National policy roadmap on efforts to end the drug overdose epidemic

The American Medical Association (AMA) and Manatt Health released a national policy roadmap in September 2019 to guide policymakers in taking action to help end the nation’s opioid epidemic. This expanded 2020 roadmap starts with our 2019 policy recommendations and an assessment of progress made.

View the national policy roadmap (PDF).

The results are mixed, with the COVID-19 pandemic creating new challenges as well as the fact that the opioid epidemic has now become a much more complicated and deadly epidemic due to illicitly manufactured fentanyl, methamphetamine, cocaine and heroin. Overdose and death related to prescription opioids has decreased slightly but remains far too high.

In addition to providing a more robust evidence base with more than 200 citations and references that highlight both the complicated nature of the nation’s drug overdose epidemic and the work being done in the states to progressively combat it, the 2020 roadmap provides important emphasis on addressing racial inequities in care for historically marginalized and minoritized communities.

The 2020 roadmap also goes into far more detail than 2019 in providing actionable recommendations and tangible examples for state legislatures, departments of insurance, attorneys general, state Medicaid officials and other key policymakers.

The 2020 national roadmap lays out specific recommendations across six major policy areas:

• Increase access to evidence-based treatments to help patients with a substance use disorder.
• Enforce mental health and substance use disorder parity laws.
• Ensure access to addiction medicine, psychiatry and other trained physicians.
• Improve access to multidisciplinary, multimodal care for patients with pain.
• Expand harm reduction efforts to reduce death and disease.
• Improve monitoring and evaluation.

Within each of these areas, the 2020 roadmap details several key themes

Policy innovations in response to the COVID-19 pandemic. The federal government and many states quickly adopted policies to ease prescribing for medications to treat opioid use disorder (MOUD) and other controlled substances. Telehealth has increased access to mental health and substance use disorder counseling and treatment. It will be important to evaluate and retain those changes in telehealth, counseling and access to MOUD that have helped sustain individuals with chronic pain and/or an SUD engaging in treatment during the pandemic.

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. The 2020 roadmap highlights many areas, for example, where health insurers have been found to routinely violate mental health and substance use disorder parity laws, but only a few states have taken meaningful action to enforce parity laws.

Medicaid often leads the way. Medicaid is a major payer for SUD treatment, serving four in ten individuals with an OUD in the United States. It often provides more comprehensive SUD care than the commercial insurance market and, in all states, has been a driving force for greater use of MOUD. Not all states, however, have expanded Medicaid and there are others that still do not cover methadone—a historically proven medication to help treat OUD.

Grants are helpful, but long-term implementation needs long-term, sustainable funding. Many best practices that are helping save lives are currently grant funded and need long-term, sustainable funding to continue benefiting individuals with an SUD. Without reliable funding streams, programs that help save lives may simply stop.

Policymakers and regulators across the country and in Washington, D.C. have spent considerable time, energy and resources on ending the nation’s drug overdose epidemic. This epidemic has led to the passage of hundreds of new laws, regulations, clinical guidelines and national recommendations.

Some are evidence-based, such as increasing access to MOUD, enforcing mental health and substance use disorder parity laws and enhancing access to harm reduction services, including continued emphasis on access to naloxone to help save lives from opioid-related overdose. These are positive gains, but there also are multiple areas needing additional attention based on our analysis:

Policy implementation remains elusive. Even as access to evidence-based treatment for OUD has been a major focus, much more work remains to ensure access to treatment for OUD. Moreover, while some policymakers have recognized the need to increase access to alternatives to opioids (ALTO), few actions have occurred to make access to ALTOs a reality. In addition, while naloxone has saved the lives of tens of thousands of Americans, comprehensive harm reduction efforts also must include increased access to sterile needle and syringe services programs.

Policies must be examined. This report highlights the need for thorough evaluation and commitment by states to further policies that work and to revise or rescind policies that are harmful to patients. This includes ensuring that policy evaluation and data collection directly address long-standing health inequities. Specifically, policies must be carefully examined to determine whether they help improve patient outcomes and reduce mortality. If they don’t accomplish these goals, they need attention.

There are many examples to learn from. The 2020 roadmap identifies many initiatives that all states can learn from and potentially adopt. This includes providing MOUD to those in justice-involved settings, removing stigma for OUD and pain, and using data to meaningfully reduce longstanding health inequities.

Demonstrating program success is a work in progress. Because many successful pilot programs are dependent on grant funding, we urge greater attention to program evaluation to help illuminate which pilot programs that may be helping hundreds of people today can be scaled up as national models that could help hundreds of thousands tomorrow.

All stakeholders can take action. This national roadmap provides recommendations that may not be easy to implement, but they are necessary to help end the epidemic. There are recommendations that can be applied by governors, state legislators, attorneys general, insurance commissioners, Medicaid officials and other policymakers. Many of the recommendations also could be implemented voluntarily by health insurance companies, PBMs and other stakeholders if they were so inclined or encouraged to do so. Patients with an SUD and patients with pain need help. The overdose epidemic is more deadly than ever. Physicians and other health care professionals must continue to take action, and the AMA stands ready to work with all stakeholders to implement these recommendations and help America’s patients.

With an increased number of people reporting worsening mental health in recent years, it is imperative that people are aware of the 988 Suicide & Crisis Lifeline (formerly known as the National Suicide Prevention Lifeline) telephone program.

People experiencing a suicidal, substance use, and/or mental health crisis, or any other kind of emotional distress can call, chat or text 988, and speak to trained crisis counselors. The national hotline is available 24 hours a day, 7 days a week.

The previous National Suicide Prevention Lifeline phone number (1-800-273-8255) will continue to be operational and route calls to 988 indefinitely.