June 05, 2019 08:37 am Chris Crawford – The AMA Opioid Task Force released recommendations on May 30 that call on policymakers to eliminate barriers to treatment for opioid use disorder/substance abuse disorder and take additional steps to end the nation's opioid misuse epidemic.
The AMA launched the task force in 2014 to identify best practices for combatting opioid abuse and to swiftly implement those practices in medical offices and other health care facilities across the United States. The AAFP is one of 27 health professional organizations that comprise the task force.
The task force's new recommendations focus on barriers to treatment for OUD/SUD and pain, along with other policies that limit patients' ability to receive care. These include prior authorization, step therapy and other administrative burdens, as well as inadequate enforcement of state and federal laws that require insurance parity for mental health and substance use disorders.
"We need help from policymakers to ensure that more people have access to treatment," said AMA President-elect and task force chair Patrice Harris, M.D., M.A., in a news release. "Physicians are responding to the epidemic, and we are seeing results: a reduction in opioid prescribing of 33 percent since 2013, increased use of prescription drug monitoring programs, enhanced education and greater co-prescribing of naloxone. But we cannot enforce parity laws or eliminate administrative barriers without the help of state and federal authorities, and that's what's limiting treatment now."
Robert "Chuck" Rich, M.D., of Bladenboro, N.C., who represents the AAFP on the AMA Opioid Task Force, told AAFP News that as the task force moved to this next level of recommendations, it noted the increasing impact of governmental and insurer policies on the recommended changes in physician behaviors that the original set of recommendations called for.
Task force member organizations cited many examples where these policies and actions/inactions have hampered the availability of treatment alternatives to opioids (both pharmaceutical and nonpharmaceutical), training of physicians interested in offering MAT and their subsequent willingness to offer MAT to their patients, Rich said.
"To increase the availability of alternative treatments to opioids for pain and to increase the availability of MAT, the task force felt that the impact of these burdensome and restrictive policies and actions must be addressed," he said.
Rich said that although a great deal of national attention and effort has been devoted to opioid prescribing by physicians (which has led to substantial reduction in prescribing numbers), the rates of overdose and death from overdose have continued to rise substantially.
"While there are multiple reasons to account for this sharp rise in overdose and death, including the increased use of street drugs as prescription opioids are increasingly restricted, the task force advocates for the expansion of substance abuse treatment and adjunctive services as the common denominator to reverse this trend," he said.
In addition to more restrictive prescribing policies, Rich said multiple factors have contributed to this trend, including changes in physician and patient attitudes about the use of opioids for chronic pain, increased monitoring of physician prescribing by regulatory boards, and the effect of pain management guidelines from multiple associations and professional organizations on prescribing habits. Not to be forgotten in this is the desire of family physicians and other health care professionals to limit patient harm and not contribute to the epidemic, he added.
"From my perspective as a family physician with now over 30 years in practice, I have seen substance abuse evolve to encompass alcohol, prescription opioids and an increasingly potent and deadly mixture of street drugs," Rich said. "Without a significant expansion of substance abuse treatment by primary care physicians and expansion of behavioral health services (including the provision of behavioral health services in primary care offices) to treat the coexisting behavioral health issues, we will never develop enough capacity to treat these patients with their increasingly complex substance abuse issues."
Add to that the fact that a large percentage of patients with OUD/SUD also have other undiagnosed, untreated or undertreated mental health disorders. Without proper treatment of patients' behavioral health disorders, the chance of successful treatment for OUD/SUD is substantially reduced, with high rates of recurrence and relapse, he said.
As for alternatives to medical treatment for OUD/SUD, Rich said restorative therapies and interventional procedures have a place in the treatment armamentarium, and treatment should be tailored to each patient via a shared decision-making process.
"Currently, we have the best data for MAT with the use of medications that include methadone, buprenorphine and naltrexone, with a need for more data about the various alternative therapies available," he said. "This is an area where we have significant research gaps that are the subject of ongoing research."
Addressing the task force's recommendation on supporting maternal and child health in those dealing with OUDs, Rich said the death rate for women from prescription drugs and heroin increased exponentially compared with that for men between 1999 and 2015.
Additionally, the number of pregnant, postpartum and parenting mothers with OUD has grown substantially during this time, affecting not only the mothers but also unborn children, children in the home and the entire family unit, he said.
"To increase the treatment of female patients in all stages of reproductive life, the task force has called for increased research, guideline development, more treatment options and increased availability of adjunctive therapies," Rich said. "By increasing the treatment of women with OUD, you are not only improving the health of the female patient but also the children born to that patient and the family unit dependent upon her for care."
Finally, Rich said there is a tremendous need for family physicians and other primary care physicians to offer MAT in their clinic setting. To accomplish this, more MAT training is needed in residency programs and for practicing family physicians, as well as more training for midlevel health care professionals those physicians employ.
"Once trained, the barriers, both real and perceived, to the provision of MAT must be addressed, including such issues as professional support and consultation, to enable our members to care for patients with OUD, addressing the stigma associated with treating patients with OUD and adequate reimbursement for providing those services," he said. "If these barriers are not addressed by our health care system, the numbers of physicians needed to treat the growing number of patients with OUD will not expand enough to meet the demand."
Related AAFP News Coverage
CDC Warns of Misapplication of Its Opioid Guideline
Family Physician Expert Offers Insight on Misinterpretations
(5/9/2019)
AMA Task Force Reports Progress on Reversing Opioid Epidemic
(6/6/2018)
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