Roadmap on State-Level Efforts to End the Opioid Epidemic

Health Update

Editor’s Note: Manatt Health and the American Medical Association (AMA) have partnered to create the “National Roadmap on State-Level Efforts to End the Opioid Epidemic: Leading-Edge Practices and Next Steps.” The roadmap is based on an in-depth analysis of the response to the opioid epidemic by four states: Colorado, Mississippi, North Carolina and Pennsylvania.

The analysis, summarized below, focuses on state efforts to improve access to high-quality, evidence-based treatment for persons with a substance use disorder (SUD) or the need for comprehensive, multidisciplinary, multimodal pain care, and to increase access to naloxone to save lives from overdose. The analysis also highlights the need to evaluate state-level data and policies to determine what is working while amending actions and policies that may be having unintended consequences. Click here to download a free copy of the complete roadmap.


Four Major Themes

Four key themes emerged from our analysis of how the states we analyzed were responding to the opioid epidemic:

1. States must be willing to use their oversight and enforcement authority. State regulators have differing degrees of authority to pursue policies and changes that can have a significant impact on reducing barriers and improving patient care, but the extent to which they use these tools to increase access to evidence-based treatment or hold payers and others accountable for impeded access varies considerably.

2. Medicaid is leading the way. Medicaid is on the front lines and often provides more comprehensive care for substance use disorders than the commercial insurance market does. There may be opportunities to extend Medicaid successes to commercial coverage. Expanding Medicaid would help even more patients.

3. Grants are helpful, but long-term implementation needs long-term, sustainable funding. Many best practices that are helping save lives are grant-funded and need long-term, sustainable funding to continue benefiting patients. Without reliable funding streams, programs that help save lives will simply go away.

4. The process of evaluating what works is just starting. Some states have undertaken efforts to evaluate current policies and programs to determine what is actually working; most of these evaluations are just beginning. Comprehensive analysis is essential in order to focus resources on successful interventions—and to revise or rescind policies that are having unintended consequences.

Lessons Learned

The four state spotlights highlight lessons learned from Medicaid directors, insurance commissioners and other state officials, but many of those lessons are relevant for governors, state regulators, attorneys general, federal policymakers, and other public- and private-sector leaders who drive states’ responses to the epidemic. In addition, many findings are most relevant for patients with either Medicaid or state-regulated commercial insurance coverage.

Individuals without affordable coverage are very unlikely to receive sustained treatment. This means that states that have expanded Medicaid coverage to low-income adults are, at baseline level, far ahead of those that have not expanded in terms of addressing this epidemic. Expanding their Medicaid programs as allowed under the Affordable Care Act (ACA) is a key step states can take to address the epidemic.

Six Areas for Action

This national roadmap highlights six key areas where regulators, policymakers and other key stakeholders can take action.

1. Access to evidence-based treatment for opioid use disorder. Remove prior authorization and other barriers to medication-assisted treatment (MAT) for opioid use disorder—and ensure MAT is affordable.

2. Parity enforcement. Increase oversight and enforcement of mental health and substance use disorder parity laws.

3. Network adequacy/workforce enhancement. Ensure adequate networks that allow for timely access to addiction medicine physicians and other healthcare professionals; this includes payment reforms, collaborative care models, and other efforts to bolster and support the nation’s opioid use disorder treatment workforce.

4. Pain management. Enhance access to comprehensive, multidisciplinary, multimodal pain care, including non-opioid and non-pharmacologic pain care options.

5. Access to naloxone. Reduce harm by expanding access to naloxone and coordinating care for patients in crisis.

6. Evaluation. Evaluate policies and outcomes to identify what is working to build on the most successful efforts, and also to identify policies and programs that may need to be revised or rescinded.

Conclusion

Policymakers and regulators across the country and in Washington, D.C., have made ending the opioid epidemic their highest priority. This epidemic has led to the passage of hundreds of new laws, regulations, clinical guidelines and national recommendations. Some policies are evidence-based, such as increasing access to MAT, removing barriers to comprehensive pain care and enhancing availability of naloxone to help prevent overdose deaths. Others, such as arbitrary prescribing limits and prior authorization for MAT, continue to hurt efforts to improve patient outcomes. There must be a thorough evaluation and commitment by states to further policies that work and revise or rescind policies that are demonstrating harm to patients.

The AMA–Manatt analyses also revealed multiple areas in which there have been positive outcomes and promising results. This includes the development of hub-and-spoke models of care, community-based naloxone access efforts, and reforms in state Medicaid agencies to improve access to non-opioid pain care. These efforts represent areas that all states can learn from and potentially adopt. Putting these efforts into action, however, will require state regulators to commit to meaningful oversight and enforcement of mental health and substance use disorder parity laws and take bold steps to identify and resolve gaps in treatment networks.

The analyses also identified several areas in which additional work can be done to further increase access to evidence-based care. This includes work being done by emergency departments to assess and refer patients to treatment for opioid use disorder, but many successful pilot programs are dependent on grant funding. Further success of these pilots will require states to commit considerable resources to ensure long-term benefits.