Raising the Standard: Review of National Opioid Policy

BT Online Editor | November 1, 2020

by Anthony T. Petrick, MD, FACS, FASMBS, and Dominick Gadaleta, MD, FACS, FASMBS

Dr. Petrick is Chief Quality Officer, Geisinger Clinic; Director of Bariatric and Foregut Surgery, Geisinger Health System in Danville, Pennsylvania. Dr. Gadaleta is Chair, Department of Surgery, South Shore University Hospital; Director, Metabolic and Bariatric Surgery, North Shore and South Shore University Hospitals, Northwell Health, Manhasset, New York; Associate Professor of Surgery, Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York.

FUNDING: No funding was provided for this article.

DISCLOSURES: The authors report no conflicts of interest relevant to the content of this article.

Bariatric Times. 2020;17(11):18–19

“Never lose hope. Storms make people stronger and never last forever.”

-Martin Luther King, Jr.

Hope is increasingly becoming a casualty of the COVID-19 pandemic. Victims of the American opioid epidemic understand the challenges of hope while living in the midst of a storm. In July 2019, Raising the Standard featured a column describing the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) effort to reduce opioid use and distribution after bariatric surgery: Bariatric Surgery Targeting Opioids (BSTOP).¹ BSTOP remains one of the few coordinated national efforts to target opioids. In this installment of Raising the Standard, we will describe the key elements of the National Opioid Policy.

Much like the impact of COVID-19, the opioid crisis has disproportionately affected the United States (US). Americans consume about 30 percent of world production of opioids, although the US has less than five percent of the global population. In 2017, the Centers for Disease Control and Prevention (CDC) reported that opioids killed more than 70,000 people in the US, more than any previous year on record. Overdose deaths were so high that they contributed to a decrease in overall life expectancy in the US for the third year in a row, depressing the average to 78.6 years.² Both media and scientific reports suggest that opioid-related overdoses are increasing during the COVID-19 pandemic; however, these statistics are difficult to validate in the absence of a national reporting system for opioid-related mortality.

Most providers are unaware that the Drug Enforcement Administration (DEA) is not involved with the administration of any state physician drug monitoring program (PDMP). PDMP is a statewide electronic database that collects designated data on substances dispensed in the state. PDMP programs are currently operational in all 50 states, as well as Puerto Rico, Guam, and the District of Columbia. Intrastate data sharing is operational in all states except California. The housing agency within a state distributes data from the database to individuals who are authorized under state law to receive the information. However, The Bureau of Justice Assistance (BJA) makes funding available through the Harold Rogers Prescription Drug Monitoring grant program. Monitoring is facilitated through the Prescription Drug Monitoring Program Training and Technical Assistance Center at Brandeis University. The center provides a comprehensive array of services, support, resources, and strategies to PDMPs, federal partners and other stakeholders to further the efforts and effectiveness of PDMPs in combating the misuse, abuse and diversion of prescription drugs.^3,4

In September 2019, the American Medical Association (AMA) released an analysis of the national roadmap to combat opioids. Rather than a coordinated federal effort, the roadmap highlights six key areas where regulators, policymakers, and other stakeholders can take action:⁵

Improving access to evidence-based treatment for opioid use disorder by removing prior authorization barriers to medication-assisted treatment (MAT) and ensuring affordability
Increasing oversight and enforcement of mental health and substance use disorder parity laws
Ensuring networks that allow for timely access to addiction healthcare professionals; this includes payment reforms, collaborative care models, and other efforts to bolster the workforce
Expanding pain management options. Enhance access to comprehensive pain care, including nonopioid and nonpharmacologic options. (i.e., BSTOP)
Reduce harm by expanding access to naloxone and coordinating care for patients in crisis
Evaluate policies and outcomes to identify what is working, building on successful efforts, and identifying policies and programs that might need to be revised or rescinded

The AMA suggested that an effective National Opioid Policy must be centered on four key themes, including the following:⁵

Vigorous state oversight and enforcement to hold payers and others accountable for restricting access by using prior authorization for MAT and by enforcing state and federal insurance parity laws
Medicaid expansion, which often provides more comprehensive care for substance use disorders than commercial insurance market
Long-term funding to advance many best practices and sustain effective opioid treatment programs
Measuring success—most of these evaluations are just beginning. Comprehensive analysis is essential to focus resources on successful interventions and to revise or rescind policies that are having unintended consequences.

While we lack a comprehensive National Opioid Policy, there are ongoing federally directed efforts to curb the opioid crisis. In October 2018, Congress passed H.R. 6, Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT) providing guidelines for providers and treatment for patients suffering from opioid dependence. The act directed that opioids must be prescribed electronically for all Medicare patients, opioid prescription patterns for hospitals and providers must be analyzed annually, and, importantly, it eliminated the “fifth” vital sign. The use of pain questions tied to performance and reimbursement was prohibited.⁶

The Centers for Medicare and Medicaid Services (CMS) has addressed the opioid crisis with efforts focused on treatment, prevention and data. CMS coverage policies now ensure some form of MAT across all CMS programs. For the first time in January 1, 2020, Medicare covers methadone for MAT provided by opioid treatment programs and all plans have at least one naloxone product on a nonbranded tier. CMS has supported best practices through drug management programs (DMPs). Although DMPs have been optional since 2019, they have been adopted by 87 percent of participants. Implementation of DMPs will become mandatory in 2022.

CMS has also developed more robust data and tracking of opioids. Policies promoting safer use have reduced the number of beneficiaries receiving higher doses of opioids (≥90 morphine milligram equivalents per day) by 45 percent between 2016 and 2019. CMS now provides a resource containing nationwide Medicaid data on substance use disorder prevalence and treatment, which facilitates both research and policy. CMS has also raised awareness with over 25,000 letters sent to Medicare clinicians comparing prescribing practices and, in June 2020, improved access to opioid use disorder treatment, with new flexibility to cover inpatient and residential treatment.⁷

COVID-19 has almost certainly increased the incidence of opioid dependence and overdose. The pandemic has increased the challenges of receiving treatment (e.g., clinic closures, public transportation disruptions, financial stressors), all of which differentially affect low-income or other vulnerable populations. The lack of a comprehensive National Opioid Policy, including a national reporting system, makes real-time tracking of the opioid problem impossible.

What is also certain is that COVID-19 has also been accompanied by other changes that can help stem the opioid pandemic:⁸

Reducing financial barriers through the emergency expansion of Medicaid
Easing restrictions on the dispensing of methadone
Expanding the role of telemedicine in the care of patients with opioid use disorder.

The national response to the COVID-19 pandemic has drawn attention to the deficiencies in national public health policy and intervention. The same deficiencies have plagued our nation’s response to the opioid epidemic. Healthcare leaders must continue to work within a challenging political system to embed the emergency provisions that have improved access to care and advance toward a comprehensive National Opioid Policy in the US.

References

Petrick AT, Gadaleta D. Raising the standard: Bariatric Surgery Targeting Opioids (BSTOP): the third MBSAQIP National Quality Improvement Project. Bariatric Times. 2019;16(7):12.
Why are Americans in so much pain? Yahoo News. https://news.yahoo.com/americans-much-pain-141918964.html. January 30, 2019. Accessed February 4, 2019.
PDMP Policies and Practices. PDMP TTAC. https://www.pdmpassist.org/Policies. Accessed October 21, 2020.
PDMP Interstate Partners. PDMP TTAC. https://www.pdmpassist.org/Policies/Maps/PDMPInterstatePartners. Accessed October 15, 2020.
National opioid policy roadmap highlights state efforts on epidemic. https://www.ama-assn.org/press-center/press-releases/national-opioid-policy-roadmap-highlights-state-efforts-epidemic. September 9, 2019. Accessed October 15, 2020.
Davis CS. The SUPPORT for Patients and Communities Act—what will it mean for the opioid–overdose crisis? N Engl J Med. 2019;380(1):3–5.
CMS Roadmap. Centers for Medicare and Medicaid Services (CMS). https://www.cms.gov/About-CMS/Agency-Information/Emergency/Downloads/Opioid-epidemic-roadmap.pdf. Accessed October 15, 2020.
Haley DF, Saitz R. The opioid epidemic during the COVID-19 pandemic. JAMA. 2020 Sep 18. Online ahead of print.