“The system is still broken. It’s still easier to get a prescription for opioids than it is to get into treatment.”
Joneigh S. Khaldun, MD, MPH, FACEP, Chief Medical Executive & Chief Deputy Director for Health, Michigan Department of Health and Human Services, discussed Michigan’s response to the opioid epidemic, leading off a panel of presenters who focused on federal, state, and private payer strategies to address the opioid epidemic.
Michigan’s data mirror the national trend in recent years of a spike in synthetic-opioid related deaths accompanied by a slight decrease in deaths attributable to prescription opioids and methadone.
Khaldun said Michigan is gaining some traction against opioid misuse through a collaborative approach that emphasizes prevention, early intervention, and treatment. For example, in 2018, the state mandated that physicians review patient histories in the Michigan Automated Prescription System (MAPS) prior to prescribing controlled substances such as opioids. Some primary prevention strategies – including youth education – are working upstream to address risk factors for substance misuse, while Michigan is also working to expand access to screening, brief intervention, and referral to treatment (SBIRT), particularly for pregnant women, as well as increased access to naloxone.
Going forward, every hospital in Michigan should have access to SBIRT, including initiating MAT in the ER, Khaldun stated. She also urged that the prior authorization for buprenorphine should be removed – this occurs when insurance requires an extra step and additional information before a medication is approved for dispensing, in this case for the treatment of opioid use disorder (addiction).
Also needed: more timely, actionable data, and more efforts to engage communities in strategies that are locally appropriate, Khaldun said. “Communities need to be able to address disparities and target strategies based on what the data show,” something that’s not possible when it can take years to access relevant information, she said.
Thomas L. Simmer, MD, who manages professional payment services in his role as Senior Vice President and Chief Medical Officer for Blue Cross Blue Shield of Michigan (BCBSM), spoke about the need for innovation in payment models to more appropriately reimburse for evidence-based care services for opioid use disorder.
“One of the things that’s obvious from this crisis is that we are going to have to innovate and change if we are going to succeed,” Simmer said, describing how his organization is working to create care models that accelerate the implementation of best practices throughout the state that have been generated by partners such as Michigan OPEN in prescribing and other areas.
The model of treatment for substance use disorder, plagued by disconnected, episodic care, “very bad handoffs,” and lacking in post-ER follow-up, is “in need of a major overhaul,” Simmer said, noting that MAT, the most empirically successful care model, is not available in the vast majority of counties in Michigan.
“We are working to change the care model to create something much more continuous and reflective of the fact that you’re dealing with a chronic condition,” Simmer said. “We fundamentally need to train and support providers throughout the state” in MAT. He also pointed to the need for more real-time data on overdose (something that the U-M Injury Prevention is working to develop), so that those in healthcare and law enforcement working can act based on current information.
As the opioid epidemic evolves, “if we aren’t connected to knowing how things are changing, we won’t be able to respond appropriately and it will delay the success in managing this crisis,” he said.
In the panel discussion, moderated by IHPI Director John Z. Ayanian, MD, MPP, Khaldun cited increased awareness about the risks of opioid overprescribing among clinicians and greater acceptance of practices like starting MAT in the ER as examples of progress in stemming the epidemic.
But, she also noted, “the data do worry me. The system is still broken. It’s still easier to get a prescription for opioids than it is to get into treatment.”
Trent-Adams said she’s been encouraged by the decrease in opioid-related deaths, as well as the emergence of new, interprofessional models that will help urban and rural communities address their unique opioid issues at the community level. However, she said her biggest worries are the recent surge in methamphetamine deaths, and the inability to respond immediately to overdoses of all types. Going forward, “I hope we’ll be able to work with law enforcement, providers, community leaders, and public and private partners to have these real-time rapid response teams to intervene whenever we see a trend in the data,” she said.
Carla Haddad, MPH, Senior Advisor on Opioid Policy in the Office of the Assistant Secretary for Health, HHS, said her greatest concern was the variability among states in opioid overdose mortality trends, and how to determine which strategies from among the “suite of effective interventions” will have the most impact for different communities.
Trent-Adams noted that many providers don’t learn how to properly assess and manage pain in a way that incorporates patient feedback, but said this should be recognized as a gap in training and knowledge rather than willful ignorance. She urged improved training around pain management, and for providers to embrace a more holistic approach, including being open to alternative therapies (citing the Air Force’s recent push toward using treatments like acupuncture and biofeedback among Veterans). On the payer side, she encouraged more broadly accepting and integrating proven pain management strategies into the reimbursement model, noting that, unfortunately, “there are lots of things that work that we can’t get reimbursed for.
“We were trained to use opioids in a manner that isn’t supported by the evidence as to their ability to control pain,” Simmer added. “Other ideas about non-pharmacological means and non-opioid prescriptions need to move forward,” he said, and also talked about the need for continued provider education of about best practices for right-sized prescribing.
“We need to be teaching in acute and outpatient settings the appropriate way to manage pain,” Khaldun added.
Of the opioids prescribed worldwide, 82% are prescribed in the U.S., Simmer noted. “Our care patterns relative to opioid use have deviated from the world norm,” he said. “The rest of the world doesn’t view opioids as the right medical option for the things we’ve gotten in the habit of using them for.”
We can learn a lot from other industrialized nations that prescribe no opioids for conditions for which these medications are routinely prescribed in the U.S., including what alternatives they offer, Trent-Adams added.
Ultimately, solutions need to be locally driven, and what works in one area may not work in another. “We need to better engage communities, and listen to the people who are impacted,” Trent-Adams said, as well as build models that are sustainable and fundable with continued benefit to the communities they serve.
“We need to understand how the community wraps around the patient for them to be successful, especially with substance use disorder,” and be able to galvanize the efforts in both rural and urban communities to meet the needs of their populations who require treatment, Trent-Adams said.
Haddad highlighted state opioid response grants from SAMHSA, a $1.4 billion investment to provide states with the flexibility to prioritize their unique needs for prevention, treatment, and recovery services. Similarly, Trent-Adams mentioned the Medicaid waiver program as another example that allows states to focus on the particular needs of their populations.
The panelists also addressed the issue of stigma as a barrier to treating substance use disorders; Trent-Adams noted that stigma also affects those living with HIV, hepatitis C, homelessness, poverty, and that substance use disorder is often the manifestation of many other conditions needing attention. Trent-Adams noted that providers need to acknowledge and understand their own inherent biases in treatment engagement, and that all disparities – gender, racial, socioeconomic – need to be addressed in a data-driven way to improve access.
The panelists also addressed the social determinants of health underlying the opioid epidemic and the sometimes stark disparities in outcomes and access; Ayanian referenced a recent U-M study showing significant racial and financial divides in opioid addiction treatment.
“Any comprehensive approach to the opioid epidemic must address social determinants of health,” Khaldun emphasized.
Trent-Adams also discussed the need to provide more comprehensive wrap-around services for substance use disorder treatment, including well-managed care transitions and follow-up care, and pointed to the Ryan White HIV/AIDS program as a potential model.
Panelists also agreed on the need for better integrated behavioral and physical health services. “If you’re managing behavioral health separately, you’re losing the ability to impact those whose chronic medical condition is highly influenced by their ability to have the energy and the coping skills to change lifestyle and to intervene in a way that is more successful,” Simmer said, and noted his optimism about increased interest on the commercial side in integrating these services.