What Is Opioid Bill's Impact on Practice?

University of Miami medical student Kasha Bornstein provides clean syringes and HIV tests to people who visit the IDEA Exchange syringe access program and clinic. Bornstein has walked people newly diagnosed with HIV from the testing office to the nearby clinic, where they can start HIV medications immediately.

But Bornstein doesn’t see how those people would have sought care without something like the syringe exchange. After all, most say they haven’t been to the doctor in years. And Bornstein remembers working as an emergency medical technician in New Orleans, Louisiana, where, for fear of prosecution, people would leave friends unconscious and not breathing after calling 9-1-1.

So when Bornstein saw the bulk of the Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act, the massive opioid bill Congress sent to the White House in the fall, Bornstein’s heart sank. The bill, Bornstein says, “continues the drug-war mindset.”

“As a public health provider and future physician, my concern is more towards making sure we are keeping people alive and safe,” Bornstein says. “Any time there is a focus on funding law enforcement at the expense of funding public health, we can depend on repeating the same data sets, unfortunately. We’re going to get the same outcomes as what has happened every other time we’ve focused on controlling the supply of drugs.”

Not everyone is quite as critical of the bill as Bornstein is. Many physicians say that the bill isn’t everything, but it’s not nothing, either. After all, it begins to address the structures that right now make it difficult for physicians to offer effective treatment to their patients with opioid use disorder, including expanded coverage and access to medication-assisted treatment. But it also forces medicine to grapple with the question of whether abstinence should be the goal, or whether harm reduction is worthwhile, too.

A Compromise Bill

The bill, which was a rare bipartisan effort, does many things. It increases regulations and criminal justice approaches. For instance, it increases U.S. Postal Service regulation to try to curb fentanyl trafficking. It also expands the Food and Drug Administration’s authority over drug imports. And it provides for potentially more drug courts instead of prison time for people using opioids.

But it also makes some shifts to health care access and coverage. For instance, it requires states to keep people younger than 21 enrolled in Medicaid while they are incarcerated. And it expands Medicaid to adults 18-26 who grew up in the foster care system, if they live in the state where they aged out of the system.

It will allow Medicaid to pay for short-term inpatient drug treatment programs from 2020 to 2023, and for prenatal care for pregnant women in such treatment.

What’s more, the bill would direct the Centers for Medicare and Medicaid Services to issue new guidance on federal reimbursement for substance use treatments via telehealth services and clarify the treatment options that are mandatory from those that are voluntary for Medicaid to cover for pain treatment, including nonpharmacologic interventions, such as physical therapy.

The bill was met by praise from the American Society of Anesthesiologists, citing the bill’s change in approach to pain management. Health IT Now’s Opioid Safety Alliance praised the expansion of telemedicine options for opioid treatment. And some state medical societies praised the partial repeal of limits to Medicaid payment for inpatient substance abuse treatment.

But it’s the provision to expand medication-assisted treatment prescribing power to nonphysician providers, such as nurse practitioners and physician assistants, and requiring coverage for those services, that drew praise from most quarters in medicine.

“It used to be pretty hard to get certified to be a Suboxone [buprenorphine/naloxone] provider,” says Mark Roberts, a University of Pittsburgh physician and director of the School of Public Health’s Public Health Dynamics Lab. “And the fact that the bill makes it easier and less problematic to have first-responders carry naloxone are good things.”

Limited Action

But “those aren’t going to fix the problem,” Roberts adds.

Indeed, some of the changes are minor. For instance, the bill expands Medicaid coverage for neonatal abstinence syndrome, but Medicaid already pays for hospital treatment for the syndrome, and some states pay for care outside of hospitals, too.

And while the bill likely will lead to new limits on opioid prescribing, Robyn Oster, research assistant at the Center on Addiction, says, “opioid prescribing rates are already on the decline.”

Besides, it might be years before the bill actually affects practice, she says. The Center on Addiction is lukewarm about the bill.

“The legislation largely focuses on requiring federal agencies to conduct studies, provide recommendations and create grant programs to determine and encourage use of best practices for treating pain and addiction, enhancing insurance coverage and using nonaddictive treatments, and providing care for vulnerable populations, such as pregnant women,” she says. “Once the studies are completed and recommendations are developed and disseminated, there likely will be more specific actions that practices should or will be required to take to help address the crisis.”

Unregulated Treatment Centers

And while the bill does include expanded treatment outside hospitals and in new drug use disorder centers, Bornstein is concerned that what’s offered at those centers might not be evidence-based.

“We do things like equine therapy [in treatment centers], when we know that the evidence base and best outcomes are with opioid-substitution therapy,” Bornstein says. “The evidence shows that if we can get someone on buprenorphine after an OD [in the emergency department], we can solve one step in the problem right there.”

But what often happens, instead, is that people are revived from their overdose and sent back to the streets, with no referral to care. In fact, Bornstein says, many of IDEA Exchange’s clients report having been yelled at for returning to the ED after another overdose.

“Yelling at them is not an evidence-based solution,” Bornstein says.

Roberts agrees.

“We know that if we give more naloxone to people, people don’t die from overdoses as much,” he says. “But if that’s all you do, what that leaves you with is more people with opioid use disorder who didn’t die. Well, that’s not a solution. It’s a Band-Aid.”

Another evidence-based approach is syringe exchange. At IDEA Exchange — whose name refers to the Infectious Disease Elimination Act of Miami-Dade County, Florida — data show overdose deaths have declined by 38 percent since the exchange launched. The clinic has diagnosed and connected to care 12 percent of clients who test positive for HIV, and 47 percent who test positive for hepatitis C.

Sixteen percent of the exchange’s clients have asked to enroll in drug rehabilitation. But not all of them want that, and you can’t force people until they are ready, Bornstein says. The bill doesn’t address the role of syringe access programs in care.

It’s not that policy makers and providers have to choose between helping people to treatment and harm reduction programs such as syringe access programs, Bornstein says. The two can work together.

“Are people going to make mistakes and fail and relapse? Absolutely,” Bornstein says. “But when they relapse, they are relapsing into a care model of the needle exchange program. And then the highest-risk outcomes — overdose, HIV infection, hepatitis C infection — are not there when they do relapse. When you examine the issue scientifically, [it makes sense to] connect all these clinical modalities that are proven to work, with low barriers to care.”

Finding Policies That Work

Bornstein also advocates for something unlikely in the United States: drug decriminalization. It could work, but it would be hard to know. Unintended consequences are common in such sweeping bills. Physicians are leading on that, too.

Roberts started his training as an economist, then went to medical school and public policy school. He always imagined himself leading. And while he has led as a member of his professional society, visiting legislators on lobbying days, today he’s more likely to lead from behind a computer.

That’s because his current challenge is to create a simulation of the current opioid epidemic and then introduce potential policy changes. If the approach, which is based on an infectious disease model, works, it could tell leaders whether their bills will really get at the heart of the epidemic before they pass them.

That’s a big “if.” The University of Pittsburgh’s Public Health Dynamics Lab received a grant from the Centers for Disease Control and Prevention to build out the model. But it will be years — and likely many policy changes — before it’s ready to test-run some policies.

Still, it stands to help leaders make better decisions themselves. Take medical marijuana and recreational marijuana, as an example. Some evidence suggests states in which people have legal access to marijuana, people use opioids less frequently. Other data indicates it could lead to further drug use. With the simulation, they could match all 50 states’ laws to their opioid epidemic and see if the laws are associated with changes in opioid use over time.

Or, consider a policy that creates warm hand-offs between EDs and substance disorder treatment.

“We’ll be able to predict the impacts of policies and where we need more information,” Roberts says. “The point of these tools is to have all the primary, secondary and tertiary effects of opioids built in, so we can understand how doing one thing effects all those parts of the epidemic.”