What the AMA suggests Congress includes in opioid legislation

To help combat opioid addiction and abuse, the American Medical Association (AMA) suggested the Senate consider more than a dozen policies on everything from allowing Medicare to cover methadone in outpatient treatment programs to creating an addiction treatment-centered alternative payment model.

In a Feb. 16 letter to the Senate Finance Committee, AMA CEO James Madara, said medical professionals have been making a difference on addressing the opioid epidemic, with the number of prescriptions decreasing and use of state Prescription Drug Monitoring Programs (PDMP) on the rise. Ending the epidemic, he wrote, will take lots of collaboration and “strong, dedicated physician leadership.”

“There is still an enormous gap between the number of people who need OUD treatment and those who are receiving it,” Madara wrote. “Opioid-related morbidity, overdoses and deaths continue to occur across the country, in communities large and small, with especially rapid growth in deaths attributed to heroin and illegally imported fentanyl.”

The AMA’s recommendations for how delivery system and payment reforms could help in addressing the crisis included:

• Require all Medicare Advantage (MA) Part D and standalone Part D plans to cover medication-assisted treatment (MAT). This would create a seventh protected class of drugs under Part D.
• Cover non-opioid analgesics and non-pharmaceutical treatments for pain. Madara also said CMS should prohibit the use of drug utilization management (DUM) requirements for these treatments to reduce administrative burden on practices and speed up access for patients.
• Allow Medicare coverage of methadone as part of opioid use disorder (OUD) outpatient treatment: “Removing this barrier is particularly important since OUD is a large and growing problem among Medicare beneficiaries.”
• Ensure quality measures don’t lead to inappropriate treatment of pain. Madara said opioid use measures should focus on how well pain is controlled, not just focus on reductions in doses: “Focusing on daily dose may serve as an indicator of whether a patients at risk of overdose and should be co-prescribed naloxone, but does not provide a signal that a physician provides poor quality care.”
• Support APMs for opioid therapy. The AMA is currently working with the American Society of Addiction Medicine on such a model called Patient-Centered Opioid Addiction Treatment, or P-COAT.
• Enhance physician education at the state level. One option AMA suggested would authorize a new grant program “to establish comprehensive state-based resources for physicians and other prescribers to consult when treating patients with pain and identifying signs of substance misuse and substance use disorders.”
• Increase access to naxalone. Naxalone can reverse the effects of opioid overdoses, but the AMA said high costs may prevent first responders or community organizations, as well as individual patients, from having it on hand.
• Support continued Medicaid coverage for OUD and pain management in any Affordable Care Act repeal or overhaul: “Medicaid expansion under the (ACA) has been a path to treatment for hundreds of thousands of individuals with opioid use disorders,” Madara wrote. “Such treatment must be sustained in any future health system reform legislation or regulation.”
• Increase inpatient treatment capacity under Medicaid and get rid of the current 15-bed limit for coverage at Institutions for Mental Diseases (IMD).
• Allow people in prison to restart Medicaid coverage up to 30 days prior to their release.
• Encourage electronic prescribing of controlled substances.
• Implement the 2016 National Pain Strategy.
• Evaluate state laws aimed at the opioid epidemic.
• Direct CMS to approve Section 1115 Medicaid waivers which include strategies on opioid abuse.

Several of the final ideas offered by the AMA’s letter were admittedly outside the jurisdiction of the Senate Finance Committee. These included increased research and funding for state-based PDMPs, enforcing existing laws on substance use disorder parity and eliminating the requirement for physicians to obtain a special waiver to prescribe buprenorphine for the treatment of OUD.

“Removing the federal waiver requirement will give many more patients new access to treatment from physicians and other qualified health care professionals,” Madara wrote. “The safety and effectiveness of MAT is well-established, and we need to do all we can to encourage more qualified clinicians to care for OUD patients.”