Policy must address racial disparities in the use of medications for opioid use disorder
According to a report from Health Affairs, people of color are less likely than white individuals to access medications for opioid use disorder, are more likely to receive the more stigmatized and burdensome methadone (versus buprenorphine) when they do receive treatment and have lower retention rates. Stigma, lack of providers and insufficient insurance coverage create such barriers. The report recommends policymakers address such disparities through strategies such as Medicaid expansion, increased grant funding for FQHCs to provide buprenorphine treatment, incentives for practitioners to work in communities of color, retention of temporary telehealth policies that allow remote buprenorphine induction, regulatory changes to allow methadone treatment in office-based settings, and Medicaid coverage of ancillary services that help address co-occurring SUDs, unemployment and unstable housing to increase treatment retention.
Source: Addressing Racial And Ethnic Disparities In The Use Of Medications for Opioid Use Disorder (Health Affairs)
Recent federal legislation enables us to adopt an earlier and broader approach to substance use prevention
According to a report from Health Affairs, the U.S. traditionally underinvests in prevention and takes a narrow, substance-specific approach that fails to address root causes, build youth resilience or prevent future addiction crises. The report states that we must rethink our approach to prevention by starting efforts earlier in a child’s life and taking a broader approach that includes not just school-based programs on avoiding substances, but also programs that address children’s mental health and offer education for caregivers, policies to limit youth exposure to substances and structural changes that facilitate healthy childhood development. These suggested changes would aim to reduce poverty, ensure housing stability and guarantee health insurance for mental health and addiction treatment, among other initiatives. While not the stated intention, the report states, COVID-19 relief legislation and other Biden administration proposals seek to invest in children and families in ways that will help mitigate risk factors of addiction, and we must seize the opportunity to measure and document potential effects on youth substance use and addiction.
New legislation introduced to support states in enforcing parity
Sens. Cassidy and Murphy introduced the Parity Implementation Assistance Act (S. 1962), which would authorize $25 million in grants to states to support their oversight of health insurance plans’ compliance with parity requirements, as long as states collect and review comparative analyses from insurers. It builds upon the sponsors’ Mental Health Parity Compliance Act of 2019, which became law in 2020 through the Consolidated Appropriations Act and provided federal and state health insurance regulators with additional tools to monitor and assure compliance with parity. Reps. Cardenas and Fitzpatrick introduced House companion legislation (H.R. 3753).
House Committee on Oversight and Reform held a hearing on the role of the Sackler family in the opioid crisis
The House Oversight and Reform Committee held a hearing this week on the harm members of the Sackler family inflicted on communities and the need for Congress to enact reforms like the SACKLER Act, which would prevent individuals who have not filed for bankruptcy from obtaining releases from individual liability through bankruptcy proceedings. Massachusetts Attorney General Maura Healey and Idaho Attorney General Lawrence Wasden testified, as well as Patrick Radden Keefe, author of the new Empire of Pain: The Secret History of the Sackler Dynasty. Rep. Maloney, chair of the committee, pressed for passage of the SACKLER Act to prevent the Sackler family from avoiding lawsuits. Several Republicans highlighted concerns that drug trafficking at the U.S.-Mexico border is contributing to the opioid crisis and called for oversight of the border to fight the crisis. Rep. Comer, ranking member, criticized Maloney for not calling a hearing on the “border crisis” and fentanyl trafficking. Rep. Tlaib responded that the Sackler family was at fault, not “immigrants or China.” Rep. Connolly labeled the requests for oversight at the border as “an attempt to distract from a main topic.” Witness Alexis Pleus, who lost a son to opioid addiction, said she was “disgusted” by committee members’ lack of concentration on the Sackler family.
Supreme Court rejects challenge to FDA's regulation of e-cigarettes
The U.S. Supreme Court rejected a challenge to the FDA’s regulation of e-cigarettes. The appeal by a vape shop and an industry trade group sought to evoke the non-delegation doctrine, a sparingly used constitutional rule that says Congress must give clear guidance to an agency before handing off its legislative responsibilities. The 2009 Tobacco Control Act gave FDA broad authority to regulate tobacco by letting FDA restrict ingredients, limit advertising to young people and block the sale of new products. It explicitly covered cigarettes and smokeless tobacco and said the FDA could bring other “tobacco products” within its purview. In 2016, the FDA said it would start regulating virtually everything that met the law’s definition of “tobacco products,” including e-cigarettes, vape pens, cigars and hookah. In their appeal, Big Time Vapes and the United States Vaping Association said Congress violated the Constitution by giving FDA such an open-ended grant of authority. The Biden administration urged the Supreme Court to reject the appeal, saying Congress made clear that the FDA should comprehensively regulate the tobacco industry to protect the public from nicotine dependence, health risks and false or misleading advertising.
Source: FDA’s Vaping Regulations Survive as Supreme Court Rejects Appeal (Bloomberg)
40th anniversary of first CDC report of HIV in the U.S. marked this week
This week marked the 40th anniversary of CDC’s first report of HIV in the U.S. A CDC study on HIV incidence in the U.S. 1981-2019 found that HIV incidence decreased by 73% from the highest number of infections in 1984-1985 to 2019. During the past four decades, the largest relative reduction in incidence occurred among persons who inject drugs, with incidence decreasing 93% from the highest annual number in 1988-1990 to 2019. Incidence has not decreased during the past decade, likely in part because of the increased drug use and needle sharing of the opioid crisis. The decrease in injection-associated HIV infections followed the implementation of syringe service programs, but such programs are not available in all areas. In a statement, CDC Director Rochelle Walensky noted the progress that has been made but highlighted the continuing epidemic and disparities in diagnoses and access to prevention and treatment. She advocates for fully funding and urgently and equitably implementing initiatives such as syringe service programs. A SAMHSA blog highlighted the increased risk people with mental health and substance use disorders have for HIV and the increased challenges they face in seeking treatment, as well as the integral role behavioral health care providers can play and the services SAMHSA grants help provide.
Source: Estimated Annual Number of HIV Infections – United States, 1981-2019 (CDC); Media Statement from CDC Director Rochelle P. Walensky, MD, MPH, on 40 years since CDC published its first report on HIV in the United States (CDC); SAMHSA Commemorates the 40th Anniversary of the AIDS Epidemic (SAMHSA)
State and local news
Cities are increasingly developing plans for police-free crisis response program
Cities nationwide are developing plans to start crisis intervention programs similar to CAHOOTS in Eugene, Oregon. The American Rescue Plan will make federal funds available to states to establish such programs, incorporating elements of the CAHOOTS Act to provide $15 million for grants to states to start mobile crisis intervention programs and three years of enhanced Medicaid funding to cover 85% of the cost of operating them. The effort to enhance mobile response efforts dovetails with the implementation of 988 emergency call lines for mental health. CAHOOTS, as well as Denver’s STAR program — modeled on CAHOOTS — and the Crisis Response Network in Phoenix — an integrated system that links crisis lines to mobile crisis units and short-term crisis facilities, which has placed a mental health specialist at the city’s 911 call center — are proving to be successful models.
Source: Enlisting Mental Health Workers, Not Cops, In Mobile Crisis Response (Health Affairs)
States addressing behavioral health needs in the 2021 legislative session
Aside from the pandemic, health care policy trends in 2021 state legislative sessions have included expanding coverage, containing health care costs, expanding telehealth access and addressing behavioral health needs. Meanwhile, legislation on telehealth often included expanding the types of services that can be covered via the technology, such as substance use disorder or behavioral health treatment. Many states are also exploring strategies to address rising behavioral health needs, focusing on both mental health and substance use. A number of states have sought creative strategies to link financing for expansions of behavioral health treatment to efforts to decriminalize substances or other initiatives. Notably, New York, Washington and Montana have enacted legislation focused on using marijuana legalization revenues to expand access to behavioral health services. States have also used this session to prepare for implementation of the 988 mental health crisis hotline. To this end, Washington, Virginia and Utah have enacted legislation levying taxes on phone lines to implement statewide or regional crisis hotlines that can accept 988 calls and support the provision of crisis services.
Source: Health Care Policy Trends From the 2021 State Legislative Session (Manatt)
Missouri becomes the last state to implement a statewide PDMP
Missouri Governor Parson signed SB 63 into law this week to create a statewide prescription drug monitoring program (PDMP). SB 63 establishes a Joint Oversight Task Force of Prescription Drug Monitoring, responsible for collecting and maintaining the prescription and dispensation of prescribed controlled substances to patients within the state. While St. Louis already had a PDMP that included much of the state, the legislature struggled for years to enact a statewide PDMP, making Missouri the last state to do so.
Source: Governor Parson Signs SB 63: Creating Statewide Prescription Drug Monitoring Program In Missouri (Missouri Governor Michael L. Parson)
Vermont decriminalizes buprenorphine
Last Tuesday, Vermont Governor Scott signed into law H. 225, a bill that decriminalizes possession of buprenorphine. The bill replaces criminal penalties with civil penalties for possession in quantities of 224 mg or less, about a two-week supply. Most people using buprenorphine illicitly do so to self-treat addiction, often because of the difficulties of obtaining formal treatment. Scott expressed some doubt about the legislation, with concerns about the lack of data related to decriminalizing the medication and its efficacy in minimizing overdoses, but said he signed the bill because it is well-intentioned and offers a potential approach to reduce the impacts of substance use disorder. Scott also signed an executive order directing the chief prevention officer to create a task force to track data to assess the impact of the decriminalization.
Source: Vermont decriminalizes buprenorphine, used to treat opioid use disorder: What to know. (Burlington Free Press)
Other news in addiction policy
We must use lessons from youth vaping to inform our response to marijuana edibles
After the federal government abdicated its responsibility to protect youth from an addictive substance being marketed to them despite calls from researchers and health professionals to rein in the vaping companies, outraged parents stepped in to press for increased regulation, leading to the raising of the federal minimum legal sale age for tobacco products, bans on flavored vaping products, removal of ads from social media and coverage by the media of the industry’s nefarious practices, among other initiatives. Many of the same warning signs seen with the rise of vaping are now emerging for marijuana edibles, including spikes in calls to poison control centers, easy access for teens and a belief in its safety, and increased frequency of use among teens. According to an op-ed published in STAT, the marketing tactics for edible marijuana products are following a similar playbook as the ones used to promote vaping, appealing to kids to gain a loyal customer base for addictive products. There is also similar government inaction in response to marijuana edibles. The op-ed argues that the limited protections states have included in their marijuana laws are inadequate, and policymakers must act to ensure that marijuana legalization does not proceed without ensuring adequate protection for children of all ages.
Source: Lessons about marijuana edibles from youth vaping (STAT)
Medicaid spending on and utilization of opioids has decreased for prescriptions to treat pain and increased for prescriptions to treat opioid overdose and use disorder
Outpatient prescription drug utilization in Medicaid increased 5% from 2015-2019, and net spending remained almost unchanged, though spending before rebates increased 23%. Psychotherapeutic agents, including antidepressants, were the second most prescribed drug group throughout the study, highlighting the key role Medicaid plays in behavioral health care coverage. Opioid prescriptions used to treat pain declined 41%, while prescriptions to treat opioid addiction and overdose increased. Buprenorphine and opiate antagonists such as naloxone and naltrexone grew from 9% of opioid prescriptions in 2015 to 30% in 2019. These also made up an increasing share of opioid spending before rebates, growing from 36% to 71% of gross opioid spending. Gross spending on other opioids decreased by 49%, reflecting the decline in the number of prescriptions to treat pain.
Source: Utilization and Spending Trends in Medicaid Outpatient Prescription Drugs, 2015-2019 (Kaiser Family Foundation)