National Roadmap on State-Level Efforts to End the Drug Overdose Epidemic | Manatt, Phelps & Phillips, LLP

Editor’s Observe: The American Medical Affiliation (AMA) and Manatt Well being launched a national roadmap in September 2019 to information policymakers in taking motion to assist finish the nation’s opioid epidemic.i Based mostly largely on in-depth analyses of the responses to the opioid epidemic in Colorado, Mississippi, North Carolina and Pennsylvania, the 2019 roadmap recognized quite a few promising methods in addition to areas the place extra work and innovation clearly have been required. Our expanded 2020 roadmap, summarized under, begins with our 2019 coverage suggestions and an evaluation of progress made. It additionally highlights areas the place there are alternatives for enchancment, in addition to offers finest practices and tangible suggestions for states to successfully tackle the drug overdose epidemic shifting ahead.

Progress Made on 2019 Coverage Suggestions

Once we take a look at the progress made since our 2019 paper, we see that the outcomes throughout states are combined, with the COVID-19 pandemic creating new challenges but in addition opening up new alternatives. For instance, the necessary nationwide deal with addressing racial inequities in well being care has uncovered big disparities in how completely different populations fare with respect to substance use problems (SUDs), but in addition generated new help for addressing these disparities. One factor that has not modified is that the 2020 roadmap is organized across the similar six important coverage targets because the 2019 model. (See Exhibit 1.)

Exhibit 1. Progress replace on AMA–Manatt Well being 2019 coverage suggestions

Proof-based remedy for opioid use dysfunction. Present the total continuum of care, together with medicines to assist deal with opioid use dysfunction (MOUD) which might be offered equitably throughout the well being care system.

  • Outcomes are combined. The COVID-19 pandemic has introduced new challenges and elevated mortality from illicit fentanyl and methamphetamine. Extra states have enacted legal guidelines prohibiting well being insurers from utilizing prior authorization for MOUD, however greater than half of the nation’s states nonetheless enable it.

Parity enforcement. Enhance oversight and enforcement of psychological well being and substance use dysfunction parity legal guidelines, together with potential analysis of payer compliance.

  • Outcomes are combined. Some states have enacted significant legal guidelines, and 30 states have joined a brand new Nationwide Affiliation of Insurance coverage Commissioners (NAIC) work group to refine regulatory instruments that may maintain insurers accountable. But state and federal oversight stays restricted, as exemplified by the common parity violations which might be discovered when states conduct compliance exams.

Community adequacy/workforce enhancement. Guarantee ample networks that enable for well timed entry to dependancy drugs, psychiatry and different physicians educated to deal with dependancy and psychological sickness; help fee reforms, collaborative care fashions, and different efforts to bolster and help the nation’s substance use dysfunction remedy workforce.

  • Rather more work stays. Revolutionary fee fashions proceed to be explored, and a few states are working arduous to extend entry to care, however thousands and thousands of Individuals with an SUD stay with out remedy.

Ache administration. Improve entry to complete, multidisciplinary, multimodal ache care, together with nonopioid and nonpharmacologic ache care choices; take away arbitrary restrictions on opioid remedy for sufferers with ache.

  • Rather more work stays. Whereas policymakers proceed to depend on arbitrary restrictions for opioid analgesics, states and insurers have achieved comparatively little to extend entry to evidence-based alternate options to opioids and different medicines and coverings which have proved price efficient in treating ache.

Hurt discount. Scale back hurt by increasing entry to naloxone, supporting sterile needle and syringe change applications, and coordinating look after sufferers in disaster.

  • Progress continues. If not for naloxone, it’s seemingly that tens of 1000’s extra Individuals would have died in 2019–2020. Some states have taken steps to extend entry to sterile needles and syringes, and emergency departments are displaying nice promise in serving to coordinate look after sufferers who expertise an overdose occasion.

Knowledge surveillance and analysis. Assist standardized information assortment and surveillance efforts, and consider insurance policies and outcomes to determine efficient insurance policies and medical interventions in order to construct on essentially the most profitable efforts, and likewise to determine insurance policies and applications that will have to be revised or rescinded.

  • Rather more work stays. States are taking motion to collect extra info, however they should take the subsequent step to show that information into efficient overdose prevention, remedy and focused interventions. Few states have evaluated whether or not present insurance policies are rising entry to care or decreasing opioid- and drug-related harms. There stays an absence of standardized information assortment efforts throughout states, and information assortment to handle racial, ethnic and gender-related inequities additionally is proscribed at finest.

Our 2020 roadmap highlights the areas the place there may be alternative for enchancment, and builds on the progress that has been made by offering actionable suggestions and figuring out finest practices for reducing boundaries and bettering entry to evidence-based look after an SUD; supporting multidisciplinary, multimodal remedy for sufferers with ache; and increasing using confirmed and promising hurt discount methods. With respect to COVID-19, which has contributed to the again-rising overdose loss of life fee, the roadmap spotlights the best way supplier networks have been decimated, but in addition highlights the accelerated use of telehealth and different coverage modifications that would grow to be a part of short- and long-term methods to enhance overdose prevention and remedy methods. Particularly because the opioid epidemic continues to evolve right into a extra lethal and sophisticated polypharmacy and illicit drug overdose epidemic, there’s a vital want for policymakers to make sure continued analysis of the effectiveness of their insurance policies and pivot when wanted. Moreover, eradicating the stigma for individuals who obtain remedy for an SUD, for sufferers with ache, and for individuals who use medication stays a long-overdue want throughout all domains.

The 2020 roadmap additionally highlights the necessity to extra straight tackle the cruel disparities and long-standing inequities in entry to SUD remedy for black Individuals and different racial and ethnic teams, together with an emphasis on making certain that coverage and medical interventions straight confront these inequities. One research discovered that for each appointment the place a black American acquired a prescription for buprenorphine, white sufferers had 35 such appointments.ii These inequities translate straight into differing mortality charges throughout racial and ethnic teams. In 2018, when the nation was starting to see a decline in overdose deaths, it was due fully to features amongst white Individuals. The speed of drug-induced deaths for American Indians, Asians, black Individuals and Latinos truly elevated and seems to have continued to extend in 2019 at a fee larger than amongst white Individuals.

Addressing the Implications of COVID-19 for the Drug Overdose Epidemic

COVID-19 has exacerbated the nation’s drug overdose epidemic, impacting folks with substance use problems and the physicians and different well being care professionals who serve them.iii Nationwide, state and native media studies point out that these strains are sharply pushing up overdose charges.iv Though not sufficient to beat rising overdose charges, suppliers and authorities companies moved shortly to allow new flexibilities to supply care choices for sufferers with an SUD and for sufferers with ache.

Drivers of will increase in overdose. The COVID-19 pandemic has created a difficult atmosphere for a lot of, together with sufferers with ache and sufferers with a substance use dysfunction/opioid use dysfunction (SUD/OUD) as a result of:

  • Extra monetary instability, stress and nervousness. The stress of contracting COVID-19 or going through the lack of relations and buddies, coupled with job loss and job insecurity, has contributed to excessive ranges of stress and nervousness.
  • Social isolation. The COVID-19 pandemic has elevated social isolation, a selected problem for folks with an SUD who depend on social connections as a part of their remedy and restoration. Whereas some peer restoration companies and teams moved on-line, these on-line boards don’t all the time work as effectively for many individuals with an SUD.
  • Disruptions in entry to remedy choices and hurt discount companies. Physicians and different well being care professionals who present dependancy drugs and behavioral well being care are being additional squeezed as states face price range shortfalls, prompting shutdowns or reductions in service choices. Potential sufferers may face extra restricted in-person choices, necessities to move COVID-19 assessments previous to securing remedy, and modifications in the place and once they can safe assist. Whereas the shift to telehealth has opened up necessary choices in MOUD entry, lack of know-how entry amongst some folks with an SUD has disrupted remedy. Hurt discount companies that present main overdose prevention might have grow to be restricted, altered hours, or grow to be tougher to succeed in throughout COVID-19.

Coverage improvements. In response to the COVID-19 pandemic, sure flexibilities have been enabled to make sure suppliers and sufferers with acute or power ache had continued entry to essential care and remedy choices. These embrace:

  • Expanded use of telehealth. In March 2020, the federal authorities provided elevated flexibility to permit for the initiation of buprenorphine by way of telehealth, together with via telephone-only companies, which has proved significantly vital for many individuals with an SUD and/or power ache.v An AMA survey of ache drugs physicians discovered that 80 p.c of doctor respondents stated that the flexibilities offered by the DEA through the COVID-19 pandemic have been both very useful or considerably useful for treating sufferers with
  • Easing entry to medicines. The federal authorities gave states the flexibleness to permit opioid remedy applications (OTPs) to help take-home doses of methadone for as much as 28 days at a supplier’s medical discretion. States additionally provided prolonged provides of medicines and, in some cases, eradicated prior authorization necessities, as really helpful by final 12 months’s AMA–Manatt roadmap, for medicine for opioid use dysfunction.vii
  • Easing counseling necessities. Even previous to COVID-19, organizations such because the Nationwide Academy of Sciences and the American Society for Dependancy Drugs have been recommending that authorities companies and suppliers enable folks to obtain MOUD even when they can’t or don’t choose to take part in really helpful counseling and remedy. In response to COVID-19, states akin to West Virginia briefly suspended counseling necessities during the general public well being emergency, making it simpler for folks to safe MOUD.viii

Fixing the Broader Structural and Systemic Boundaries to Remedy

Past the precise challenges raised by COVID-19, entry to evidence-based care stays a barrier to many searching for remedy for an SUD as a result of ongoing structural and systemic challenges. We as soon as once more emphasize:

  • States have to be keen to make use of their oversight and enforcement authority. State regulators have differing levels of authority to pursue insurance policies and modifications that may have a big influence on decreasing boundaries and bettering affected person care, however the extent to which they use these instruments to extend entry to evidence-based remedy or maintain payers and others accountable for impeded entry varies significantly.
  • Medicaid usually leads the best way. Medicaid is a serious payer for SUD remedy, serving 4 in ten people with an OUD in america. It usually offers extra complete SUD care than the industrial insurance coverage market and, in all states, has been a driving drive for higher use of MOUD.ix Throughout the COVID-19 pandemic, many states have used their Medicaid flexibility to supply further funding to SUD suppliers going through declining income and new COVID-19–associated prices, in addition to to dramatically develop use of telehealth for SUD remedy.x
  • Grants are useful, however long-term implementation wants long-term, sustainable funding. Many finest practices which might be serving to save lives are presently grant funded and want long-term, sustainable funding to proceed benefiting people with an SUD. With out dependable funding streams, applications that assist save lives might merely cease. This concern has grow to be much more necessary with the massive inflow of federal {dollars} through the COVID-19 pandemic and the potential that termination of those emergency funds will depart gaping holes that will probably be exceptionally arduous to fill for states going through vital price range pressures.
  • Analysis should embrace each coverage outcomes and surveillance information to handle prevention. Few states have undertaken efforts to guage present legal guidelines, insurance policies and applications to find out whether or not these insurance policies, applications and legal guidelines are working to extend entry to evidence-based care and cut back hurt. In the event that they haven’t had their meant outcomes, it’s crucial to critically look at why and tackle coverage shortcomings. Equally, state-level surveillance efforts should develop and develop in a number of methods. Not solely should information assortment and surveillance efforts embrace nonfatal overdose in addition to mortality to make sure assets are used to help overdose prevention and remedy, however elevated emphasis have to be positioned on information assortment and surveillance that’s disaggregated to focus on variations by race, ethnicity, age, gender and different components vital to confronting well being inequities. In designing analysis research, it will likely be vital to transcend slim cost-benefit analyses to measure outcomes in broad social phrases.


Work stays for states to make sure entry to evidence-based remedy, to make sure hurt discount efforts are superior, to handle long-standing well being inequities, and in the end, to make sure progress is made in addressing the broader drug overdose epidemic.

  • Coverage enactment has been in depth. The epidemic has led to the passage of a whole lot of recent legal guidelines, laws, medical pointers and nationwide suggestions. Some are evidence-based, akin to rising entry to MOUD, imposing psychological well being and substance use dysfunction parity legal guidelines, and enhancing entry to hurt discount companies, together with continued emphasis on entry to naloxone to assist save lives from opioid-related overdose.
  • Coverage implementation stays elusive. Whilst entry to evidence-based remedy for OUD has been a serious focus, rather more work stays to guarantee entry to remedy for OUD. Placing insurance policies into motion requires further steps, which is why the majority of suggestions within the report deal with tangibly eradicating boundaries to evidence-based remedy for OUD and imposing state and federal parity legal guidelines. Medical health insurance corporations and different payers should change their practices or sufferers will proceed to be harmed.
  • Insurance policies have to be examined and evaluated for effectiveness. The report highlights the necessity for thorough analysis and dedication by states to additional insurance policies that work and to revise or rescind insurance policies which might be dangerous to sufferers. This consists of making certain that coverage analysis and information assortment straight tackle long-standing well being inequities.
  • There are various examples to be taught from. The AMA–Manatt analyses reveal a number of areas during which there have been constructive outcomes and promising outcomes. This consists of the event of hub-and-spoke fashions of care, community-based naloxone entry efforts, and reforms in state Medicaid companies to enhance entry to multidisciplinary, multimodal ache care. The 2020 roadmap identifies many initiatives that every one states can be taught from and probably undertake. This consists of offering MOUD to these in justice-involved settings, eradicating stigma for OUD and ache, and utilizing information to meaningfully cut back long-standing well being inequities.
  • Demonstrating program success is a piece in progress. The report identifies many areas during which further work might be achieved to additional improve entry to evidence-based care, together with pilot tasks being achieved by emergency departments to evaluate and refer sufferers to remedy for OUD. As a result of many profitable pilot applications are depending on grant funding, we urge higher consideration to program analysis to assist illuminate which pilot applications which may be serving to a whole lot of individuals at the moment might be scaled up as nationwide fashions that would assist a whole lot of 1000’s tomorrow.
  • All stakeholders can take motion. The nationwide roadmap offers suggestions that might not be straightforward to implement, however they’re essential to assist finish the epidemic. There are suggestions that may be utilized by governors, state legislators, attorneys basic, insurance coverage commissioners, Medicaid officers and different policymakers. Most of the suggestions additionally could possibly be carried out voluntarily by medical health insurance corporations, PBMs and different stakeholders in the event that they have been so inclined or inspired to take action. Sufferers with an SUD and sufferers with ache need assistance. The overdose epidemic is extra lethal than ever. Physicians and different well being care professionals should proceed to take motion.

i This report discusses intimately the necessity to change terminology from “opioid epidemic” to “drug overdose epidemic.” There are a number of causes for doing so, together with the truth that what might have begun a decade in the past as an epidemic of opioid misuse, overdose and loss of life associated to prescription opioids has now grow to be a way more sophisticated and lethal epidemic as a result of illicitly manufactured fentanyl, methamphetamine, cocaine and heroin. Hurt associated to prescriptions has decreased barely however stays far too excessive. The terminology is vital to make sure that coverage interventions deal with the bigger epidemic slightly than primarily prescription “opioids.”

ii Lagisetty PA, Ross R, Bohnert A, Clay M, Maust DT. Buprenorphine Remedy Divide by Race/Ethnicity and Fee. JAMA Psychiatry. 2019;76(9):979–981. doi:10.1001/jamapsychiatry.2019.0876.

iii In response to a latest American Academy of Dependancy Psychiatry (AAAP) COVID-19 Buprenorphine Supplier Survey Report, 70% of suppliers have been involved that sufferers have been experiencing psychological well being misery through the pandemic, and virtually half of suppliers who responded have been involved that their sufferers confronted vital boundaries to utilizing telephones or unstable housing throughout this time, impeding the suppliers’ skill to supply medicines through the pandemic for his or her sufferers with opiate use dysfunction (OUD). Supply: Accessed October 20, 2020.

iv American Medical Affiliation (AMA). Problem Temporary: Reviews of Will increase in Opioid- and Different Drug-Associated Overdose and Different Issues throughout COVID Pandemic. American Medical Affiliation, Advocacy Useful resource Heart; 2020:17. Accessed October 28, 2020.

v Substance Abuse and Psychological Well being Providers Administration (SAMHSA). FAQs: Provision of Methadone and Buprenorphine for the Remedy of Opioid Use Dysfunction within the COVID-19 Emergency. SAMHSA; 2020:4., 2020.

vi A problem temporary describing the important thing findings from the survey is offered right here:

vii Substance Abuse and Psychological Well being Providers Administration (SAMHSA). Opioid Remedy Program (otp) Steerage. 2020. Up to date on March 19, 2020. Accessed October 22, 2020.

viii State of West Virginia Division of Well being and Human Assets, Bureau for Medical Providers. Memorandum to West Virginia Medical Suppliers Concerning Remedy Assisted Remedy Providers Counseling/Remedy Necessities. 2020. Up to date Might 20, 2020. Accessed October 4, 2020.

ix Probably the most profitable applications might be present in Virginia. See, for instance, An Analysis Report Ready for the Virginia Division of Medical Help Providers, Dependancy and Restoration Remedy Providers, Entry and Utilization Throughout the Second 12 months (April 2018–March 2019). Virginia Commonwealth College. Accessible at Accessed October 20, 2020.

x State Methods to Assist Entry to Substance Use Dysfunction Remedy Providers via the COVID-19 Pandemic. Nationwide Governor’s Affiliation; 2020:16. Accessed October 30, 2020.

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