sales.
• Marijuana policy impacts social and health equity through the criminal legal system, social equity programs and social determinants of health. Legalization has spurred efforts such as expungement of marijuana offenses, assistance with industry participation for disproportionately impacted groups, and community reinvestment programs, but there are issues across these policies.

Recommendations: The report outlines many recommendations, including:

• The Centers for Disease Control and Prevention (CDC) should develop and evaluate education campaigns about marijuana, specifically for vulnerable populations; monitor marijuana cultivation, sales, use and health impacts; and create best practices for state regulation, including ways to limit youth access.
• Congress should close the Farm Bill loophole and lift research restrictions on marijuana.
• State regulators should require training and certification for all marijuana business staff; automatically expunge or seal records for past low-level marijuana offenses; adopt and enforce quality standards; and better enforce minimum-age requirements to prevent youth access.
• The National Institutes of Health (NIH), CDC, state/local/tribal health authorities, and private entities should support a research agenda focused on public health outcomes of different approaches to marijuana regulation.

Source: US health authorities need to play a larger role in cannabis policy, a new report says (Associated Press); A Patchwork of Cannabis Laws Creates Health Risks, Study Finds (New York Times)

In a blog, National Institute on Drug Abuse (NIDA) Director Nora Volkow explains that commercial interests are an important component of the social determinants of substance use disorder.

The main point: Three of the four biggest industrial contributors to worldwide morbidity and mortality are alcohol, tobacco and ultra-processed foods. The success of these industries is maximized by products able to trigger compulsive consumption, including substance use disorder.

The details: New industry sectors are emerging to capitalize.

• Vaping: Great progress has been made in reducing smoking in the U.S., but the rapidly growing vaping industry could jeopardize this if not properly regulated.
• Marijuana: The marijuana industry has presented new opportunities for commercial interests to drive drug consumption. Products are often designed to appeal to children, marketing increases adolescents’ odds of using marijuana, and legalization and the diversification of products have led more people to use marijuana.
• Opioids: Pharmaceutical companies were responsible for aggressively marketing opioids in the late 1990s, which fueled the opioid crisis.
• Social media: The tech sector has emerged as a contributor to substance use disorder and related behaviors. Drugs are marketed on social media, and studies have linked adolescent social media use to substance use and worsened mental health. Social media companies are incentivized to design products to be used compulsively and to market those products toward young people (lifelong users).
• Online gambling: Online gambling and sports betting are legal in an increasing number of states, providing new opportunities for businesses to prey on individuals vulnerable to gambling addiction.

Going forward: Policy interventions similar to those that have been successful for tobacco and alcohol can mitigate the harms of these other industries.

• However: Research is needed to understand how these interventions may be applied to other domains and the impact of existing policies.

Conclusion: History has shown that businesses often put profits over public health. Research to understand how commercial interests affect public and individual health is needed to guide policies and inform evidence-based prevention and treatment.

Source: Commercial interests contribute to drug use and addiction (National Institute on Drug Abuse)