Ending the Opioid Epidemic: Best Practices and Next Steps

Health Update

Editor’s Note: The American Medical Association (AMA) and Manatt Health are undertaking in-depth analyses of four states’ responses to the opioid epidemic to identify best practices and next steps to address the crisis. In the January “Health Update,” we summarized the first spotlight analysis , examining the actions Pennsylvania is taking to fight the opioid epidemic. Below we summarize the second analysis, focusing on Colorado’s efforts to battle the crisis in three areas: substance use disorder (SUD) treatment, pain management and harm reduction. To download the full analysis free, click here. To register for our upcoming webinar, sharing the findings from all four analyses, click here. (See our next story for more details on the webinar.)

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Colorado has addressed the opioid epidemic with an array of public and private initiatives. In 2013, Governor Hickenlooper launched a yearlong process to develop the Colorado Plan to Reduce Prescription Drug Abuse—one of the first statewide, comprehensive initiatives in the nation. Involving national experts and more than 200 stakeholders, the process resulted in the establishment of the Colorado Consortium for Prescription Drug Abuse Prevention, which includes representatives from the Colorado Medical Society and state and federal agencies, as well as healthcare professionals, public health officials and nonprofit organizations.

The Consortium is playing a leading role in shaping the state response to opioid misuse and diversion. It also is addressing stimulants and sedatives, as well as heroin and other illicit drugs.

There has been a 21% reduction in opioid prescriptions since 2013, but the loss of life and the emotional toll of the epidemic continue. Although Colorado’s death rate from opioid overdoses fell from 2014 to 2015, it rose again in 2016. This is consistent with national trends—and demonstrates that it will take more than cutting opioid prescriptions to end the opioid epidemic. Considering the significant challenges, it is important to identify promising practices, review the evidence on the extent to which they are working and identify potential next steps.

In a new spotlight analysis, the AMA and Manatt Health highlight the work of two Colorado agencies—the state Medicaid agency (the Colorado Department of Health Care Policy and Financing (HCPF) and the Division of Insurance (DOI), housed within the Department of Regulatory Agencies—which are at the forefront of the fight to end the opioid crisis. These two agencies address coverage issues that determine what care is accessible and affordable to the approximately 20% of Coloradans covered by Medicaid and 59% covered by individual or group insurance.

Where Is Colorado Succeeding?

New efforts to expand treatment. In May 2018, Colorado adopted a package of laws to address the opioid epidemic, including taking an initial step to reduce prior authorization barriers to medication-assisted treatment (MAT), new funding to expand the workforce of physicians and other healthcare professionals in rural and underserved areas, and plans to open up Medicaid coverage of SUD treatment provided in residential settings.

New parity policy. Colorado also enacted a 2018 law establishing an office of the ombudsman to assist state residents in accessing behavioral healthcare and requiring the DOI to report on compliance with mental health and SUD parity laws. The DOI is performing market conduct examinations to assess compliance.

Opioid alternatives in Medicaid. The state has expanded access to non-opioid pain management strategies in Medicaid, including coverage of non-opioid prescription medications and alternative therapies, such as physical therapy and occupational therapy, as well as a new option for up to six behavioral health visits in a primary care setting to support screening and early intervention.

Engaging the provider community. Colorado has an impressive array of stakeholders led by the Colorado Consortium for Prescription Drug Abuse Prevention, which has more than 500 individual and organization representatives, including the Colorado Medical Society, state and federal agencies, numerous healthcare professional organizations, public health officials, and nonprofit organizations. The Consortium’s public health focus has played a leading role in shaping the state’s response to addressing the epidemic, including action-oriented work groups and one of the most comprehensive data surveillance dashboards in the country.

Initial success of pilot projects. The six-month Colorado Opioid Safety Pilot reduced the use of opioids in 10 emergency departments by 36% using effective alternatives to opioids, such as lidocaine injections. This successful project is now being implemented in hospitals statewide. Kaiser Permanente offers its members the Integrated Pain Service, an eight-week program for high-risk opioid patients who want to learn alternative options for managing pain. Colorado emergency departments also are seeing success with initiating patients on buprenorphine and helping refer them to treatment.

Expanded naloxone access. Colorado was one of the first states to enact sweeping naloxone access laws and continues to advance policies—including executing a standard order for naloxone, adopting Good Samaritan protections and eliminating prior authorization for naloxone in Medicaid—to distribute naloxone to help save lives from overdose.

Where Can Colorado Build on Its Successes?

Eliminate barriers to treatment, including through mental health and SUD parity enforcement. Colorado should advance further efforts to remove prior authorization barriers for patients; continue building state infrastructure to remove barriers to adequate networks and address workforce shortages; and continue expanding enforcement of mental health and SUD parity laws through audits and active review of benefits packages, prior authorization policies and cost-sharing obligations.

Expand access to providers of medication-assisted treatment (MAT). Especially in the 31 counties without access to MAT providers, it is critical to expand access to treatment through statewide, sustainable initiatives that incentivize providers to offer MAT and to ensure physicians and patients can access services, including physician consults, behavioral and mental healthcare services, housing, employment, and other resources that often are part of a well-established hub-and-spoke model.

Leverage successful pilots. Colorado should identify and learn from best practices in the state to provide comprehensive, multimodal pain care (i.e., the Colorado Opioid Safety Pilot). Colorado also should work closely with stakeholders to review and reform benefit design and formulary requirements to ensure patients have access to non-opioid alternatives.

Foster connections to treatment. Colorado should build on its naloxone access successes through statewide education efforts with physicians and other key stakeholders, linking patients whose lives were saved with evidence-based treatment to begin and sustain recovery. Colorado should leverage the Consortium’s surveillance efforts to identify where to target state and federal grant dollars to expand access to treatment.

Conduct timely, practical evaluations. It is important to evaluate the policies, programs and other efforts in the state to determine what is truly working to improve patient care and reduce opioid-related harms, including understanding relationships between current policies and clinical outcomes to further successful initiatives while amending those that may be having unanticipated consequences.