Committee: Bold Changes Needed to Tackle Opioid Disorder, Infectious Disease Effectively

A consensus report released today from a panel of medical professionals and academicians suggests that the health care system has largely failed to address the scourge of infectious disease intertwined with the opioid crisis. Some of the recommendations offered in the report of The National Academies of Sciences, Engineering and Medicine would shatter the status quo in service delivery and payment.

Based mainly on evidence collected from community health programs that have sought to more closely integrate services for opioid use disorder (OUD) and infectious diseases, the committee that was formed in response to a directive from the U.S. Department of Health and Human Services (HHS) issued numerous recommendations for lifting barriers to greater integration. Some of the more dramatic—and in some circles, likely to be highly controversial—recommendations include:

• Allowing physicians and other eligible providers to prescribe buprenorphine without undergoing the training that is currently required under the Drug Addiction Treatment Act (DATA) of 2000.

• Denying approval of Medicaid state plan amendments for states that impose prior authorization requirements for medications to treat OUD, including those that mandate concurrent psychosocial counseling with medication.

• Integrating methadone treatment with general medicine by allowing methadone to be delivered in primary care settings.

• Supporting wider dissemination of harm reduction strategies through several approaches, including encouraging more continuing medical education in harm reduction and allowing use of federal funds to purchase injection equipment at syringe services programs.

Authors of the report wrote that “there is a great deal to be accomplished at the intersection of opioid use disorder and infectious diseases at many points in the health care system, as well as across society more broadly. It is essential to dismantle the barriers impeding prevention and treatment.”

Silos cause damage

The committee, chaired by Carlos del Rio, M.D., professor of medicine and chair of the Hubert Department of Global Health at the Emory University School of Medicine, lays part of the blame for the lack of integration of OUD and infectious disease services on traditional substance use treatment models that deliver care independently of other medical treatment. This has led to increases in HIV and hepatitis C outbreaks among individuals who inject drugs and those who use drugs and engage in unsafe sexual practices, the report states.

The report lists nine primary barriers to integration of OUD and infectious disease services. Among them are:

• Prior authorization requirements on medication treatments for OUD, which the committee says burden providers and block access to much-needed treatment for patients. The report states that providers should be able to prescribe whichever drug and dose is most appropriate for the individual patient, with no restrictions such as a step therapy requirement or a mandate to offer concurrent psychosocial counseling.

• The provider requirements under the DATA 2000 waiver for prescribing buprenorphine. Training requirements of 8 to 24 hours, depending on the type of provider, have been burdensome to some and have not been as clinically relevant as other training opportunities available elsewhere, the report states. Committee member Sandra Springer, MD, associate professor of medicine at the Yale School of Medicine, tells Addiction Professional that panel members' interviews with program leaders and their own personal experiences led to the conclusion that the existing training is “inadequate with respect to real-world/hands-on patient treatment.” Instead, Springer says, “we suggest additional training of all clinicians starting as students to residents to beyond residency about screening, diagnosis and treatment of OUD and other [substance use disorders] is necessary.”

• An inadequate distribution of the treatment workforce. Among the report's recommendations in this area is for the Health Resources and Services Administration (HRSA) to devote more resources toward encouraging providers of all types to work in rural areas where infectious disease outbreaks are more likely to occur.

• Financing limitations that impede access to potentially helpful services such as case management and peer-based recovery services. Here, the committee suggests that the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act can serve as a model for comprehensive prevention, treatment and recovery services targeting OUD and infectious disease.

• Restrictions that prohibit billing of state Medicaid for behavioral and physical health visits on the same day, as well as same-day billing by different providers for the same patient or by one provider for two different diagnoses. The committee recommends that state Medicaid administrators lift any and all of these restrictions.

• Limits on harm reduction services that can function as an entry point to additional medical care. A summary of the recommendations in this section gives strong backing to eliminating restrictions on syringe services programs, but does not directly address the topic of safe injection sites.

Removing some of these restrictions, the report states, would allow for the leveraging of facilities such as methadone clinics, primary care clinics and correctional facilities as ideal integrated care sites for individuals with OUD and infectious diseases.