COVID-19 policy recommendations for OUD, pain, harm reduction

The AMA is providing the following policy recommendations to help states and others with specific policy recommendations amid the COVID-19 global outbreak. These recommendations are to help guide policymakers reduce the stress being experienced by patients with an opioid use disorder (OUD) and pain as well as support efforts to continue harm reduction efforts in communities across the United States. Read about examples of these efforts.

• The AMA is greatly concerned by an increasing number of reports (PDF) from national, state and local media suggesting increases in opioid-related mortality—particularly from illicitly manufactured fentanyl and fentanyl analogs.
• The AMA urges governors to adopt new U.S. Drug Enforcement Administration (DEA) guidance (PDF) providing flexibility for physicians managing patients with opioid use disorder. This includes authorizing prescriptions for buprenorphine for the treatment of opioid use disorder to new and existing patients based on an evaluation via telephone.
• Designate medications to treat addiction (buprenorphine, methadone, naltrexone) and medications to reverse opioid-related overdose (naloxone) as “essential services” to reduce barriers to access during “shelter-in-place” orders. The U.S. Drug Enforcement Administration has already waived federal requirements for in-person visits before controlled substance prescribing; we encourage states to take similar action for their controlled substance regulations.
• Prohibit cost-sharing and prior authorization for medications used to treat addiction, including buprenorphine, methadone and naltrexone; allow for a 90-day prescription for patients receiving buprenorphine; payers should suspend all day limits on residential and intensive out-patient therapy.
• States should request a blanket exception to SAMHSA for Opioid Treatment Programs (OTP) (PDF) to receive Take-Home doses of a patient’s medication for opioid use disorder.
• Remove any restrictions on the Medicaid preferred drug lists to help avoid medication shortages. This includes ensuring coverage for methadone for patients receiving care in an OTP.
• Correctional and justice settings should temporarily waive strict requirements for submitting drug tests, in-person counseling and “check-ins” and similar requirements; suspend consequences for failure to meet strict reporting, counseling and testing requirements, including removal from public housing, loss of public benefits, and return to jail or prison. Additional efforts must be made to ensure people receiving MAT in criminal justice settings receive help in transitioning to care after release.

• Adopt DEA guidance (PDF) authorizing physicians to prescribe opioid medications to existing patients without an in-person evaluation; authorize the prescription to be sent to the pharmacy via telephone.
• Waive limits and restrictions on prescriptions for controlled substances, waive for the period of state and national emergency the restrictions on dose and/or quantity as well as refills.
• Waive requirements for electronic prescribing of controlled substances, including requirements for an in-person evaluation for patients requiring a refill; provide liability protections for physicians who prescribe controlled substances for current patients the physician believes in good faith is stable and compliant with taking his or her medications.
• For patients with chronic pain, waive testing requirements and in-person counseling requirements for refills; allow for telephonic counseling to fulfill state prescribing and treatment requirements.
• Enhance home-delivery medication options for patients with chronic pain.
• Issue brief: Reducing barriers to vital pain medication during the COVID-19 pandemic (PDF): The AMA is strongly urging legislators, regulators, governors and policymakers to remove additional barriers to pain treatment to help ensure that patients with pain have access to the treatments prescribed by their physician while remaining safe, reducing travel and unnecessary exposure to potential infection.

• Designate supplies provided by harm reduction organizations as “essential services” to reduce barriers to access during “shelter-in-place” orders.
• Provide assistance to harm reduction organizations to help ensure adequate supplies of naloxone to continue community-based naloxone distribution efforts.
• Ensure continuity of syringe services programs, including provision of PPE. Expand PPE priority to include harm reduction organizations and other community-based organizations that provide services to people who inject drugs to help protect against the spread of infectious disease.
• Implement, as part of an Executive Order or other initiative, specific policies to increase access to sterile needle and syringe exchange services. The state of Maine provides a good example.
• Emphasize the importance of naloxone to help save lives from opioid-related overdose. The AMA encourages physicians to continue to co-prescribe naloxone to patients at risk of overdose when it is clinically appropriate to do so. The AMA Opioid Task Force has identified several factors (PDF) physicians should consider. Patients also are encouraged to take advantage of state standing orders that allows patients to obtain naloxone directly from a pharmacy without a patient-specific prescription.
• Include in future grant requests an emphasis on sterile needle and syringe services programs. As the U.S. Substance Abuse and Mental Health Services Administration—and other federal agencies—are provided new funding for emergency grants, grant funding to support sterile needle and syringe exchange can help protect public health, reduce the spread of blood-borne infectious disease and encourage those with an opioid use disorder to enter treatment.

• Taking action on opioid use disorder, pain & harm reduction during COVID-19