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February 21, U.S. News & World Report
If states want to drastically improve access to opioid addiction treatment, expanding Medicaid is the best place to start, a new analysis indicates.
Medicaid expansion draws a clear divide along state lines in terms of who has access to opioid use disorder treatment and who does not – despite some federal action in recent years to try to make treatment more accessible to all Americans, according to the report, published Thursday by the Urban Institute, an economic and social policy think tank based in the nation's capital.
Researchers measured Medicaid spending and prescriptions from 2010 to 2017 for the opioid overdose reversal medication naloxone, as well as buprenorphine and naltrexone, two drugs that can blunt opioid cravings and are often paired with counseling for an approach called medication-assisted treatment. While both Medicaid expansion and non-expansion states saw gains in prescriptions to treat opioid use disorder during the time period studied, patients in states that had expanded Medicaid may have been better off.
"There were increases in almost every state for the treatment of opioid use disorder using buprenorphine and naltrexone, but the states that expanded Medicaid more rapidly had higher treatment rates per enrollee," says Lisa Clemans-Cope, a principal research associate and health economist in the Health Policy Center at the Urban Institute.
Between 2013 – the year before major Affordable Care Act provisions went into effect – and 2017, Medicaid spending on opioid treatment prescriptions climbed 171 percent in states that had expanded the federal health program, compared with 72 percent in states that had not expanded Medicaid by 2017, the analysis shows.
The study's authors also cited previous research that found "no evidence of large-scale substitution from cash or other payers to Medicaid" – indicating most of the gains were among patients who previously had no access to treatment.
"In the non-expansion states, they're really leaving their people without a good option for affordable treatment," Clemans-Cope says. "These medications are really effective, and part of more comprehensive care for many individuals that can really make a big difference in mortality, as well as the experience of their families and their communities."
Overall spending on the three medications rose from $190 million in 2010 to $887.6 million in 2017, after researchers adjusted for the average rebates drugmakers paid to states. The fastest growth was between 2014 and 2016, when most states adopted Medicaid expansion.
As of January 2019, 17 states had not enacted Medicaid expansion, though three – Idaho, Nebraska and Utah – have approved expansion via ballot measure. Several of the non-expansion states saw an above-average number of opioid deaths in 2017, including Florida, Missouri, North Carolina, South Carolina, Tennessee, Utah and Wisconsin. Taken together, those seven states saw 10,502 opioid deaths that year, roughly a fifth of the national total.
Yet the number of overdose deaths remained high in some expansion states as well – such as Ohio and West Virginia – indicating that while expanding Medicaid is a major step policymakers can take to improve access to treatment, it isn't enough to ensure access for covered patients, who are disproportionately affected by opioid use disorder.
Some expansion states also have been hit hard by street fentanyl, a synthetic substance that is significantly more potent than heroin. In 2017, for example, the majority of Ohio's 4,293 opioid overdose deaths involved fentanyl and related substances.
That means more people could be getting into treatment in an area, but parallel to those gains, others could be dying at a rapid pace as fentanyl and its analogues creep into the drug supply, sometimes without users realizing, Clemans-Cope says.
"It's a little bit of a complicated picture to separate treatment from what's basically a poisoning of the opioid supply," she says.
A slew of other state-level policies also affect patients' treatment access. While buprenorphine is covered by all state Medicaid programs, some require prior authorization to prescribe the medication. Others have enacted dosage limits for the drugs, or have limited formulations of the medications available.
Still, Clemans-Cope says that as the epidemic continues to take its toll on the country, more doctors should be prepared to treat opioid use disorder, even if they aren't addiction specialists. In California, for example, a tiny share of prescribers had waivers to prescribe buprenorphine, according to Urban Institute researchers.
"Mostly, prescribers are not stepping up to the plate to provide treatment," she says. While some patients will need more specialized treatment, "there are people who can be treated effectively in primary care office, by someone who isn't an addiction specialist but has received some special training to prescribe buprenorphine."
A strong showing of Wisconsin Chapter members attended ASAM's 50th Annual Conference in Orlando last week. During the meeting, WISAM past president Aleksandra Zgierska, MD led a meet-up of Wisconsin attendees.
During the conference, WISAM was presented with an award certificate for the 25th anniversary of our chapter. Brian Lochen, MD, one of the original co-signers of the Wisconsin Chapter Charter agreement, was on hand to graciously accept the award and to safeguard its return to Wisconsin.
Michael Miller, MD, DFASAM, DLFAPA, is among the physicians and leaders in the field of addition medicine being honored at the American Society of Addiction Medicine’s 50th Annual Conference this weekend in Orlando.
Doctor Miller will receive the John P. McGovern Award on Saturday. The award recognizes “an individual who has made highly meritorious contributions to public policy, treatment, research, or prevention which has increased our understanding of the relationship of addiction and society.”
Doctor Miller, a past president of the Wisconsin Chapter, ASAM, currently serves as its Policy/Legislative Chair.
March 21, Wisconsin Health News
The Department of Health Services is providing more money to help counties and tribes expand access to medication-assisted treatment for those with opioid use disorder, DHS Secretary-designee Andrea Palm announced Wednesday.
The grants, which come from federal money awarded to the state, will head to:
Department of Health Services Secretary-designee Andrea Palm said Wednesday that the agency is hoping to build off former Gov. Scott Walker’s administration's work in addressing the opioid epidemic.
“The previous administration called for all hands on deck in the response to the opioid problem and inspired the entire state with the mantra, ‘Hope. Act. Live,’” Palm said at a forum in Green Bay Wednesday. “That’s something DHS takes to heart.”
Palm said Walker’s administration laid a “strong foundation” for addressing the epidemic.
Gov. Tony Evers’ budget proposes taking more federal money to expand Medicaid, which Palm touted as a way to get more people medication-assisted treatment.
The money would also go toward leveraging federal funding to pilot a hub-and-spoke model of care.
A state commission proposed the model last year, which was detailed in a report released at the final meeting of the Governor's Task Force on Opioid Abuse last December.
The model involves establishing a health home for people with substance use disorders, she said.
“It’s important to me and the leadership at DHS that we don’t lose sight of other substance use disorders, even as we focus on ending the opioid epidemic,” she said. “We need to build a healthcare system that is prepared to address behavioral healthcare more broadly.”
Palm said large parts of Wisconsin don’t have access to treatment and services. They’d pilot the model in two rural areas and one urban area in the state.
March 20, Wisconsin Health News
National experts broke down the health and legal aspects of marijuana at a Tuesday panel in Madison.
There's some evidence that marijuana can reduce nausea in patients undergoing chemotherapy as well as reduce pain in adults with chronic pain, according to Dr. Ron Wallace, a professor of epidemiology and internal medicine at the University of Iowa College of Public Health and Medicine. Wallace worked on a national report summarizing marijuana’s health effects.
Those with multiple sclerosis who use marijuana also report fewer muscle spasms. But Wallace said that the effects of cannabinoids were “modest."
“Cannabis can help a little bit,” he said at an Evidence-based Health Policy Project briefing. “But it’s not clear whether it’s better than the other options that are out there.”
There’s some evidence that long-term cannabis smoking can worsen respiratory problems and exacerbate some mental conditions, he said. Cannabis can also impair learning, memory and attention.
But it’s unclear how cannabis relates to heart attack, stroke and diabetes. And it’s not known how using marijuana during pregnancy affects pregnancy and childhood outcomes.
Determining marijuana's health effects can be difficult due to a host of issues, including a lack of standardization among the drug, federal restrictions and little funding for research, Wallace said.
Karmen Hanson, program director of behavioral health at the National Conference of State Legislatures, said 34 states have legalized medical marijuana.
Most states require or allow dispensaries and patient registries. They also have a list of specific conditions that patients can use medical marijuana.
But each state’s program is unique and legislators have to design programs that work best for their state, Hanson said.
“No two programs are going to be alike,” she said. “You can’t take what has worked in Colorado and drop it into Wisconsin.”
Gov. Tony Evers’ budgetwould legalize medical marijuana, but parts of it face opposition from Republican leaders.
Attorney General Josh Kaul called Tuesday for increasing access to treatment, taking action to prevent people from becoming addicted to opioids and holding drug traffickers and others accountable for their role in the opioid epidemic.
Speaking at an opioid forum in Green Bay, Kaul said the state should ensure more Wisconsinites have access to treatment and expand local programs that are working well.
He also called for taking federal money to expand Medicaid to get more people access to healthcare.
Wisconsin has done well on raising awareness, but it needs to take more action to prevent people from being addicted, Kaul said. That includes continuing work on reducing overprescription of opioids and its drug take back days.
He also suggested looking at the legalization of marijuana in other states and seeing whether it was effective as an alternative to opioids.
“My view is that I would have a doctor prescribing that patient medical marijuana than an opioid in almost every case,” he said.
Kaul also said large-scale drug traffickers need to be held accountable as well as those who created the epidemic.
Those who “reaped massive profits off the creation of the epidemic owe money back,” he said.
“It’s critical that we learn what caused this epidemic so that we don’t repeat the mistakes that were made as this epidemic was created,” he said
Summer is only a few months away, and the Wisconsin Medical Society has teamed up with the Medical College of Wisconsin (MCW) and the University of Wisconsin School of Medicine and Public Health (UWSMPH) to make sure your health care team is prepared.
From Asthma to Zika: A Physician's Guide to Summer is being held April 5-6 in Madison. Focusing on emerging health trends in infectious disease, environmental health and trauma, the new two-day education conference features a full lineup of speakers from MCW and UWSMPH, plus the opportunity to fulfill opioid education required by the Medical Examining Board and plenty of time to network with colleagues from across the state. s teamed up with the Medical College of Wisconsin (MCW) and the University of Wisconsin School of Medicine and Public Health (UWSMPH) to make sure your health care team is prepared.
Click here for details including session descriptions, speaker bios and registration information. The conference has been approved for AMA PRA Category 1 Credit™. Application for CME credit with the American Academy of Family Physicians is pending.
This quarterly recurring conference, taking place on May 22, 2019; September 11, 2019 and November 20, 2019, creates an educational forum in which primary care providers present cases of patients with complex pain to a multidisciplinary medical team.
The team consists of specialists in:
The team will offer patient-specific recommendations for
Patient identifiers will be removed so that other providers can attend the case presentations and learn the team’s recommendations for controlling pain and improving function.
This conference is designed to support providers’ efforts to develop multi-modal, pain management plans for their complex, chronic pain patients.
Providers on the May 22nd team include:
The conference will recur quarterly and team members may vary. If you would like to present a case at a future conference, please email james.shropshire@unitypoint.org.
This conference is generously funded by the UnityPoint Health-Meriter Foundation.
STATEMENT OF ACCREDITATION UnityPoint Health - Meriter is accredited by the Wisconsin Medical Society to provide continuing medical education for physicians.
AMA CREDIT DESIGNATION STATEMENT UnityPoint Health - Meriter designates this live activity for a maximum of 1.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity
The Wisconsin Medical Society and the Wisconsin Society of Addiction Medicine (WISAM) have raised concerns that a recent letter sent by the U.S. Department of Justice (DOJ) could have negative unintended consequences for patients trying to receive medically necessary treatment.
The letters were sent February 4 to more than 180 Wisconsin physicians, physician assistants and nurse practitioners who are “prescribing opioids at relatively high levels compared to other prescribers,” but did not specify if those comparisons reflected different types of patient populations that exist—a critical variable considering that some clinicians spend the bulk of their practices treating patients who experience pain or who are being weaned off addictive drugs, including opioids.
“We’re very concerned that these letters will alarm prescribers to the point that they may get out of the pain treatment arena altogether,” said Society President Molli Rolli, MD, in a press release distributed statewide today. “For years, Wisconsin’s physicians, elected officials and law enforcement leaders have collaborated to find the best ways to combat the opioids crisis; these letters seem to pivot into an area where physicians are threatened with criminal sanctions even if the treatment provided is medically appropriate.”
The DOJ letter admits that those receiving the letter haven’t been accused of any criminal wrongdoing: “Your prescriptions may be medically appropriate, and we have made no determination that you are violating the law.”
However, WISAM President Matthew Felgus, MD, said, “You have to get pretty deep into the letter to see that disclaimer. So essentially the letter is saying ‘you’re not doing anything illegal, but we’re watching you’—that’s a very new law enforcement attitude compared to what we’ve seen over the last several years, so it’s quite troubling.”
A recent report from the state’s Prescription Drug Monitoring Program (PDMP) shows that the total number of opioids and other monitored prescription drugs dispensed in Wisconsin has decreased 29 percent between 2015 and 2018—a drop of almost 1.5 million prescriptions.
“We’re making progress in reducing the amount of opioids being prescribed; at the same time, it’s important to remember that it’s already very difficult for some patients in Wisconsin to get quick access to legitimately needed care,” said Dr. Felgus. “Prescribers receiving this letter may think twice about continuing to see patients who have pain treatment needs—and those patients risk turning to street drugs when they can’t see a physician who is trying to wean them off opioids altogether.”
Both Dr. Felgus and Dr. Rolli emphasized that physicians are grateful for law enforcement efforts to help combat the opioid epidemic and suggested that the state’s Medical Examining Board—made up of 10 physicians and three public members—is best-suited to determine if a physician should face sanctions for providing inappropriate care.
“We hope to continue to collaborate with law enforcement on efforts like Wisconsin’s Dose of Reality initiative and drug take-back days, which have resulted in literally tons of unused prescription drugs being turned in to law enforcement offices for destruction, and that what appears to be a more punitive stance in the DOJ letter is an anomaly rather than a new standard,” said Dr. Rolli.
Wisconsin Society of Addiction Medicine563 Carter Court, Suite B,Kimberly, WI 54136
