Where We Stand
Section: Substance Abuse
Policy: AMA 2019 Opioid Task Force Recommendations
Appendix L
The OMA participates on the AMA Opioid Task Force comprised of the American Medical Association, American Osteopathic Association, and 25 specialty and state medical societies as well as the American Dental Associations.
American Medical Association
American Osteopathic Association
American Academy of Addiction Psychiatry
American Academy of Family Physicians
American Academy of Hospice and Palliative Medicine
American Academy of Neurology American
Academy of Orthopaedic Surgeons
American Academy of Pain Medicine
American Academy of Physical Medicine and Rehabilitation
American Association of Neurological Surgeons and Congress of Neurological Surgeons
American College of Emergency Physicians
American College of Occupational and Environmental Medicine
American College of Physicians American College of Obstetricians and Gynecologists
American Dental Association
American Psychiatric Association
American Society of Addiction Medicine
American Society of Anesthesiologists
American Society of Clinical Oncology
Arkansas Medical Society
California Medical Association
Massachusetts Medical Society
Medical Society of the State of New York
New Mexico Medical Society
Ohio State Medical Association
Oregon Medical Association
Utah Medical Association
The AMA has issued recommendations in the past focused on those ways in which physicians could take specific actions to help reverse the opioid epidemic. With the inclusion of all specialty societies and several states, the AMA has issued reports that demonstrate progress in several areas around the Prescription Drug Monitoring Programs (PDMPs), necessary education to ensure education and training on effective, evidence-based treatment, to support and advocate for comprehensive care for patients in pain with a substance use disorder (SUD), to remove the stigma associated with SUDs, to expand naloxone access in the community and to work with patients to promote safe storage and disposal of opioids and all medications.
The OMA Policy committee, in its discussion of the opioid issues in July 2019, requested that the Opioid Task Force review the AMA’s policies for possible consideration as a task force recommendation.
These recommendations are listed below:
1. Remove prior authorization, step therapy and other inappropriate administrative burdens or barriers that delay or deny care for FDA-approved medications used as part of medication-assisted treatment (MAT) for opioid use disorder (OUD).
In the midst of an epidemic, and given the clear evidence in support of MAT as a proven medical model to support recovery, save lives, reduce crime and improve quality of life, the AMA Opioid Task Force calls on all payers—commercial insurers, self-insured plans, Medicare, Medicaid—as well as pharmacy benefit management companies (PBMs) to end prior authorization and other unnecessary utilization management protocols for the treatment of opioid use disorder. This also includes ensuring that MAT is available on the lowest cost sharing tier to promote affordability as well as prompt availability. Multiple payers in states (e.g. Maryland, New York, Pennsylvania) already have taken these steps—now it is time for all payers to support increased access to MAT.
2. Support assessment, referral and treatment for co-occurring mental health disorders as well as enforce meaningful oversight and enforcement of state and federal mental health and substance use disorder parity laws.
Very high rates of mental health disorders co-exist among patients with opioid use disorders as well as among patients with chronic pain conditions leading to increased risk for suicide. The 2017 National Survey on Drug Use and Health found, however, that 92 percent, or 19.7 million people, with a substance use disorder receive no treatment, and 57 percent, or 46.6 million people, with a mental illness receive no treatment. The Task Force continues to urge physicians to appropriately assess and refer patients for substance use and mental health disorder treatment. At the same time, the Task Force notes that the federal Mental Health Parity Addiction and Equity Act is more than 10 years old, and to improve access to care and reverse the effects of the opioid epidemic, the Task Force believes that insurers need to be held accountable for complying with their legal obligations. This means that health insurance companies must have addiction medicine, addiction psychiatry and psychiatric physicians not only in the network but accepting new patients as well as mental health and substance use disorder parity coverage that is on par with medical and surgical benefits. Anything less is unacceptable.
3. Remove administrative and other barriers to comprehensive, multimodal, multidisciplinary pain care and rehabilitation programs.
The AMA Opioid Task Force supports patients having access to the right treatment at the right time without administrative barriers or delay from health insurance carriers or other payers and pharmacy benefit or behavioral health management companies. There is no question that the nation’s physicians have reduced opioid analgesic supply—both in volume and dose strength— but there has not been a concomitant increase in access to or affordability of evidence-based non-opioid alternatives. The Task Force further notes that the therapies listed below may not be appropriate for all patients, which is why enhanced education and access to pain and palliative medicine specialists also is encompassed as part of this recommendation. As part of current
and future efforts to reverse the nation’s opioid epidemic, the Task Force supports increased research and access to evidence-based treatment, including: Medication, including non-opioid pain relievers, anticonvulsants, antidepressants, musculoskeletal agents, anxiolytics as well as opioid analgesics when appropriate.
The Task Force notes that physicians and patients now face a multiplicity of new laws, guidelines and policies from payers, PBMs and national organizations, which are often contradictory. • Restorative therapies, which include physical therapy, occupational therapy, physiotherapy, therapeutic exercise, osteopathic manipulative therapy (OMT), and other modalities such as massage and therapeutic ultrasound. • Interventional procedures, such as neuromodulation, radio frequency ablation, peripheral nerve stimulation, central and peripheral nerve ablation, spine surgery and steroid injections, and other emerging interventional therapies as part of the multimodal pain care plan.
This recommendation further calls for more detailed regulatory review of formulary and benefit design by payers and PBMs to ensure that patients have affordable, timely access to evidence-based non-opioid alternatives, pharmacologic and non-pharmacologic. In conducting such reviews, the Task Force urges policymakers to work closely with physicians to ensure appropriate clinical input.
The Task Force further affirms that some patients with acute or chronic pain can benefit from taking prescription opioid analgesics at doses that may be greater than guidelines or thresholds put forward by federal agencies, health insurance companies, pharmacy chains, pharmacy benefit management companies and other advisory or regulatory bodies. The Task Force continues to urge physicians to make judicious and informed prescribing decisions to reduce the risk of opioid-related harms, but acknowledges that for some patients, opioid therapy, including when prescribed at doses greater than recommended by such entities, may be medically necessary and appropriate.
4. Support maternal and child health by increasing access to evidence-based treatment, preserving families, and ensuring that policies are non-punitive.
The Task Force believes it is essential to specifically highlight the important roles of physicians and policymakers in ensuring the unique needs of pregnant, postpartum and parenting women and children are met. OUD among women of reproductive age and pregnant, postpartum and parenting women has increased over recent years, mirroring the epidemic seen in the general population. According to the U.S. Department of Health and Human Services Office of Women’s Health, the number of women dying from overdose of prescription drugs rose 471 percent between 1999 and 2015, compared to 218 percent for men, and heroin deaths among women increased at more than twice the rate of men. MAT is the recommended evidence-based treatment for pregnant and breastfeeding women with OUD. Threats of incarceration, immediate loss of child custody, and other potential punishments drive pregnant, postpartum and parenting women away from vital prenatal care and treatment. Research has found that non-punitive public health approaches to treatment result in better outcomes for both moms and babies. The Task Force believes that additional efforts are needed for patient and public education as well as outreach to policymakers to ensure evidence-based care guides treatment options for maternal and child health.
5. Support reforms in the civil and criminal justice system that help ensure access to high quality, evidence-based care for OUD, including MAT.
The AMA Opioid Task Force believes that all persons entering jails or prisons (both for men’s and women’s facilities), while incarcerated, and upon release, will benefit from enhanced opioid use disorder screening protocols to identify those persons arrested if they are currently on MAT, or would like to begin treatment. The Task Force also supports the use of evidence based protocols for maintaining continuity of care for persons released from jail or prison, including—as necessary—enrollment in Medicaid, coordination with peer counseling or other services to ensure the person has linkages to treatment providers in the community, and other such services so as to maintain access to and a continuum of care to sustain and promote recovery. This recommendation also applies drug courts and other diversion services to support evidence-driven care for persons with an opioid use disorder.
The OMA remains committed to supporting future efforts to address all substances of abuse and addictive potential beyond prescription opioids and emphasizes the importance of maintaining the integrity of the provider-patient relationship. This includes but is not limited to the review and recommendation for state guidelines when appropriate. Representatives of OMA currently participate on the Governor’s Opioid Epidemic Task Force, the AMA Opioid Task Force, the OHA Tapering Guidelines Workgroup and the PDMP workgroup.