Opioid Crisis: A Call to Action
It is well known that America is in the midst of an opioid epidemic from both prescribed and illicit use. To appreciate the scope of this crisis, consider the following stats:
- 70,630 people died from an overdose in 2019 compared to 36,096 who died in car accidents.
- 1.6 million people had an opioid use disorder in the past year.
- 745,000 people used heroin in the past year.
- 10.1 million people misused prescription opioids in the past year.
Federal Efforts to Beat Opioid Epidemic
To address this epidemic, the White House launched New Actions and Funding to Address the Overdose Epidemic and Support Recovery on September 23, 2022.
The $1.5 billion initiative funds all 50 states and territories to treat substance use disorders and remove barriers to key tools like naloxone, a medication that can reverse opioid overdoses.
The U.S. Food and Drug Administration (FDA) will release new guidance to ease restrictions on naloxone. Currently, there are legal barriers limiting access to naloxone in some states.
Pew Charitable Trusts Examines State-level Opioid Policies
Opioid treatment programs (OTPs) are the only healthcare facilities that can offer patients all three FDA-approved medications for opioid use disorder (OUD): methadone, buprenorphine, and naltrexone. These drugs reduce the negative effects of withdrawal without producing the euphoria of the original drug of abuse.
But in a recent report, Pew Charitable Trusts found that nearly all states have rules governing OTPs that are not evidence-based and limit access to care or diminish the patient experience, decreasing the likelihood of success.
The rules governing OTPs exist at the federal and state levels: The federal government establishes baseline requirements, and states can add additional layers of requirements on top.
The report examines OTP regulations across all 50 states and DC as of June 2021 in two areas:
- Access to care: Regulations that affect the ease with which patients access care at OTPs, such as whether services are available at convenient times or whether patients must obtain a government ID.
- Patient experience: Rules that affect how patients receive care. State regulations can help or hinder access to high-quality, evidence-based care aligned with federal rules and tailored to meet patients’ needs.
Pew Finds Many State Barriers to Effective Opioid Treatment
The following are some excerpts that demonstrate restrictive state barriers to effective treatment:
Restrictions on new OTPs
Nineteen states and the DC restrict providers from opening new OTPs in some way:
All 20 require a certificate of need, a legal document demonstrating a need for a new facility. And Indiana limits the number of new facilities that can open.
West Virginia is the most restrictive state, with a legal moratorium disallowing new OTPs.
Hours of operation
Requiring OTPs to be open outside of regular business hours (e.g., outside of 8 a.m.-5 p.m.) provides flexibility for clients who may find it difficult to go to the clinic each day due to other responsibilities such as work or family obligations.
Only nine states require OTPs to be open outside of business hours.
Requiring pharmacist services
Federal law allows methadone administration by various licensed health care professionals, including registered nurses, licensed practical nurses, or other health care professionals who are otherwise authorized to dispense opioids.
However, 15 states require OTPs to hire a pharmacist or a consultant pharmacist to guide the appropriateness and safety of medication use.
Inflexible counseling requirements
Requiring patients to participate in a set counseling schedule (e.g., a minimum number or length of sessions) to stay in treatment or receive take-home medication is not in line with federal regulations, and strict counseling requirements can reduce a client’s persistence in treatment.
Twenty-three states impose a set counseling schedule. These rules can be tied to eligibility for take-home medication.
In Oklahoma, for example, patients move through five phases of treatment based on time in treatment and compliance with program rules, including participation in a set number of individual and group counseling sessions per phase. Each phase allows for more take-home doses. Therefore, the frequency of having to travel to OTP decreases.
Forcing people to leave treatment for violating program rules
It’s common for people who use opioids to also use multiple substances and return to opioid use, even among people on medications for opioid use disorder (MOUD).
Although federal guidelines and recommendations list neither as a reason to end medication treatment and research supports that continuing MOUD is safer than suddenly stopping treatment, some programs “administratively discharge”—or terminate—clients because of continued drug use.
Only Massachusetts and South Dakota prohibit administrative discharge for not being abstinent.
All states allow administrative discharge for missed methadone doses, although federal guidelines recommend reassessing patients who miss more than four methadone doses rather than terminating their treatment.
Pew Finds Some Examples of Effective Opioid Treatment
While most of the report is critical of state efforts to curb opioid addiction, there are some examples provided that demonstrate good practices.
Medication units
Allowing OTPs to open medication units—locations that may offer dosing and urine screens and are affiliated with an existing OTP—can make treatment more convenient for patients who receive methadone by expanding the locations where they can receive care.
Eleven states explicitly permit medication units. Ohio specifically allows medication units to operate in homeless shelters, jails, prisons, local boards of public health, community health centers, residential treatment providers, small counties, and counties in Appalachia.
Government ID
Some people—including undocumented immigrants, people who have been incarcerated, and those experiencing homelessness— face challenges in obtaining an ID. Requiring a client to show a government ID can be a barrier to care.
Conversely, California allows OTPs to provide patient identification cards that include the individual’s photo, a unique identifier, and a physical description. This allows the OTP to verify the patient’s identity before dispensing methadone without requiring a government ID.
Closing
Data shows that many states make it harder for OTP patients to access and remain in treatment.
Pew suggests that as overdose deaths continue to climb, state policymakers should make changes so that more people get the lifesaving treatment provided in these settings.
Research and materials for this article were compiled, written, and distributed on behalf of the National Public Health Information Coalition. The views and opinions expressed in this blog are those of the various authors and do not necessarily reflect the official policy or position of the National Public Health Information Coalition or its members.
References:
https://www.hhs.gov/opioids/about-the-epidemic/index.html
https://crashstats.nhtsa.dot.gov/Api/Public/ViewPublication/813209