America’s drug-overdose epidemic is getting worse. Nearly 90,000 U.S. overdose deaths took place between September 2019 and September 2020, a tally that represents the highest figure since the late 1990s, based on provisional data from the Centers for Disease Control and Prevention (CDC).
And while the physical isolation and financial insecurity caused by COVID-19 accounted for some of the increase, the trend predated the pandemic, pointing to an uncomfortable truth: U.S. drug policies just aren’t keeping up with what’s happening on the ground.
At a virtual meeting of the annual Rx Drug Abuse & Heroin Summit, the AMA’s president, Susan R. Bailey, MD, and director of science and drug policy, Amy B. Cadwallader, PhD, summarized the steps that must be taken at the policy level, in the community and in the exam room to reduce morbidity and mortality from drug overdose (see slides from their talk).
President Joe Biden also made a virtual appearance at the summit, in which he noted that breaking the stigma associated with addiction is a key part of ending the nation’s drug overdose epidemic. The AMA has applauded the Biden administration’s first-year drug policy priorities.
“We have to ensure policies support individualized patient care,” Dr. Bailey said. “COVID has taught us—in clear and sometimes extremely harsh light—that data and evidence-based care must guide treatment and policy decisions.”
The overdose epidemic is now largely driven by illicitly manufactured and adulterated fentanyl and fentanyl analogs, Dr. Bailey and Cadwallader explained in their keynote presentation at the summit. There has also been a sharp increase in deaths from methamphetamine and cocaine.
“Policies and actions need to focus on this new reality, not on limiting prescriptions for patients in pain who really need them,” Cadwallader said in an interview with the AMA.
She and Dr. Bailey recommended the following.
Reevaluate how opioid-use disorder treatments are prescribed. The most obvious barrier is prior authorization, but there are others, including the X-waiver, which allows physicians with specific training to provide medications for addiction treatment. One problem with it is that it increases the stigma associated with treatment of opioid-use disorder (OUD).
“Removing barriers to buprenorphine and methadone will increase access to evidence-based treatment, remove stigma and save lives,” Dr. Bailey said. “That’s why we recommend eliminating the X-waiver for buprenorphine and continuing the current telehealth and other flexibilities for treating patients with OUD and pain for the duration of the nation’s drug-overdose epidemic.”
Eliminate ineffective opioid prescribing restrictions. Many prescribing restrictions are arbitrary, not evidence-based or simply don’t work, leaving patients with pain unable to access the care they need.
“Physicians have reduced opioid prescribing by more than 40% since 2012–2013, yet health insurance companies have failed to increase access to, or affordability of, nonopioid pain care options since then,” Cadwallader said.
Better enforce laws around coverage of mental health and substance use disorders. Numerous state and federal parity laws require insurers to provide mental health or substance-use disorder treatment benefits that are equal to medical care benefits, but only a few states have taken action to meaningfully enforce these laws.
Expand harm-reduction policies. Boosting access to naloxone to reverse opioid overdoses is one example. Removing barriers to needle- and syringe-exchange programs is another evidence-based intervention to reduce harms.
“But we also need to look beyond those two,” Cadwallader said. “For example, states need to review their Good Samaritan laws to make sure they don’t punish bystanders who try to help someone who is overdosing.”
Extend telehealth flexibilities for prescribing buprenorphine for opioid-use disorder. These were established early on in the pandemic by the federal public health emergency. Congress and the Biden administration should continue these flexibilities for at least the duration of the national opioid epidemic, and states should codify them in law.
Collect better data, and do a better job of sharing it. The CDC tracks fatal overdoses nationwide, but there isn’t a comparable source on nonfatal overdoses.
“Public health interventions—to be equitable and effective—must be evidence-based and that also requires high-quality, transparent, standardized data if we are going to meaningfully address the nation’s drug overdose epidemic,” Dr. Bailey said.
Collaborate more broadly. To reach everyone who needs help, physicians need to work with stakeholders outside of medicine, including community activists and religious leaders.
End the stigma. Patients may fear being judged or labeled when seeking medications to treat their pain, and physicians, likewise, can be afraid to suggest or prescribe opioid analgesics. And the same is true for medications to help treat opioid-use disorder.
The AMA believes that science, evidence, and compassion must continue to guide patient care and policy change as the nation’s opioid epidemic evolves into a more dangerous and complicated illicit drug-overdose epidemic. Learn more at the AMA’s End the Epidemic website.
