WSW Hearing and Markup Report

WSW Review of the Second Meeting of the Commission on Combating Drug Addiction and the Opioid Crisis: Presentation of the Interim Report of the Commission, July 31, 2017

TThis afternoon, the President’s Commission on Combating Drug Addiction and the Opioid Crisis held its second official meeting to release an interim report and detail its recommendations.

A review of the remarks by the Commissioners is below, followed by a summary of the Interim Report’s key recommendations and a list of the additional issues that the Commission plans to evaluate and make recommendations on in its final report to be issued by October 1, 2017.

Commissioner Chairman Governor Chris Christie (R-NJ)

  • Above all, the Commission’s Interim Report recommends that the President declare a national emergency under the Public Health Service Act or Stafford Act;
  • The President should take a series of actions through new authority or mandates to federal departments and agencies that would do the following (a detailed review of the Interim Report is below):
    • Provide relief from the IMD Exclusion through waivers to states to immediately expand access to SUD treatment.
    • Mandate all medical and dental schools to provide training in opioid prescribing and detecting of substance abuse disorders and require new continuing education on opioid prescribing practices and proper management of pain;
    • Enhance the use of Medication Assisted Treatment (MAT)
    • Expand naloxone access via standing orders, ensuring that all law enforcement officers have access to naloxone, providing model legislation on prescribing of naloxone to patients at-risk of overdose, and ensure states have Good Samaritan Laws;
    • Prioritize the development of fentanyl detection sensors which can be dispersed to state and local law enforcement;
    • Increase utilization of PDMPs
    • Change patient patient privacy laws specific to addiction to encourage information sharing with patients and their families;
    • Redouble enforcement of the Mental Health Parity and Addiction Equity Act;

Former Congressman Patrick J. Kennedy

  • The issue of equity is an issue of civil rights;
  • Many families have to litigate to get access to care consistent with MHPAEA, which is an unfair burden upon them in addition to struggling with addiction itself.
  • Substance abuse is shunned and that is why it is not getting attention from insurance providers.

Governor Roy Cooper (D-NC)

  • We must work to ensure that states have flexibility to use Medicaid for SUD treatment and provide relief from the IMD Exclusion;
  • We must work with law enforcement to divert people to treatment because they understand that this is not an issue that can be resolved with arrest;
  • We must expand the access to medication assisted treatment but also expand access to healthcare plans that cover substance abuse disorders.

Professor Bertha Madras, Ph.D.

  • The medical community will be crucial in understanding substance abuse disorders;
  • We need to integrate mental and physical health in our plans in order to resolve the systematic issue;
  • We need to address the flow of fentanyl but also need to focus on prevention campaigns.

WSW Summary of the Interim Report

A central recommendation of the President’s Commission is for President Trump to declare a national emergency under either the Public Health Service Act or the Stafford Act, both to authorize federal departments and agencies to take decisive action to respond to the opioid epidemic and signal to the public the urgency of the opioid epidemic.

The Commission’s top recommendations for the Interim Report included:

Provide Relief from the Medicaid Institutions of Mental Diseases (IMD) Exclusion

  • Rapidly increase treatment capacity through HHS waivers to states.
  • Notes that legislation is required to repeal the IMD Exclusion, that HHS should be able to provide rapid waivers with the emergency declaration “and arguably without it.”
  • States that “this is the single fastest way to increase treatment availability across the nation.”

New mandates for prescriber education

  • New requirements for education on opioid prescribing risks and risks for developing SUD, as well as for the proper treatment of pain for all DEA registrants.
  • Key quote: “The overwhelming percentage is due to a lack of education on these issues in our nation’s medical and dental schools and a dearth of continuing medical education for practicing clinicians.”
  • Notes work in MA, AZ, CT, PA, NY, and UT to expand continuing medical education requirements for prescribers of opioids, as well as a new NJ law that requires prescribers to discuss the risks of opioid dependence with their patients prior to the first prescription. Urges national implementation of these initiatives.
  • Calls on CDC and FDA to finalize, review and recommend national training standards working with the Accreditation Council for Continuing Medical Education (ACCME) to ensure training courses are coordinated with other federal agencies, professional societies, medical schools, and residency programs to avoid discrepancies.
  • ACCME would also develop analytics to determine whether courses change practices or increase patient referrals to treatment.

Expand access to MAT

  • Establish and fund a federal incentive to enhance access to Medication-Assisted Treatment (MAT).
  • Require that all modes of MAT are offered at every licensed MAT facility and that those decisions are based on what is best for the patient.
  • Recommends NIH work with industry to facilitate testing and development of new MAT treatments.
  • Recommends that CMS require all federally-qualified health centers (FQHCs) to mandate that their staff physicians, physician assistants, and nurse practitioners possess waivers to prescribe buprenorphine.
  • CMS should also send a letter to state health officials requesting that state Medicaid programs cover all FDA-approved MAT drugs for OUD.
  • HHS should also mandate that all FDA-approved MAT should be offered by authorized providers, not just one or two of the approved options.

Expanded access to naloxone

  • The Secretary of HHS should be empowered “to negotiate reduced pricing for all governmental units” to ensure that naloxone is in the hands of every law enforcement officer in the US.
  • HHS and other federal agencies should make recommendations on ways to identify persons who have overdosed and been revived with naloxone and the feasibility of notification of their primary care and other physicians caring for them to change the medications they receive and reduce risks of future overdose.
  • Key quote #1: “Naloxone is a lifesaver that rapidly reverses opioid overdose. It is the first line of defense in many parts of our country; if we lose someone to overdose we obviously have no chance to treat them and return them to a productive life.”
  • Key quote #2: “The Federal Government should ensure that naloxone is made available when there is the greatest chance for an overdose. Accordingly, model legislation should include a requirement that naloxone is prescribed in combination with any CDC-defined high-risk opioid being prescribed.”

Fentanyl detection and interdiction

  • Prioritize funding for fentanyl detection sensors and disseminate them to federal, state, local and tribal law enforcement agencies. DHS, Customs and Border Protection, the FBI, and DEA would be involved in this effort.

Prescription Drug Monitoring Programs

  • Recommends that President Trump direct the VA and HHS to lead an effort to have all state and federal PDMP systems to share information and to set a deadline of July 1, 2018 to achieve this data sharing.

Reform patient privacy laws to ensure that information about a patient and SUD is available to health care providers.

  • Recommends that 42 CFR Part 2 be changed to permit more information sharing about a patient between providers and family members.

Enforcement of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA)

  • Recommends robust enforcement of MHPAEA by the state and federal agencies responsible for implementing the law, including specifically USDOL. Recommends that regulators be required to levy penalties against health plans that violate MHPAEA, and that information about parity violations should be made available to the public.

The Commission identified the following issues of interest to be evaluated for purposes of the Commission’s final report, noting that Commissioners would travel around the country to gather additional information and feedback on these matters:

  • Development of a national prevention strategy using “big data analytics” to devise targeted prevention messages that employ cutting-edge methods of marketing and communications.
  • Evidence-based prevention programs for schools, and tools for teachers and parents to enhance youth knowledge of the dangers of drug use, as well as early intervention strategies for children with environmental and individual risk factors (trauma, foster care, adverse childhood experiences (ACEs), and developmental disorders).
  • The need for satisfaction with pain level as a satisfaction criteria through which health care providers are evaluated by HHS.
  • Workforce access and training needs within the treatment community nationally, with a particular focus on the regions of the country with the highest overdose deaths.
  • Improvements in treatment programs, based on adherence to principles of evidence based treatment, continuum of care, outcome measures, and patient education on quality treatment.
  • Research initiatives and opportunities to combat the epidemic and enhance treatment options, including alternative pain management strategies, and treatment for vulnerable populations such as pregnant women, and substance-exposed infants through work by the NIH, HHS, CDC, FDA, SAMHSA, and pharmaceutical partners.
  • Opportunities to further the practice of substance use screenings and referrals through CMS quality measures.
  • Opportunities for patient protections providing better information about the risks and benefits of taking prescription opioids.
  • Supply reduction of heroin, fentanyl analogs and counterfeit pills through coordinated federal and state law enforcement initiatives.
  • Targeted data collection and analytics needed to identify most effective prevention and treatment strategies, quality treatment access programs, reimbursements, and aid to law enforcement activities. The possibility of a behavioral health surveillance system run through CDC that tracks prevalence rates, treatment modalities, and comorbidities with other illnesses in real-time.
  • Regulatory or statutory changes to reduce commercial insurance barriers to MAT, such as dangerous fail-first protocols and onerous and frequent prior authorization requirements.

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Rob Zucker is a Partner at Winning Strategies Washington, a DC-based government relations firm, where he focuses on public health policy, funding and advocacy, including Substance Use Disorder treatment and other issues related to the federal response to the opioid epidemic.

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