Policy News Roundup: February 15, 2024

Key reads

OUD treatment is effective but underutilized, perpetuating the crisis

Even though we are now starting to talk about addiction as a public health issue, policies, clinical approaches, care models and funding still reflect the idea that addiction is a moral failing that deserves punishment. The treatment paradigm has not caught up, as exemplified by the onerous regulation of methadone. The punitive regulations create barriers that prevent many from accessing care. Buprenorphine prescribers are far more common in white communities, while methadone clinics are more prevalent in Black and Hispanic neighborhoods. A common misconception is that recovery with buprenorphine or methadone isn’t “real” recovery. Barriers to treatment are tied to other crises including homelessness, poverty, mental illness, untreated trauma and loneliness, as well as racism and mass incarceration. There is a shortage of care providers, particularly in rural areas. Sociological and economic contributors to the crisis are often neglected. Research has outlined promising approaches to address the crisis, some of which have started to gain traction, including harm reduction, medications in jails/prisons and bridge clinics. Bringing methadone into normal medical settings would open access. For some patients, it might help to disentangle addiction care from formal medical settings and make treatment more culturally authentic.

Source: We have treatments for opioid addiction that work. So why is the problem getting worse? (Vox)

Prevention and treatment needed for families impacted by the opioid crisis

Few adults with opioid use disorder (OUD) receive treatment, and few treatment sites provide “family-friendly” treatment. Action is needed to save lives, support parents in recovery, break the multigenerational chain of addiction and prevent the opioid epidemic from affecting future generations. Family-focused, evidence-based interventions can increase resilience and wellbeing in children and can help parents, but they have not been routinely offered by behavioral health agencies serving individuals with OUD. Treatment sites generally focus on the individual. Challenges to implementing such programs include staffing, competing programmatic priorities, billing, stigma and financing of prevention, treatment and recovery. Policymakers and service providers should broaden their harm reduction approach to include reducing negative consequences across generations. Prevention is cost-effective but not adequately funded nor appropriately supported within billing structures. Lawmakers should support increased prevention funding and allocate opioid settlement funds toward increasing access to family-friendly treatment. Education across professions and integrated organizational and billing structures are needed. Behavioral health agencies should embrace a holistic, integrated approach to treatment and recovery support, including the need to address family needs, when conducting intakes and developing treatment plans to include prevention for future generations.

Source: Prevention: The Missing Link In Our Efforts To Support Families Impacted By The Opioid Epidemic (Health Affairs)

DEA settles with distributor Morris & Dickson

The Drug Enforcement Administration (DEA) announced a settlement with pharmaceutical distributor Morris & Dickson for failing to maintain effective controls against diversion of controlled substances, including failure to report to the DEA thousands of unusually large opioid orders. The DEA is allowing Morris & Dickson to stay in business, reversing an earlier order stripping the company of its licenses. As part of the settlement, the company agreed to admit wrongdoing, comply with heightened reporting requirements, surrender one of its two DEA certificates of registration and forfeit $19 million. Last May, the DEA revoked both of Morris & Dickson’s licenses after an investigation found the distributor kept shipping drugs for nearly four years after a federal judge recommended the harshest penalty for its disregard of rules. The DEA did not say why it disavowed the earlier order. While Morris & Dickson has managed to stay open, several of the pharmacies it supplied have closed, had their licensed revoked by the DEA or have been criminally prosecuted.

Source: DEA Announces Settlement with Morris & Dickson Co., LLC (Drug Enforcement Administration); DEA reverses decision stripping drug distributor of licenses for fueling opioid crisis (Associated Press)

Most adolescents being assessed for SUD treatment use substances due to stress-related factors

A study by the Centers for Disease Control and Prevention of adolescents being assessed for substance use disorder treatment in the U.S. between 2014 and 2022 found that the most commonly reported motivation for substance use was “to feel mellow, calm, or relaxed” (73%), with other stress-related motivations among the top reasons, including “to stop worrying about a problem or to forget bad memories” (44%) and “to help with depression or anxiety” (40%). The study found 50% reported using substances “to have fun or experiment.” The majority of adolescents reported using substances with friends (81%) or using alone (50%). More than half of respondents who reported past-30-day intentional misuse of prescriptions reported using them alone. Interventions related to reducing stress and mental health concerns might reduce these motivations for substance use among adolescents. Education for adolescents about harm reduction strategies, including the dangers of using alone and how to recognize and respond to an overdose, can reduce risk for fatal overdose.

Source: Characteristics of Alcohol, Marijuana, and Other Drug Use Among Persons Aged 13–18 Years Being Assessed for Substance Use Disorder Treatment — United States, 2014–2022 (Centers for Disease Control and Prevention)

CDC study suggests no benefit to law enforcement administration of high-dose naloxone

In 2021, the Food and Drug Administration approved an 8 mg intranasal naloxone product, but no studies have examined outcomes among persons who receive the 8 mg product and those who receive the usual 4 mg product. The New York Department of Health supplied some New York State Police troops with 8 mg intranasal naloxone between March 2022 and August 2023. No significant differences were observed in survival, mean number of naloxone doses administered, presence of most post-naloxone signs and symptoms, post-naloxone anger or combativeness or hospital transport refusal between 4 mg and 8 mg recipients. However, persons who received the 8 mg naloxone had 2.5 times the risk for opioid withdrawal signs and symptoms, including vomiting, than did those who received the 4 mg product. This study suggests no benefits to law enforcement administration of higher-dose naloxone. More research is needed to guide public health agencies in considering whether 8 mg naloxone confers additional benefits for community organizations.

Source: Comparison of Administration of 8-Milligram and 4-Milligram Intranasal Naloxone by Law Enforcement During Response to Suspected Opioid Overdose — New York, March 2022–August 2023 (Centers for Disease Control and Prevention)

SAMHSA finalizes SUD patient record privacy rules

The Department of Health and Human Services (HHS) finalized modifications to the Confidentiality of Substance Use Disorder (SUD) Patient Records regulations at 42 CFR Part 2. The final rule increases coordination among providers treating patients for SUD, strengthens confidentiality protections through civil enforcement and enhances integration of behavioral health information with other medical records. The rule was informed by the CARES Act, which required closer alignment with HIPAA rules. The rule includes modifications to permit use and disclosure of Part 2 records based on a single patient consent given once for all future uses and disclosures for treatment, payment and health care operations; permit redisclosure of Part 2 records by HIPAA covered entities and business associates in accordance with the HIPAA Privacy Rule; provide new rights for patients under Part 2 to obtain an accounting of disclosures and to request restrictions on certain disclosures; expand prohibitions on the use and disclosure of Part 2 records in civil, criminal, administrative and legislative proceedings; provide HHS enforcement authority, including imposition of civil monetary penalties; and outline new breach notification requirements.

Source: HHS Finalizes New Provisions to Enhance Integrated Care and Confidentiality for Patients with Substance Use Conditions (Substance Abuse and Mental Health Services Administration)

HHS and HUD work to address homelessness and behavioral health

The Department of Health and Human Services (HHS) and Department of Housing and Urban Development (HUD) selected eight states and D.C. to participate in the Housing and Services Partnership Accelerator initiative to strengthen partnerships across housing, disability, aging and health sectors. The Accelerator will help states unlock resources to reduce homelessness by addressing health-related social needs. HUD and HHS will provide the states with technical assistance and opportunities for state peer-to-peer exchange to support implementation of clinically indicated housing-related services and supports under Medicaid for people with complex health needs experiencing or at risk of being unhoused, including people with disabilities, older adults, people with mental health or substance use disorders and people with other chronic medical conditions. The U.S. Interagency Council on Homelessness also met to discuss how the federal government can provide more support for state/local efforts to meet the needs of people experiencing homelessness and mental health/substance use disorders. The Council heard from leaders in Arizona and Colorado about their approaches.

Source: Biden-Harris Administration Partners with States to Address Homelessness; At USICH Meeting, Council Focuses on Innovative Solutions for Homelessness and Mental Health (Department of Health and Human Services)

Buprenorphine prescribing requirements and limitations vary by state

As of March 1, 2023, 19 states and D.C. had statutes and/or regulations that explicitly governed buprenorphine prescribing for opioid use disorder (OUD) in non-opioid treatment program settings. These include decriminalization of buprenorphine possession, regulations surrounding initial evaluations, counseling and drug testing requirements, regulation of perceived patient “noncompliance,” tapering requirements and dosage restrictions. Fifteen states explicitly incorporated federal law provisions related to the X-waiver, no longer consistent with federal law. Fourteen states and D.C. required counseling for patients prescribed buprenorphine for OUD, with four establishing minimum counseling frequency. Seventeen states and D.C. required testing when prescribing buprenorphine for OUD, with eight specifying frequency. Six regulated buprenorphine initiation dosages, and seven regulated maintenance dosages. Fourteen regulated how a practitioner responds to patient “noncompliance.” State policymakers should remove outdated references to the X-waiver; align state law with evidence-based best practices; coordinate consistent policymaking across levels of governments; and center and involve impacted communities in policymaking.

Source: Buprenorphine Prescribing Requirements and Limitations (Center for Public Health Law Research)

Alabama awards opioid settlement funds, including for family services

The Alabama Department of Mental Health awarded $8.5 million in opioid settlement funds. The largest total of over $730,000 went to the Alabama Alliance of Boys & Girls Clubs for mental health and trauma-informed care and substance use prevention for youth. The second largest total of $600,000 went to Altapointe Health Systems to provide rapid detox services and expand medications for addiction treatment under the current crisis care model. Other settlement awards included those funding prevention and education, safe storage/disposal, harm reduction, treatment (including outpatient, residential, inpatient, detox and medications), recovery housing and other recovery services, peer support, reentry services, outreach and support services, care for women (including pregnant and postpartum women with addiction), services for justice-involved individuals, programs for veterans, support for loved ones of those involved with substance use and a family resource model to provide family-centered coaching to strengthen family networks for those impacted by substance use disorder.

Source: Alabama Department of Mental Health gives out $8.5 million in opioid settlement awards (1819 News)

D.C.'s stabilization center has surpassed 1,000 admissions in first three months

In just over three months, the D.C. Stabilization Center, where people who have used substances or alcohol can safely recover for up to 24 hours under the care of nurses and peer mentors, has surpassed 1,000 admissions. Nearly 60% of patients used alcohol and at least 10% opioids, based largely on self-reporting. Naloxone was administered twice. The center also sees cases involving PCP, K2 and xylazine. Nurses typically do a urine test and breath analysis on patients, who change into scrubs and can shower and eat. Officials say they do not yet have a plan for tracking the long-term progress of patients. About 17% of total admissions have gone to residential treatment or a shelter or gotten a referral for other behavioral health care. Paramedics have brought the vast majority of patients to the center, though others come via friends or family or walk in on their own.

Source: How D.C.’s first sobering center could ease drug and alcohol addiction (The Washington Post)

Prior authorization requirements create barriers to SUD care

Addiction medicine specialists say prior authorization, which has particularly targeted buprenorphine, is adding barriers to treatment. Insurance companies can require urine tests, pill counts, dosage limits and patient education or counseling. Prior authorization requires doctors to fill out lengthy forms and wait for approvals. It makes patients feel stigmatized and delays treatment during an often narrow window when someone is willing to enter treatment. Prior authorization is typically reserved for expensive or second-line therapies, but buprenorphine is first-line therapy for opioid use disorder (OUD) and not expensive. Prior authorization for buprenorphine is the result of stigma. For-profit health plans in Republican-leaning states tend to require prior authorization more frequently, suggesting the tactic is shaped more by cost control pressures and partisan concerns about diversion than science about the medication. Prior authorization is especially harmful in Medicaid, which most people who receive OUD treatment use. However, at least 13 states prohibit Medicaid from imposing prior authorization on OUD medications (citing a Partnership to End Addiction/Legal Action Center report).

Source: Doctors fighting US opioid epidemic say insurance barrier impedes treatment (The Guardian)