Politicians lasered in on the fentanyl crisis in a recent senate finance committee hearing.

 Senators pointed to the importance of medications for opioid use disorder (MOUDs) as a highly effective but underused fentanyl treatment. Research demonstrates that only about one in four people in need of MOUDs receive the treatment. 

To mitigate the rising tide of fentanyl-related deaths, senators recommended easing access to MOUDs by reducing prior authorizations, improving incarcerated people’s access to opioid use disorder (OUD) treatment and through expanding community-based models.

U.S. Senator Ron Wyden (D-Oregon) took aim at large commercial health insurance plans that use Medicaid programs “as a piggy bank,” accepting Medicaid dollars while delaying care for opioid use disorders.

“I’m very concerned that big health insurers like UnitedHealth and Aetna that contract with Medicaid are using “prior authorization” at high rates and that is causing delays and denial of this treatment,” Wyden said. “As patients suffer and these mega-corporations post record profits, they are also dragging their feet providing the Committees with answers about these tactics. These multi-billion dollar companies owe answers to taxpayers about how these Medicaid dollars are being used.”

Prior authorizations lead to delays in accessing treatment, which can be life-threatening for a person seeking MOUDs, like methadone or buprenorphine, according to Dr. Caleb Banta-Green, a research professor at the University of Washington School of Medicine, who testified as a witness at the hearing.

Prior authorizations and other processes like credentialing, are also known to contribute to the low usage of behavioral health services among Medicaid and Medicare enrollees. Despite having disproportionately high rates of mental health conditions and SUDs, only 8% of Medicaid enrollees received behavioral health services.  

Along with improving access to MOUDs, Banta-Green also recommended higher doses of some of these medications.

Research has demonstrated that higher doses of buprenorphine are more effective at keeping patients who use fentanyl in treatment. FDA guidelines for buprenorphine were based on people who use heroin, but fentanyl’s emergence in the illicit drug market has necessitated higher doses. 

Starting a patient on a low dose may cause the patient to not believe in the drug’s effectiveness and lead them to discontinue treatment, Banta-Green said.

The senate hearing highlighted several other problems exacerbating the fentanyl crisis, including incarcerated people’s lack of access to OUD treatment.

“States are working on their own initiatives to support access to care for people before coming out of incarceration who need uninterrupted care, including my state,” Wyden said. “These reforms are a start towards being responsive to what law enforcement officials are asking for: getting people help for their addiction before they get out of jail so they don’t come back.”

One of the hearing’s guest speakers, Dr. Jeanmarie Perrone, director of the Center for Addiction Medicine and Policy at the University of Pennsylvania, recommended a solution modeled after the largest federal program directed to combat the HIV/AIDS epidemic.

The Ryan White HIV/AIDS program funds cities, counties, states and local community-based organizations to provide HIV care. The program was also used as a model for the recently introduced Comprehensive Addiction Resources Emergency (CARE) Act.

Perrone recommended a similar funding model to establish regional networks of telehealth addiction bridge treatment to prevent patients from stopping medication when transitioning care.

“We have found that two-thirds of our telehealth patients were recently on Suboxone, yet were discharged from a care setting without a timely follow-up, or lost insurance, or faced a life event where their care was disrupted,” Perrone said. “Experiencing opioid cravings without medications drives patients back to the street, only to face the most lethal supply and potentially overdose.”

Telehealth models can also help mitigate long appointment wait times in rural areas that face provider shortages, Perrone said.

Laws restricting the use of telehealth to prescribe MOUDs were softened by COVID-19 era flex abilities, which are set to expire at the end of 2024. Efforts are being made to maintain these flexibilities. For example, the Telehealth Modernization Act of 2024, introduced in March, would create permanent access to telehealth services for Medicare beneficiaries. 

“We must sustain current exceptions to federal regulations for telehealth and create billing parity for the services,” Perrone said.

Senator Maria Cantwell (D-Washington) identified community-based treatment models as another method to mitigate the impacts of fentanyl. Specifically, Banta-Green testified about community-based health hubs that offer drop-in, same-day visits designed to provide same-day access to MOUDs.

This model was found to lead to a 68% reduction in fatal overdoses in a Washington-based study. 

Banta-Green distinguished these hubs from certified community behavioral health clinics (CCBHCs).

“We’re purposely not using a clinic-based model,” Banta-Green said. “We’re going into community settings, programs that are serving folks who are unhoused, really getting out into these community-based programs where folks already go. There’s also quite a bit of focus on infectious disease testing and treatment … So there’s definitely some parallels, but there are some distinctions as well.”

Cantwell also highlighted that these hubs were more streamlined and cost-efficient than existing models.