Drug overdose deaths may be on the decline in parts of the U.S. for the first time in years, but the opioid epidemic is far from over.
Contributing to the epidemic’s complexity is payers’ refusal to comply with state and federal parity laws and barriers to access medications for opioid use disorder (MOUD), according to the American Medical Association’s annual overdose epidemic report.
“We need unwavering commitment to expand access to lifesaving medications, enforce parity laws, and address the glaring gaps in harm reduction,” Dr. Bobby Mukkamala, president-elect of the AMA and chair of the AMA Substance Use and Pain Care Task Force. “We cannot stand by as outdated policies and insurance barriers prevent patients from accessing evidence-based care.”
While MOUDs, including buprenorphine, methadone and naltrexone, are the most effective treatments for OUD, more than a third of SUD treatment facilities do not offer the medications.
The number of buprenorphine prescriptions dispensed from retail pharmacies increased from 2017 to 2021, but that number plateaued beginning in 2021. While it is unclear why prescriptions have plateaued, the AMA identified several barriers to access.
Racial, ethnic and geographic factors greatly influence a person’s access to lifesaving treatments. Lack of prescribers in racially and ethnically diverse areas results in Black, American Indian/Alaska Native, Asian and Hawaiian/Pacific Islander people having significantly less access to MOUD treatment.
Other barriers include state and insurers’ prior authorization and dosage requirements for buprenorphine, too few pharmacies stocking buprenorphine, and concerns regarding DEA requirements.
“Health insurance companies and other payers continue to fail and otherwise refuse to comply with state and federal laws requiring parity in coverage for mental illness and substance use disorders,” the report read. “Policymakers have not held health insurance companies and other payers accountable for these failures.”
The AMA recommended that states take action to reduce barriers to MOUD access to reduce drug-related mortality. This recommendation includes that states remove prior authorization requirements for MOUD, including for higher doses of buprenorphine and that all incarcerated people have access to MOUD treatment throughout their sentence and are connected to community-based care after release.
Along with recommending easier access to MOUDs, the AMA also recommended improved access to contingency management which is used to treat stimulant use disorder.
Stimulants have become a key driver of overdose-related deaths and are often used in conjunction with fentanyl. In 2023, approximately five million people used cocaine, almost four million misused prescription stimulants and 2.6 million used methamphetamine, according to the AMA report.
No FDA-approved medications for stimulant use disorder (StUD) exist, however. The most effective StUD treatment is contingency management, in which providers reward positive behavior changes relating to substance use.
Contingency management is twice as effective as other StUD treatments, according to the AMA. Despite its efficacy, less than 10% of SUD treatment programs offer contingency management.
While policymakers have made some efforts to improve access to contingency management, more work must be done.
“The AMA, our Substance Use and Pain Care Task Force and the nation’s physicians continue to urge policymakers, health insurance companies and other payers to once and for all remove barriers to evidence-based treatment for substance use disorders, pain care and harm reduction initiatives,” Mukkamala said. “Delays or denials of this care only [result] in increased suffering and death. Ending the epidemic is possible, but much more work must be done.”
