Time to Unleash Drug Treatments for Addiction

A National Academies panel on Thursday urged radical changes in state and federal law to improve treatment and prevention of opioid use disorder, which in turn would cut the nation’s infectious disease burden.
The committee’s 10 members — comprising academics, medical professionals, epidemiologists, nurses, and health policy specialists — recommended scrapping mandatory waivers for buprenorphine prescribers; eliminating prior authorization requirements for buprenorphine and all FDA-approved treatments for opioid use disorder; and allowing methadone treatment to be delivered in primary care settings.

The committee held that one reason for the “unprecedented number of HIV and viral hepatitis outbreaks” is that substance use disorder treatment is siloed from delivery of other medical care.
Also, “well-intentioned policies” such as increasing reliance on prescription drug monitoring programs, intended to curb access to prescription opioids, have had unintended consequences — sometimes driving people to illicit injected drugs such as heroin.
As the number of people who inject drugs increased, so did the risk of infectious disease.
The good news is that preventing and treating opioid use disorders can improve infectious disease outcomes, the authors noted.
For instance, patients with a co-occurring opioid use disorder and HIV will be better at complying with their HIV medication regimens if their treatment plan also includes medication for opioid use disorder.
“In this way removing barriers for opioid use disorder treatment is, in itself, a process to improve prevention, and treatment for infectious disease,” the report said.

Moreover, when substance use disorder and infectious disease services are better coordinated, co-located or, ideally, fully integrated, healthcare becomes “simpler, more accessible and patient centered.”
End DATA Waiver, Prior Authorization
One of the report’s most dramatic recommendations is to eliminate state-level prior authorization requirements for buprenorphine. The authors say this additional step delays access to evidence-based care for patients with opioid use disorder and increases the risk of infectious disease due to patients’ continued drug use.
To put federal teeth into such a policy, the Centers for Medicare & Medicaid Services should withhold approval of any requests for Medicaid state plan amendments from states that maintain prior authorization requirements, the report said.
A federal law enacted two decades ago mandates that providers seeking permission to prescribe buprenorphine complete an 8- to 24-hour training course. But the committee said this waiver “poses a barrier for some providers.”

For that reason, the committee recommended that Congress amend the legislation to drop that requirement.
In speaking with clinician prescribers, the report’s authors found that many believed the mandated training was “inadequate and clinically irrelevant.”
For that reason, the committee recommended that any organizations that currently offer training should examine its curriculum and its usefulness and “provide newly trained providers with greater access to experienced peers.”
Another recommendation: the Substance Abuse and Mental Health Services Administration (SAMHSA) should offer additional funds and grants aimed at “expand[ing] mentorship networks for providers.”
Additionally, the report called on Congress to eliminate the cap on the number of patients that prescribers can serve.
The report also addressed barriers to methadone treatment for opioid use disorder. It recommended federal legislation to let clinicians provide the drug in primary care settings. As the law now stands, methadone can only be prescribed for addiction treatment in certain licensed and regulated facilities — i.e., dedicated opioid treatment programs.

Conversely, the committee noted that with 1,600 opioid treatment programs across the country in 2018 serving 380,000 patients each year, it’s a mistake — a “missed opportunity” — that such programs do not frequently offer testing and treatment for infectious disease.
The committee therefore suggested that the Department of Health and Human Services consider instituting “universal, opt-out-testing and connection to treatment for infectious diseases,” particularly in methadone-based opioid treatment programs.
But on the thorny issue of 42 CFR Part 2, often known simply as “Part Two” — the federal rule that defines the right of access among different stakeholders to patients’ records from substance use disorder treatment programs — the committee mostly punted.
The report suggested that SAMHSA either align Part Two with the Health Insurance Portability and Accountability Act or “alter the definition of which specific service programs” are encompassed in Part Two.
“[T]here is significant debate about whether and how changing this regulation would jeopardize patient privacy or allow providers to deliver more coordinated, effective care,” the authors noted.
SAMHSA should “formally engage with patients, advocacy groups, the general public, and legal experts” to weigh the pros and cons of wider data sharing, the report concluded.

https://www.medpagetoday.com/psychiatry/addictions/84534