New strategies needed to address the overdose crisis
An American Medical Association report found that physicians have prescribed 44% less opioids over the past decade and have increased their use of prescription drug monitoring programs (used more than 910 million times in 2020, up from 750 million in 2019 and 61.5 million in 2014), though overdoses have continued to climb. The number of health care providers waivered to prescribe buprenorphine to treat opioid use disorder has increased (with 104,000 now waivered), though 80-90% of those with addiction do not get treatment. The report urges lawmakers to remove barriers to medications to treat opioid use disorder (e.g., remove prior authorization, continue telehealth flexibilities); remove barriers to treatment in jails and prisons; increase access to care rather than punishment for those who are pregnant and parenting; increase access to affordable, evidence-based care for pain; increase efforts to ensure parity compliance; improve data collection; and support harm reduction services.
COVID-19 presents an opportunity to re-think the addiction treatment system
COVID-19 has presented an opportunity for more accessible and on-demand treatment through virtual resources. Federal and state agencies have waived regulations on telehealth, medication access and reimbursement to make it easier to access treatment during the emergency. There is federal legislation to make many of these changes permanent. Even without changes to federal law, federal agencies have the legal authority to extend many protections. However, many people do not have access to a phone or computer or a private and safe place to talk, and enhanced use of technology magnifies the need for strict privacy and consent standards. COVID has highlighted fragmented systems, exacerbated conditions that mental health and substance use disorders thrive in and highlighted the disproportionate impact on communities of color. A re-imagined system must include easy initiation of treatment and medication; seamless payment and service provision; incorporating housing, food and economic mobility; addressing racial disparities in treatment access; ensuring equitable access to care and technology; social connection; and purpose.
Source: Re-imagining Mental Health and Addiction Treatment After COVID-19 (Georgetown O’Neill Institute)
CMS awards $15 million for mobile crisis intervention
The Centers for Medicare and Medicaid Services awarded $15 million in planning grants to 20 states to support expanding community-based mobile crisis intervention services for Medicaid beneficiaries. By connecting people experiencing a behavioral health crisis to a specialist or treatment, these services, which will be available 24/7, will help reduce reliance on law enforcement when people are experiencing a behavioral health crisis and may help prevent unnecessary incarceration. The grants, funded by the American Rescue Plan, will provide resources for state Medicaid agencies to assess community needs and develop programs to bring crisis intervention services to individuals experiencing behavioral health crises. They will help states integrate community-based mobile crisis intervention services into their Medicaid programs. Funds can be used to support assessments of current services; strengthen capacity and information systems; ensure that services can be accessed 24/7; provide behavioral health care training for multidisciplinary teams; or seek technical assistance to develop state plan amendments, demonstration applications and waiver program requests under Medicaid.
Source: Biden-Harris Administration Awards $15 Million to 20 States for Mobile Crisis Intervention (Department of Health and Human Services)
Democrats propose tobacco and nicotine taxes to pay for their legislative package
Democrats are targeting tobacco and nicotine to help finance their reconciliation package. The proposal would raise existing federal levies on cigarettes and cigars and introduce new taxes on e-cigarettes. Democrats say the changes could help raise $100 million in revenue over the next 10 years. Health experts and activists have heralded the effort, but the idea has faced criticism from Republicans, who oppose the broader agenda. Tobacco excise taxes are assessed on companies, which generally pass the expenses to consumers in the form of price increases. To Republican lawmakers, the higher taxes put Democrats at risk of violating President Biden’s promise not to raise rates on Americans who make less than $400,000. The White House has argued, however, that the proposed taxes do not violate the pledge, as the tax would not directly affect Americans’ incomes.
Source: Democrats target cigarettes and vaping as potential sources to pay for $3.5 trillion economic package (Washington Post)
States report challenges with and lack of oversight for telehealth for behavioral health services
The Health and Human Services Office of the Inspector General conducted a survey of state Medicaid directors from 37 states that provide behavioral health services via telehealth through managed care. The survey was designed to provide insight into states’ challenges with and evaluations/oversight of telehealth for behavioral health services as of Jan. and Feb. 2020, before the expansion of telehealth due to COVID. While most states can identify which services are provided via telehealth, a few reported being unable to, limiting their ability to evaluate and oversee telehealth. Only a few states have evaluated the effects of telehealth, but they found increased access and reduced costs. Many do not conduct monitoring and oversight of telehealth. Challenges with using telehealth include a lack of training, limited internet connectivity, difficulties with protecting the privacy/security of personal information, the cost of infrastructure and interoperability issues, lack of licensing reciprocity and difficulties with obtaining informed consent.
Source: Opportunities Exist To Strengthen Evaluation and Oversight of Telehealth for Behavioral Health in Medicaid; States Reported Multiple Challenges With Using Telehealth To Provide Behavioral Health Services to Medicaid Enrollees (Department of Health and Human Services Office of the Inspector General)
State and local news
Siloed care harms people with co-occurring mental health and substance use disorders
The California Health Care Foundation released a report based on interviews with Medi-Cal beneficiaries with co-occurring mental health and substance use disorder, as well as family members/friends, providers, administrators and subject matter experts, to understand how people with dual diagnoses experience treatment and highlight impediments to care. Care is divided into separate systems for mental health, addiction and physical health. Each system has its own data and financing mechanisms, charting requirements and privacy regulations. The siloed system is cumbersome for patients and providers. Presenting symptoms are diagnosed as either mental illness or addiction, but rarely both, determining where people enter care and how they self-identify. This puts them at risk of relapse or never having their illnesses fully treated. There is a high risk of experiencing homelessness in this population. Coordinated care across systems works. Many with dual diagnoses emphasized that they achieved well-being only when all their providers worked together and when other support (e.g., housing, employment training and placement, transition from residential treatment or incarceration), were available.
Source: In Their Own Words: How Fragmented Care Harms People with Both Mental Illness and Substance Use Disorder (California Health Care Foundation)
Purdue bankruptcy plan formally approved and appealed
U.S. Bankruptcy Judge Robert Drain formally approved the Purdue bankruptcy reorganization plan. However, the attorneys general from Connecticut, Maryland, Washington and D.C., as well as the U.S. Bankruptcy Trustee, have all announced appeals. The chief objection is that members of the Sackler family would be granted protection from lawsuits over opioids. Connecticut and Washington, as well as the U.S. Trustee, have filed motions for a stay, aiming to suspend the approval of the plan. The motions note that previous Supreme Court rulings support their case and that other courts have held that bankruptcy proceedings cannot be used to release claims against non-debtors like the Sacklers.
Source: Use of OxyContin profits to fight opioid formally approved (Associated Press); Connecticut Attorney General William Tong files motion for stay in Purdue Pharma bankruptcy case. Opioid manufacturer would be freed from lawsuits under bankruptcy deal. (Hartford Courant); U.S. Seeks to Block Bankruptcy Plan That Would Free Sacklers From Opioid Claims (New York Times)
Ohio announces settlement with opioid distributors
Ohio reached an $808 million agreement with Cardinal, AmerisourceBergen and McKesson. Cities/counties will begin receiving compensation as early as November. The money is guaranteed even if the national agreement with the distributors doesn’t come to fruition. The settlement is scheduled to be paid out over 18 years. The distribution plan targets 85% of the money for local distribution – 55% for a foundation created to disburse the money and fund programs that benefit those affected by opioids and/or prevent addiction, 30% for community recovery programs and 15% for the state. The companies must establish a centralized independent clearinghouse to provide aggregated data and analytics about where drugs are going and how often; use data-driven systems to detect suspicious orders from pharmacies; terminate pharmacies’ ability to receive shipments and report those companies to state regulators when they show signs of diversion; prohibit shipping of and report suspicious orders; and prohibit sales staff from influencing decisions related to identifying suspicious orders.
Source: AG Yost Announces Ohio’s Historic $808 Million Settlement with Opioid Distributors (Ohio Attorney General)
Other news in addiction policy
CDC examines xylazine as an emerging threat in overdose deaths
A Centers for Disease Control and Prevention study examined the impact of xylazine, an animal sedative not approved by the Food and Drug Administration for use in humans, on overdose deaths in 38 states and D.C. in 2019. Xylazine can cause respiratory depression, slowed heart rate and hypotension. When used as an adulterant in opioids, it can increase risk for fatal overdose. Xylazine was detected in overdose deaths in the majority of the states. Xylazine was listed as a cause of death in 64% of deaths in which it was detected. The majority of xylazine-involved deaths were among males, non-Hispanic White individuals and those from Northeast states. Nearly all also involved another drug, mostly fentanyl. While few overdoses were xylazine-positive, the involvement of xylazine in overdose deaths in multiple jurisdictions is concerning and warrants surveillance.
Source: Notes from the Field: Xylazine Detection and Involvement in Drug Overdose Deaths — United States, 2019; Notes from the Field: Xylazine, a Veterinary Tranquilizer, Identified as an Emerging Novel Substance in Drug Overdose Deaths — Connecticut, 2019–2020 (Centers for Disease Control and Prevention)
Report examines recovery support service models and financing
Third Horizon Strategies released a white paper examining current investments in recovery support services. It provides an overview of federal programs and funding for recovery support services, provides background and examples of current efforts (recovery housing, recovery community centers, peer recovery support services, education-based recovery services, culturally responsive recovery supports) and opportunities for expansion.
Source: Enhancing Community Recovery Capital in America: Recovery Support Service Models, Efficacy, and Financing (Third Horizon Strategies)
Presenting New Directions for Substance Use Prevention
Substance use prevention, along with treatment and recovery support, is a key component of the public health approach needed to transform how our nation addresses addiction. Yet prevention historically has been underfunded. Initiatives have been narrow, drug-specific and concentrated on the adolescent years, when youth risk behaviors are most likely to manifest.
A growing body of research on the effects of adverse and positive childhood experiences, along with neuroscientific evidence emerging from the National Institute on Drug Abuse’s Adolescent Brain Cognitive Development Study on the importance of social and structural determinants of health, have made it increasingly clear that the roots of addiction risk and resilience are planted very early in life.
Friends of NIDA, the Partnership to End Addiction, and the American Psychological Association invite you to join us for a free webinar on new directions for substance use prevention on Monday, September 27th from noon to 1:15pm.