Leading-Edge Practices for Ending the Opioid Epidemic

Health Update

Editor’s Note: The American Medical Association (AMA) and Manatt Health are undertaking in-depth analyses of four states’ responses to the opioid epidemic to identify best practices and next steps to address the crisis. In the first spotlight analysis, summarized below, we analyze Pennsylvania’s response to the epidemic in three areas: substance use disorder treatment, pain management and harm reduction. To download the full analysis free, click here

The second spotlight analysis, focusing on Colorado, is also now available here. Watch for our summary of key highlights in next month’s “Health Update.”   

______________________________________

Pennsylvania has been hit hard by the opioid epidemic, with prescription opioid-related overdoses growing in the early 2000s—and, more recently, high volumes of heroin and fentanyl coursing through the Commonwealth, given its strategic location as a major transportation hub.

Pennsylvania’s challenges make an ideal case study of how strong leadership can make a difference—even if the fight is not over yet. In January 2018, Governor Tom Wolf issued and has continued to renew a 90-day opioid disaster declaration. He also has mobilized an interagency task force to treat patients and reduce harm.

There has been a 28% decline in opioid prescriptions since 2013, but the loss of life and the emotional toll of the epidemic continue to climb. Consistent with national trends, Pennsylvania’s opioid-related death rate increased sharply from 2015 to 2017 despite the state’s actions. The increase demonstrates that it will take much more than cutting opioid prescriptions to solve the opioid crisis. It will require a concerted federal and state partnership to bring the epidemic under control.

Pennsylvania is not alone in finding that the epidemic continues to evolve. Even as the rate at which physicians are prescribing opioids declines, heroin and illicit fentanyl—a synthetic opioid that is 50 to 100 times more potent than heroin—are rushing in to drive up death rates.

A new spotlight analysis by the AMA, Manatt Health and the Pennsylvania Medical Society highlights the work of two agencies—the state Medicaid agency (housed in the Department of Human Services) and the Pennsylvania Insurance Department (PID)—that are at the forefront of the fight. These two agencies address coverage issues that determine what care is accessible and affordable to the 27% of Pennsylvanians covered by Medicaid and the Children’s Health Insurance Program (CHIP) and the 24% who are fully insured with individual or group coverage.

Where Is Pennsylvania Succeeding?

Comprehensive support for medication-assisted treatment (MAT). Pennsylvania has adopted multiple measures to increase access to MAT for substance use disorders, considered essential for evidence-based treatment. These include eliminating prior authorization requirements for MAT and establishing 45 Centers of Excellence—offering both mental and behavioral healthcare services—to expand access to MAT.

Enforcement of parity laws. The PID is actively reviewing benefits packages, prior authorization policies and cost-sharing obligations to enforce mental health and parity laws. The PID found significant parity violations in a market conduct exam and is in the process of completing exams on all leading insurers.

Medically based oversight for Medicaid patients. Pennsylvania has combined medical oversight of patients on opioid therapy with expanded access to non-opioid pain management strategies in Medicaid, including coverage of non-opioid prescription medications, as well as alternative therapies, such as physical therapy, occupational therapy and behavioral health services.

Comprehensive naloxone access. A statewide standing order and stakeholder support for increased naloxone access have helped save lives by reducing deaths from overdoses.

Where Can Pennsylvania Build on Its Successes?

Continuum of care for patients with substance use disorders. Pennsylvania should continue to build out state infrastructure and ensure that health insurers and Medicaid identify and remove barriers to adequate networks and create strategies to overcome workforce shortages. Infrastructure improvements include further development of hub-and-spoke arrangements, including leveraging federal funding to turn grant programs into sustained practices.

Pain care. The commonwealth should identify best practices for providing comprehensive, multimodal pain care. It should work closely with stakeholders to review and reform benefit design and formulary requirements to ensure patients have access to non-opioid alternatives.

Naloxone access. Pennsylvania can build on its naloxone access success through statewide education efforts with physicians and other key stakeholders.

Evaluation. Pennsylvania should continue to build on efforts underway at the Department of Health to evaluate the commonwealth’s efforts and determine what is truly working to improve patient care and reduce opioid-related harms, including understanding the relationships between current policies and clinical outcomes, to advance successful initiatives while amending those that may be having unintended consequences.