AMA cites need to remove barriers to evidence-based care for patients with pain or a substance use disorder

The American Medical Association’s Opioid Task Force report  released today shows a dramatic increase in fatalities involving illicit opioids, stimulants (e.g. methamphetamine), heroin and cocaine and a similarly dramatic drop in the use of prescription opioids.  

The changing landscape of the opioid epidemic poses challenges for the health care system, which must pivot to treat people in danger of overdose from all drugs.  The AMA is calling on stakeholders – including health insurers and policymakers – to remove barriers to evidence-based care. Red tape and misguided policies are grave dangers to pain patients and those with an opioid-use disorder.

Physicians have reduced opioid prescribing, increased use of state prescription drug monitoring programs (PDMP) and increased the prescribing of naloxone. Physicians also have continued to educate themselves on safe prescribing, pain management and recognizing signs of addiction. More than 50,000 physicians and other health care professionals have become certified to provide treatment for opioid use disorder in the past three years. Yet, illicit drugs are now the dominant reason why drug overdoses kill more than 70,000 people each year.

According to the U.S. Centers of Disease Control and Prevention (CDC), from the beginning of 2015 to the end of 2019:

• Deaths involving illicitly manufactured fentanyl and fentanyl analogs increased from 5,766 to 36,509;
• Deaths involving stimulants (e.g. methamphetamine) increased from 4,402 to 16,279;
• Deaths involving cocaine increased from 5,496 to 15,974;
• Deaths involving heroin increased from 10,788 to 14,079;
• At the same time, deaths involving prescription opioids decreased from 12,269 to 11,904. (Deaths involving prescription opioids reached their high in July 2017 with 15,003.)

“The nation needs to confront the fact that the nation’s drug overdose epidemic is now being driven predominantly by highly potent illicit fentanyl, heroin, methamphetamine and cocaine, although mortality involving prescription opioids remains a top concern,”  said AMA Opioid Task Force Chair Patrice A. Harris, M.D., M.A., who also is the AMA’s immediate past president. “If it weren’t for naloxone, there likely would be tens of thousands additional deaths. It is past time for policymakers, health insurers, pharmacy chains and pharmacy benefit managers to remove barriers to evidence-based care for patients with pain and those with a substance use disorder.”

Key points from the 2020 report:

• Opioid prescribing decreases for a sixth year in a row. Between 2013 and 2019, the number of opioid prescriptions decreased by more than 90 million — a 37.1 percent decrease nationally.[1]

• Prescription Drug Monitoring Program (PDMP) registrations and use continue to increase. In 2019, health care professionals nationwide accessed state PDMPs more than 739 million times – a 64.4 percent increase from 2018 and more than an 1,100 percent increase from 2014. More than 1.8 million physicians and other health care professionals are registered to use state PDMPs.[2]

• More physicians are certified to treat opioid use disorder. More than 85,000 physicians (as well as a growing number of nurse practitioners and physician assistants) now are certified to treat patients in-office with buprenorphine— an increase of more than 50,000 from 2017.[3]

• Access to naloxone increasing. More than 1 million naloxone prescriptions were dispensed in 2019—nearly double the amount in 2018, and a 649 percent increase from 2017.[4]

The report highlighted that despite medical society and patient advocacy, only 21 states and the District of Columbia have enacted laws limiting public and private insurers from imposing prior authorization requirements on substance use disorders’ services or medications, according to the Legal Action Center. Even fewer states have taken meaningful action to enforce mental health and substance use disorder parity laws. While access to legitimate opioid analgesics has decreased in every state, no state has taken meaningful action to require health insurers to increase access to non-opioid pain care or to remove arbitrary restrictions on access to opioid therapy. A recent survey from The American Board of Pain Medicine found 92 percent of pain medicine physicians said they have been required to submit a prior authorization for non-opioid pain care.

Specific actions that policymakers can take, include:

• Remove prior authorization, step therapy and other inappropriate administrative burdens or barriers that delay or deny care for FDA-approved medications used as part of medication-assisted treatment (MAT) for opioid use disorder.
• Support assessment, referral and treatment for co-occurring mental health disorders as well as enforce meaningful oversight and enforcement of state and federal mental health and substance use disorder parity laws, including requiring health insurance companies to demonstrate parity compliance at the time of their rate and form filing.  
• Remove administrative and other barriers to comprehensive, multimodal, multidisciplinary pain care and rehabilitation programs.
• Support maternal and child health by increasing access to evidence-based treatment, preserving families, and ensuring that policies are non-punitive.
• Support increased efforts to expand sterile needle and syringe services programs as well as reforms in the civil and criminal justice system that ensure access to high quality, evidence-based care for opioid use disorder, including MAT.
• Implement systems to track overdose and mortality trends to provide equitable public health interventions that include comprehensive, disaggregated, racial and ethnic data collection related to testing, hospitalization, and mortality associated with opioids and other substances.

“We know that ending the drug overdose epidemic will not be easy, but if policymakers allow the status quo to continue, it will be impossible,” Dr. Harris said. “This is particularly important given concerns that the COVID-19 pandemic is worsening the drug overdose epidemic. Physicians will continue to do our part. We urge policymakers to do theirs.”

The report can be found here.