There has been much discussion around NY State and the country about a surge in heroin usage and overdose deaths. Although the perception is that a drop in “doc shopping” caused the increase in heroin usage, the picture is complex and the history goes back further than some may realize. Heroin usage started to rise significantly in the US in the early 1990’s when dealers started to sell a more purified form which allowed one to achieve a significant high by snorting instead of using intravenously (80-90% pure vs. 10-20%). In addition, the cultural norm for teens and young adults had shifted where experimentation with multiple drugs in addition to alcohol and marijuana became the norm. Ultimately, if these patients did not stop snorting heroin, the disease process would progress and they would end up on IV heroin, with all the associated risks including HIV, Hepatitis C, or overdose deaths.
After the rise of heroin, Oxycodone was approved by the FDA in 1996 and with it came the rise in opioid pain medication abuse. Over the last 15 years, we have seen a steady rise in both opioid pain medication and heroin abuse. Since 2011, with publicity and discussion about the proposed ISTOP Law, there was a small decrease in “doc shopping” in 2012 and 2013. Since the mandatory lookup in the PDMP (Prescription Drug Monitoring Program) started in August 2013, resulting in more than 40,000 look ups per day, NY State DOH reports that “doc shopping” has been reduced by 75% and opioid prescriptions have been reduced by 5-10% statewide. With increased usage of the PDMP and law enforcement actions, it appears that supplies of opioid pain medications on the streets have been reduced. However, the drug dealing industry is adapting to these changes. Drug dealers have increased the supply and distribution of heroin and prices have dropped. As a result it appears that heroin usage continues to increase and may be surging in some areas of NY State and the country.
While opposing the mandatory PDMP lookup of each and every patient every time a controlled medication prescription is written, MSSNY, NYSPA and other physician groups supported the recent upgrades to the PDMP that have greatly improved accessibility and utility of information available. Trying to address the opioid epidemic and rising overdose deaths, physician leaders from MSSNY and NYSPA called for such improvements to the PDMP over 3 years before the ISTOP law was introduced. The PDMP Database has become a useful tool to combat “doc shopping” and prescription drug abuse. However-there is more work to be done.
When addressing substance use disorders, psychiatrists find that there are systemic obstacles that need to be addressed including: stigma; lack of awareness and understanding of substance use disorders among patients, the public and medical community; lack of access to treatment; and discriminatory practices by insurance plans that may violate Federal or State parity laws. One egregious example includes the sudden denial of Suboxone brand of Buprenorphine for stabilized patients with opioid use disorders -with plans going further to deny the substitute brand Zubsolv which they actually recommended as preferred, forcing patients into withdrawal while time consuming appeals take place.
It’s time for all of us to acknowledge that substance abuse is a medical problem, not a character flaw. We have to offer treatment, without judgment of persons with substance use disorders. A multi-faceted societal solution is needed including:
- Increased access to screening and treatment in primary care and psychiatric offices and clinics
- Increased substance abuse training during medical school and residency training
- Increased CME for practicing physicians in family medicine, internal medicine, pediatrics, obstetrics and gynecology, emergency medicine and psychiatric medicine regarding screening, diagnosis, treatment and referral for specialized addiction treatment – with each physician choosing CME based on their individual practice and patients’ needs
- Increased access to specialized addiction treatment services including detoxification programs, intensive outpatient residential and inpatient rehabilitation programs
- Expanded access to medication assisted treatment for alcohol and substance used disorders including Buprenorphine for opioid use disorders
- Increased CME for office based primary care physicians and psychiatrists to become certified to prescribe Buprenorphine, a unique opioid agonist/antagonist that has a substantial evidence base for improving outcomes and reducing overdose deaths in persons with opioid use disorders
- Increased public education regarding: safe storage and disposal of medications and strategies to limit diversion; the importance of sharing information with medical professionals regarding all prescribed medications
- Increased education of youth regarding the dangers of substance abuse, signs they or a friend may need help for substance abuse, and 911 laws that prevent prosecution of someone for substance possession who calls 911 in the event someone with them may have overdosed on alcohol or other drugs
- Changes in the criminal justice system including usage of drug and mental health courts and focus on diversion into treatment for non-violent drug related crimes
- Expanded awareness, education and access to Emergency Naloxone Kits that now can be used by basic level EMT’s, law enforcement, or friends and family of someone with an opioid use disorder in the event of a relapse and accidental overdose
- Increased public and private funding for initiatives listed above
Psychiatrists and Addiction Medicine physicians find that there are several obstacles that limit access to care and timeliness of care for persons with substance use disorders. Since relapses are common and motivation for treatment often fluctuates with Substance Use Disorders (particularly when a patient is in withdrawal), obstacles to access or delays in treatment too often contribute to or prolong setbacks with substance use disorders. Timely, if not immediate, access to care during windows of motivation can be the difference between success or failure or even sometimes life and death for someone with a substance use disorder. Too often, insurance plans
- Don’t adequately cover substance abuse assessments or treatments by non-psychiatrist physicians
- Carry out a “fail first” policy whereby a patient must first “fail” or relapse in a lower level of treatment before a higher level of care is covered
- Require time consuming and treatment delaying prior approval processes for medications needed to manage withdrawal or to assist substance abuse treatment to reduce risk of relapse
- Deny continued treatment, citing a relapse as the reason for no longer covering treatment stating arbitrarily that the plan is not working, or citing a lack of relapse as the reason treatment has succeeded and is no longer needed.
Insurance plans don’t stop covering treatment of diabetes or other medical problems because the treatment is succeeding, and they don’t stop covering treatment of medical conditions because there is a setback such as an elevation of blood sugars, myocardial infarction or CVA-such discriminatory practices with substance use disorders must end. Such practices may well be a violation of the Federal Mental Health Parity and Addiction Equity Act which requires plans to cover care for mental illnesses and substance use disorders the same as they cover other medical conditions. Enforcing the Federal Parity Laws, the NY State Attorney General’s Office recently investigated and achieved settlements against 5 insurance plans or mental health/addictions benefit management companies for such discriminatory practices against persons with mental health and addiction disorders. Patients, families and physicians need to keep the pressure on insurance plans and pharmacy benefit managers by appealing each and every unreasonable denial, and by filing complaints with the NY State Division of Insurance and the NY State Attorney General’s Healthcare Bureau.