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Featured topic and speakers
Bobby Mukkamala, MD, chair of the AMA Substance Use and Pain Care Task Force, discusses the CDC’s provisional data that showed a decline in drug overdose deaths. Dr. Mukkamala breaks down the numbers and how physicians and the AMA can help to end the overdose epidemic. AMA Chief Experience Officer Todd Unger hosts.
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Speaker
- Bobby Mukkamala, MD, chair, AMA Substance Use and Pain Care Task Force
Transcript
Unger: Hello and welcome to the AMA Update video and podcast. On the heels of National Addiction Treatment Week, today we're talking about the current overdose landscape and the crucial role that physicians play in addiction treatment and recovery. Here with me today is Dr. Bobby Mukkamala, chair of the AMA Substance Use and Pain Care Task force and AMA president-elect in Flint, Michigan. I'm Todd Unger, AMA's chief experience officer in Chicago. Dr. Mukkamala, it's great to see you.
Dr. Mukkamala: Thank you. It's good to be here with you too.
Unger: Well, last week was National Addiction Treatment Week. But several weeks before that, overdose numbers were already making headlines for a different reason, I think, than we've talked about before. This time it was for an unprecedented drop in overdose deaths. Dr. Mukkamala, what is happening with the numbers?
Dr. Mukkamala: Well, a little more than a month ago, the CDC published preliminary data that showed between April of 2023 and April of 2024, overdose deaths declined by about 10% nationally to roughly 101,000. And that's the largest decrease on record. So that's awesome.
Non-fatal overdoses are also down more than 10%. So some states have reported even greater discovery-- or greater decreases than the national rate. So for example, in Kentucky, overdose deaths dropped by more than a third between April 2023 and March 2024. In Arizona, in Maine, in Vermont, all recorded recent decreases of about 15%. In North Carolina's illicit fentanyl overdose death fell by more than 30% in a year.
So public health officials are calling this a major breakthrough in efforts to reduce the effects of illicitly manufactured fentanyl in the nation's drug supply, so the culprit drug that caused the spike in the first place. So this is definitely good news. And any increase in mortality is good news. But there are still more than 100,000 people who have died and these are preventable deaths. So we still have a lot of work to do.
Unger: So you mentioned kind of getting control of that illicit fentanyl production as being a key driver. Is there anything else that you see is driving the decrease?
Dr. Mukkamala: Well, I wish we knew for sure. We don't know specifically. The data just isn't there for specific conclusions. But it's likely due to many different factors, some of which are more likely to prevent in some states than others. And it's not only the decreases that are interesting here, it's the pace of that decrease. So much of it has happened in just the past few months and for reasons that aren't exactly clear.
So some think that the tools we use to reverse the opioid overdoses, such as naloxone, are working, and that's likely playing a positive role in keeping people alive. Naloxone is certainly much easier to find and has also become more affordable. And so there are more naloxone products and also other opioid overdose reversal medications that are available now. So we urge all physicians to prescribe them to their patients at a risk of overdose.
And it's also possible that the more syringe service programs are reaching people more effectively and thus the use of fentanyl test strips could be helping, and so these are what we call harm reduction tools that we've long advocated for. And finally, it's also possible that people who use drugs are using differently. That is because of how deadly illicitly manufactured fentanyl is, people might not be using it as much. So lots of possibilities, all of which are good.
Unger: Now, you mentioned, up front, great news in terms of the percentage decline, but we still have 100,000 people or so dying of overdose. So there's a lot of work to do, I think, to use your words. So in your mind, where do things stand right now and how should physicians be thinking about the numbers?
Dr. Mukkamala: Yeah, well, we've got to remember that the number of overdose deaths that we're seeing prior to this drop were extraordinarily high. And we still don't know if this decrease is a blip or the beginning of a sustained downward trend. So in medicine, when I see a patient, I'm deciding whether to go with treatment A or treatment B, I don't do both at the same time because if the patient gets better, well, that's wonderful. I won't know which helped.
And so, even if the numbers are trending in the right direction, this is still a huge problem and too many people are dying. And it's also a problem that we don't know why. So it's great that fewer people are dying, but without knowing why, it's hard to separate what's working from what's not and advocate for a particular solution.
So all of these deaths are preventable. So even one death is too many. And that's what last week's National Addiction Treatment Week, as you mentioned, is really about. The week is organized by the American Society of Addiction Medicine, and the AMA is a co-sponsor, as we have been for years in the past.
So every year that week serves as a reminder that addiction is a treatable chronic disease, not a moral failing. It's a welcome change in the mindset about how we think about people with a substance use issue. Everyone can play an impactful role in saving lives in communities affected by addiction, if we think about it that way.
Unger: What do you see as the physicians kind of specific role in helping to end this pandemic and hopefully turn this into a trend?
Dr. Mukkamala: Yeah, so physicians' expertise and compassion are pivotal in spreading awareness that recovery is possible. So the AMA has worked to help remove barriers to care for patients with opioid use disorder, including making it easier for physicians to prescribe buprenorphine to treat patients. So buprenorphine helps control the cravings, and it's a critical part to helping individuals lead normal lives.
So what we need is for more physicians to screen for opioid use disorder and to prescribe buprenorphine when needed. Primary care and other specialties treat many chronic diseases, and opioid use disorder needs to be part of that instead of being thought of as some type of parallel condition. So even with these falling numbers, the stigma still exists, and the medical community has to be a leader in removing that stigma.
And fear of being judged or shamed can keep people from seeking care or treatment in the first place. And so it's also important to have them accessing harm reduction tools that we have available. So judging our patients doesn't help their disease. And it shouldn't just-- it shouldn't be part of any medical practice, that judgment. We need to understand that patients with a substance use disorder have a chronic disease.
And the AMA and the Nation's Medical Societies continue to emphasize the need to treat patients with addiction, with care and compassion. And we've made progress, but we know there's much more work to be done. And reducing stigma will save lives.
Unger: That's an excellent point. Unfortunately, stigma is not the only barrier here. There are other barriers that can make it really difficult for people to get the treatment that they need. What are some of the other barriers that really need to be addressed?
Dr. Mukkamala: Yeah, so let's talk about three of the biggest barriers. So health insurance companies that deny and delay care, pharmacy chains that don't stock lifesaving medications, and policies that punish pregnant people for having a substance use disorder. One of the biggest health insurance company barriers that physicians are all too familiar with is prior authorization.
So health plans make physicians spend hours on paperwork and phone calls to justify proven evidence-based treatment for opioid use disorder. If a patient with a substance use disorder is forced to wait for care, that patient is going to likely suffer intense and painful withdrawal symptoms. They might return to using illicit substances and overdose and die, all because of these insurance company hurdles.
I mean, it's bad enough to have prior authorization create delays in treating patients with cancer. But to have a patient that's finally gotten to the point in their mind that they acknowledge and are ready to seek treatment for their substance use disorder, but then run into a wall of prior authorization, it's just inexcusable.
Second, for opioid use disorder, buprenorphine is generally considered the gold standard of treatment. But more than 40% of pharmacies don't even stock this medication. The gold standard, and 40% don't stock it. The stigma of not wanting those patients in the pharmacy likely plays a big factor.
And there are still many states that have laws essentially criminalizing addiction when a person is pregnant. And so what happens is that rather than doing everything possible to get a pregnant person into treatment so their pregnancy can be safely and effectively managed, state laws subject pregnant people to intrusive investigations that actually scare them away from seeking care.
So rather than improve care, these punitive laws make it worse for the pregnant person, the fetus, the newborn and other family members. So the AMA wants to encourage pregnant people who use substances to seek care without fear. And that's going to take changing state laws in many cases.
Unger: So you mentioned really a kind of a triple set there of obstacles, starting with one of the things we talk a lot about on this program, and that is prior authorization, but also having the drug in stock so people can access this, and then a web of laws, so to speak, that make those barriers even more difficult. Right in the sweet spot of AMA's activities, can you tell us a little bit more about what the AMA is doing on those fronts?
Dr. Mukkamala: Sure. Yeah. And we're doing a lot. So the AMA advocacy team is actively working to overcome many of these barriers, and has been for some time. So on the barriers mentioned above, the AMA is working closely with departments of insurance and state medical societies to remove prior authorization for medications for opioid use disorders.
And we're fighting hard to increase the penalties against insurance companies who violate the law by having inadequate networks of physicians to treat addiction and mental illness, mental health parity, in name only, but not really in a meaningful way. And so, the AMA is fighting to increase the evidence-based care by urging the DEA to maintain helpful telehealth rules that allow treatment via audio only and audio visual patient visits.
And the AMA is urging departments of insurance to investigate and hold accountable these health insurance companies that illegally deny or delay care for substance use disorder. And we've also developed model state legislations to revise punitive state laws that punish pregnant people with a substance use disorder and hopefully start to remove the fear and stigma that they feel. So I mean, I could go on and on, but the bottom line is that we already have succeeded on multiple fronts, but there's much more work to do.
Unger: That's great news. Dr. Mukkamala, I'm curious, what's the single most important thing that you'd like physicians to take away from today's conversation?
Dr. Mukkamala: With this latest number, I would say that we're making progress on dealing with this epidemic. There's a glimmer of hope with this latest data. We're still losing 100,000 friends and family members to this illness. And we have issues with substance use disorder itself, and we have issues with the environment in which we practice that make it challenging to do the right thing that we've just discussed.
So we need to work beyond our individual professions. We need to work collaboratively on all of these things to continue to reverse this trend.
Unger: Dr. Mukkamala, thank you so much for joining us today and for all the work that you and the task force continue to do to address this devastating epidemic. To learn more about the AMA's efforts and get involved, visit end-overdose-epidemic.org. The AMA is also making it easier for physicians to complete their required DEA training for the MATE Act.
AMA members can now access four curated CME courses designed specifically for practice settings and specialties. Check out the link in the episode description to learn more. That wraps up today's episode, and we'll be back soon with another AMA Update. Be sure to subscribe for our new episodes and find all our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today. Please take care.
Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.
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