|Category||NGA||President's Commission||Current Progress||SAFE TAKE||Status Change|
2018 > 2020
|Last Edit: July 2020|
|Public Awareness; Family Outreach & Support||The Administration should develop an evidence-based national campaign to promote prevention and reduce stigma.||Pres. Comm. #5: The Administration should fund and collaborate with private sector and non-profit partners to design a wide reaching, multi-platform national campaign addressing the hazards of substance use, the danger of opioids, and stigma.||Green - Completed|
On June 7, 2018, the Trump Administration unveiled the first set of public awareness ads to combat the opioid crisis.
Link to White House Press Release Here.
|While this goal has been achieved, PSAs and Awareness Campaigns have mixed results. To be successful, they require having the resources to provide recovery, treatment, and support options for those with substance use disorders. |
Communities do not have to wait for a national campaign that suits them - they can create their own campaigns! In fact, awareness campaigns that are more targeted can be very successful.
|Public Awareness; Family Outreach & Support||Pres. Comm. #49 The Office of National Drug Control Policy, federal partners, including the Department of Labor, large employers, employee assistance programs, and recovery support organizations should develop best practices on substance use disorders and the workplace.||Green - Completed|
Rules for federal employees: Federal Drug-Free Workplace Program, which includes specifics for The National Laboratory Certification Program.
Additionally, SAMHSA has a Drug-Free Workplace Toolkit that provides information to help employers develop and sustain successful drug-free workplace programs.
|Tool kits have emerges, going a step further than best practice guidelines because it gives employers a real place to start. However, the intended parties called upon by the President's Commission to complete this work have seemingly left that responsibility to SAMHSA to create and maintain. Moving forward, it would be helpful to have ONDCP and DOL support these initiatives by promoting them to employers.||Yellow > Green|
|Public Awareness; Family Outreach & Support||Pres. Comm. #50: The Office of National Drug Control Policy should work with the Department of Justice, the Department of Labor, the National Alliance for Model State Drug Laws, the National Conference of State Legislatures, and other stakeholders to develop model state legislation/regulation for states to decouple felony convictions and eligibility for business/occupational licenses, where appropriate.||Yellow - Some Progress|
The Trump Administration supports The First Step Act, intended to make our justice system more fair and assist former inmates when transitioning back into society.
In December 2019, Congress passed the Fair Chance Act as part of the National Defense Authorization Act of 2020 (S.1790), which prohibits federal government employers, and private-sector federal contractors, from asking about job applicants’ criminal history until a conditional offer of employment has been extended.
The Restoration of Rights Project provides a 50 State Comparison detailing Criminal Record in Employment & Licensing laws. However, based on data from April 2018, 35 states, D.C., and over 150 cities and counties have adopted a fair-chance policy.
|While these efforts have not been taken up nationally, the federal government and several states and counties have shown support for initiatives that prevent employers from viewing an applications criminal history at the beginning of the application process, as a means of mitigating the effects of one's past relationship with substance use. However, progress is still slow moving. This recommendation must be addressed to ensure that the social determinants that promote drug use are mitigated to help reverse the opioid epidemic. |
As one of the more radical suggestions coming from the President's Commission, it is important for the federal government to address the fact that several federal and state laws still prohibit drug offenders from working a multitude of jobs, regardless of if their drug history poses a risk for future success in a role.
SAFE considers this an outreach endeavor because it will only work as a destigmatizing function if businesses are on board and increase opportunities for those who are in recovery.
|Orange > Yellow|
|Prescription Medicine||Pres. Comm. #6: Various federal agencies should develop model statutes, regulations, and policies with stakeholders that ensure informed patient consent prior to an opioid prescription for chronic pain.||Green - Completed|
H.R. 6, SUPPORT for Patients and Communities Act, requires Medicare Advantage plans and part D prescription drug plans to provide information on risks associated with prolonged opioid use and non-opioid therapy coverage.
In May 2019, The Pain Management Best Practices Inter-Agency Task Force released their Final Report to detail updates, gaps, inconsistencies, and recommendations.
Additionally, many states are creating their own laws and guidelines including Michigan and New York
|While H.R. 6, SUPPORT for Patients and Communities Act, is a step in the right direction its scope is limited because it only addresses one population receiving opioids. |
The Pain Management Best Practices Inter-Agency Task Force completed their Final Report as suggested by the 2018 original SAFE Take. While SAFE had concerns about this Task Forces ability to share their findings, their release shows this Commission Recommendation was fulfilled.
Many states taking initiative to pass their own laws in line with this recommendation can create more pressure for federal agencies to publish model regulations and for other states to continue passing laws to support this.
|Yellow > Green|
|Prescription Medicine||Pres. Comm. #7: Health & Human Services (HHS) should coordinate the development of a national curriculum and standard of care for opioid prescribers - to supplement the Centers for Disease Control (CDC) guideline targeted to primary care physicians.||Green - Completed |
HHS offers several resources to encourage safe opioid prescribing practices.
The CDC introduced a 12 part online training course for providers called Applying CDC’s Guideline for Prescribing Opioids: An Online Training Series for Healthcare Providers to encourage safe and more effective opioid prescribing practices based on their 2016 publication: CDC Guideline for Prescribing Opioids for Chronic Pain.
The FDA has a timeline including the actions they have taken to address the opioid epidemic, including a December 2019 consensus report commissioned by the FDA to help frame opioid prescribing guidelines for acute pain.
States, such as Pennsylvania, have made efforts to produce a statewide opioid prescribing curriculum. Many medical schools have also taken steps to alter their curriculum to address the opioid crisis.
|Healthcare providers and their patients must have enough information to help them determine if the benefit of an addictive medication outweighs the risk. The CDC guidelines were complex and long (52 pages) and created controversy over whether or not they hurt patients with unique healthcare needs who depend on opioids for chronic and acute pain. The online training aims to mitigate these issues and offers an incentive for health professionals by allowing them to earn free continuing education credits for completing courses. |
H.R. 6 SUPPORT for Patients and Communities Act instructed FDA to develop evidence-based opioid analgesic prescribing guidelines (where they don't exist), consult stakeholders and other agencies in creating them, and report on how they will be used to protect the public health. This includes a requirement to make a clear statement that the guidelines are intended to inform prescribers and patients in clinical decisions and not restrict, limit, delay, or deny coverage. The FDA has attempted to fulfill this instruction by commissioning the consensus report and gathering up to date and appropriate information.
State and institutional support highlights the importance of this recommendation and builds on the work doing by the federal agencies.
|Yellow > Green|
|Prescription Medicine||Pres. Comm. #8: Federal agencies should collect participation data on prescribing patterns, matched with participation in continuing medical education (CME) data to determine effectiveness and to share with clinicians, stakeholders, and state licensing boards.||Orange - Unknown||Some of these organizations are better equipped to handle this than others. While state Prescription Data Management Programs can identify patterns of prescribing, these programs don't always talk to programs in other states or federal systems.|
States and private entities can already do this, and some healthcare systems have already taken it upon themselves to start tracking patterns and directing educational efforts based on the results. If you would like to learn more about how to implement this kind of change locally, S.A.F.E. can help.
|Prescription Medicine||Pres. Comm. #9: The Administration should develop a model training program to be disseminated at all levels of medical education on screening for substance use and mental health status to identify at-risk patients.||Green - Education Organizations Leading|
Association of American Medical Colleges (AAMC) has a list of efforts on their efforts and responses.
SAMHSA and HRSA have a list of screening tools providers can use.
|This effort seems to be moving forward primarily because of groups like the Association of American Medical Colleges (AAMC), the Accreditation Council for Graduate Medical Education (ACGME), the Accreditation Council for Continuing Medical Education (ACCME), and the other medical education organizations. This is because they have an inherent interest in it being a successful model.|
|Prescription Medicine||Pres. Comm. #10: Congress should amend the Controlled Substances Act to allow the Drug Enforcement Agency (DEA) to require that all prescribers desiring to be relicensed to prescribe opioids show participation in an approved Continuing Medical Education (CME) on opioid prescribing.||Yellow - State Progress |
State Requirements for Pain Management CME
|State licensing boards have the ability to provide and require CMEs with this focus. Getting the Controlled Substances Act amended will take time and may not have the desired result. Supporting the states in their effort may be the better approach.||Red > Yellow|
|Prescription Medicine||Pres. Comm. #11: Health and Human Services, Department of Justice, Drug Enforcement Agency, Office of National Drug Control Policy, and pharmacy associations should train pharmacists on best practices to evaluate legitimacy of opioid prescriptions and not penalize them for denying inappropriate prescriptions.||Orange - Unknown||Some of these organizations are better equipped to handle this than others. The last DEA guide on prescription fraud was published in 2000 and their focus has been more on distribution than individual pharmacists. The variability of licensing and education requirements for pharmacy staff in each state would also be a factor. This is probably best achieved through an inter-agency working group.|
|Prescription Medicine||Pres. Comm. #52: Federal agencies, including Health & Human Services (NIH, CDC, CMS, FDA, and the SAMHSA), Department of Justice, the Department of Defense, the Veterans Administration, and Office of National Drug Control Policy, should engage in a comprehensive review of existing research programs and establish goals for pain management and addiction research (both prevention and treatment).|
Pres. Comm. #53: Congress and the Federal Government should provide additional resources to the National Institute on Drug Abuse (NIDA), the National Institute of Mental Health (NIMH), and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) to fund the research areas cited above.
|Green - Lots of Action||Good News! National Institute of Health (NIH) has started the HEAL Initiative (Helping to End Addiction Long-Term) with $500 million in federal appropriations for a variety of efforts, including increased research to:|
Improve Treatments for Opioid Misuse and Addiction; Expand therapeutic options for opioid addiction, overdose prevention and reversal; Enhance treatments for infants born with Neonatal Abstinence Syndrome (NAS)/Neonatal opioid withdrawal syndrome (NOWs); Optimize effective treatment strategies for opioid addiction; Enhance Pain Management; Understand the biological underpinnings of chronic pain; Accelerate the discovery and pre-clinical development of non-addictive pain treatments; Advance new non-addictive pain treatments through the clinical pipeline.
There is still a lot of shuffling of money and priorities as well as partnerships that may still be awaiting funding. Look forward to more efforts on this front.
|Prescription Medicine||Pres. Comm. #54: Center for Medicare & Medicaid Services (CMS), Food and Drug Administration (FDA), and the United States Preventive Services Task Force (USPSTF) should implement a fast- track review process for any new evidence-based technology supporting substance use disorder (SUD) prevention and treatments (further research of Technology-Assisted Monitoring and Treatment for high-risk patients and SUD patients).||Red|
- Focusing Elsewhere
|The process for creating fast-tracking in a way that preserves that accountability could be a distraction from ongoing efforts to address the opioid crisis. Current “fast-tracking” efforts of these federal agencies are focused on growing access to existing evidence-based treatment where there are currently shortages (i.e. Medicaid Innovation Accelerator Program).|
|Prescription Medicine||Pres. Comm. #55: The Commission recommends that commercial insurers and the Center for Medicare & Medicaid Services (CMS) fast-track creation of Healthcare Common Procedure Coding System (HCPCS) codes for FDA - approved technology-based treatments, digital interventions, and biomarker-based interventions. NIH should develop a means to evaluate behavior modification apps for effectiveness.||Orange - |
|Technological interventions will only be as good as the support system ready to act when technology detects a crisis or an opportunity to intervene. If there is no support available, the person still faces a crisis alone.This is a growing area of research for many healthcare challenges, but progress specific to SUD treatment is unknown. Some of this could come up in the investment and research from recent government funding.|
|Prescription Medicine||Pres. Comm. #56: The Commission recommends that the FDA establish guidelines for post-market surveillance related to diversion, addiction, and other adverse consequences of controlled substances.||Yellow - In progress|
FDA resources: Guidances (Drugs), Step 5: FDA Post-Market Drug Safety Monitoring, and Abuse-Deterrent Opioid Analgesics
|Understanding whether or not anti-abuse and deterrent properties of medication are functioning as designed or being overridden, as OxyContin time release coating has been, is a critical part of medicinal safety. |
The FDA continues to evaluate its process to ensure safety around diversion and abuse.
In 2008, the FDA was funded to create Sentinel, another post-market surveillance program which complemented the Adverse Events Reporting System (FAERS) already in place. While the FAERS public dashboard is currently updated, some of the FAERS webpages on the FDA website contain links that are outdated or have been removed. The President’s Commission report does not mention this program in relation to this recommendation so it is unclear if it was considered in this recommendation. While originally assumed that the relaunch of the Drug Abuse Warning Network (DAWN) under the Substance Abuse and Mental Health Services Administration in 2019 would assist with this data in post-market stage, currently there is no evidence of DAWN data beyond 2014.
|Green > Yellow|
|Prescription Medicine||Pres. Comm. #42: The Commission recommends further use of the National Health Service Corps to supply needed health care workers to states and localities with higher than average opioid use and abuse.||Green - Steady Funding |
National Health Service Corps (NHSC)
|HRSA’s National Health Service Corps (NHSC) received $105 million in Fiscal Year 2018 to expand and improve access to quality opioid and substance use disorder (SUD) treatment in rural and underserved areas nationwide. This funding was appropriated again for 2019.|
|Prescription Medicine||Provide guidance (HHS) on best practices for care following an overdose to treating hospitals (ex - initiating MAT).||Pres. Comm. #31: Health & Human Services (HHS), Center for Medicare & Medicaid Services (CMS), Substance Abuse and Mental Health Services Administration (SAMHSA), the Veterans Administration (VA), and other federal agencies should incorporate quality measures that address addiction screenings and treatment referrals. HHS should review the scientific evidence on the latest opioid use disorder (OUD) and SUD treatment options and collaborate with the U.S. Preventive Services Task Force (USPSTF) on provider recommendations.||Green - Some Progress||SAMHSA’s Treatment Improvement Protocol (TIP) 63: Medications for Opioid Use Disorder, updated in 2020, offers screening, assessment, treatment and referral guidelines for primary care settings. |
HR 6 Support for Patients and Communities Act includes a demonstration project to increase access to comprehensive, evidence-based outpatient treatment for Medicare beneficiaries with opioid use disorders and includes the development of measures of quality and outcomes for treatment, but does not specifically address measures for screening and referrals.
|Prescription Medicine||The Drug Enforcement Agency should remove the requirement for medical residents to apply for federal waiver to prescribe buprenorphine - already practicing under physician supervision.||Yellow - Slow Moving, But Gaining Popularity|
Officials from several states penned this letter to HHS Secretary Alex Azar asking for legislation to eliminating the waiver requirements.
H.R.2482 - Mainstreaming Addiction Treatment Act of 2019 sought to eliminate Buprenorphine Waivers
|Currently, doctors, and other healthcare providers made recently eligible under H.R. 6 Support for Patients and Communities Act, must go through training to receive a waiver to prescribe buprenorphine, an opioid agonist, used to treat opioid use disorder. The hurdles to treat an opioid use disorder are much greater than the hurdles to prescribe the opioids that lead to such a disorder. In order to increase access to this important tool in treating OUD, laws have been changed to increase the number of patients that a waivered provider can treat and the types of providers that can use waivers, but the requirement to receive the training and apply for a waiver remains in place.|
Despite no official legislation passed to remove the waiver, there is clear momentum. The letter sent by officials from New York, New Mexico, Idaho, Louisiana, Maryland, Indiana and Oregon highlights state's interests while the proposed bill not only expressed the desires of states and Congress members, but underscores the bipartisan support behind this effort. Several other entities support this effort as well.
|Red > Yellow|
|Prescription Medicine||Congress should extend buprenorphine prescribing privileges (via the Comprehensive Addiction and Recovery Act) to Advanced Practice Registered Nurses (APRNs).||Green - Completed||H.R. 6 SUPPORT for Patients and Communities Act provides permanent extension of prescribing authority for physician assistants and nurse practitioners. It also provides authority for clinical nurse specialists, certified nurse midwives, and certified registered nurse anesthetists for five years.|
|Prescription Medicine||Health & Human Services and the Drug Enforcement Agency, via exceptions under the public health emergency declaration, should issue policy guidance on providing Medication Assisted Treatment (MAT) via telehealth and encourage providers to use it. Congress should provide a permanent fix to ensure rural populations can access MAT after the public health emergency declaration expires - (currently prohibited by Ryan Haight Online Pharmacy Consumer Protection Act).||Pres. Comm. #41: The Commission recommends that federal agencies revise regulations and reimbursement policies to allow for substance use disorder treatment via telemedicine.||Yellow - Progress, But Gaps Still Exist|
2018 HHS guidance about using telehealth to provide MAT
DEA clarification on the Use of Telemedicine While Providing MAT
State level telehealth innovations to care for those with SUDs:
California's California MAT Expansion Project
Michigan's New Horizon Substance Use Recovery Network
State Telehealth Laws & Reimbursement Policies:
Fall 2019 Center for Connected Health Policy (CCHP) Report
CCHP Laws & Reimbursement Policies Map updated last in February 2020.
|There have been efforts to better incorporate the use of telehealth for the treatment of opioid use disorder, specifically when it comes to MAT. HHS has taken steps to implement additional guidance on using telehealth to provide MAT. Additionally, the DEA has offered clarification on how programs and providers can avoid violating The Ryan Haight Online Pharmacy Consumer Act, which requires an in-person patient evaluation before receiving a prescription for a controlled substance from someone's provider. States have also committed to furthering this mission, with many creating programs in rural communities or passing state level laws that include provisions allowing for the prescribing of controlled substance in a telehealth setting while forgoing the in-person examination. |
While telehealth can be helpful, continued improvements are needed. This HHS publication shows that there must be additional measures besides telehealth. For example, there are issues with addressing populations without access to broadband and devices equipped for telehealth which often still require a “physical examination,” performed via video and other computer facilitated equipment.
H.R. 6 SUPPORT for Patients and Communities Act required the Centers for Medicare & Medicaid Services to issue guidelines to states for providing services via telehealth for treatment of substance use disorder (SUD) that are federally reimbursed. It also expands the use of telehealth services by eliminating certain statutory originating site requirements for telehealth services furnished to Medicare beneficiaries for the treatment of SUDs and co-occurring mental health disorders which began on July 1, 2019.
|Prescription Medicine||Pres. Comm. #44: The Commission recommends HHS implement naloxone co-prescribing pilot programs to confirm initial research and identify best practices. ONDCP should, in coordination with HHS, disseminate a summary of existing research on co-prescribing to stakeholders.||Yellow - Needs More Effort|
HHS Naloxone and Co-Prescribing Guidance
Medstar Health Naloxone Guidelines including training material resources"
|H.R. 6 SUPPORT for Patients and Communities Act includes a provision supporting co-prescribing of naloxone in emergency rooms for patients brought in with an overdose, but doesn’t address co-prescribing in conjunction with opioids for patients in primary care or other specialty settings. |
The Indian Health Service's website has guidance on co-prescribing of naloxone. The Surgeon General has issued guidance such as his Advisory on Naloxone and Opioid Overdose , which has made it clear that having a high portion of the population carrying naloxone is a priority, and that co-prescribing is an integral part of saving lives from this epidemic. This information should be provided more widely.
While overwhelmingly evident that co-prescribing naloxone for SUD patients can save lives, more work is still needed to make this intervention a reality. While many states are dispensing Naloxone and beginning various pilot programs, such as this one in Washington D.C., HHS has yet to take the lead on a program as comprehensive as what is outlined in the recommendation. Additionally, there has been no mention of this from ONDCP.
|Prescription Medicine||The Office of the National Coordinator for Health Information Technology within Health & Human Services should require that electronic health record (EHR) vendors make their systems interoperable with all state prescription drug monitoring programs (PDMPs).||Red - Very little movement||In April 2020, CMS released its Roadmap: Strategies to Fight the Opioid Crisis. While it highlights the importance of accessing PDMP data within EHR, only one-third of providers had this ability as of 2019. |
Additionally, It’s unclear how big the differences might be between PDMP systems, but considering every state but Missouri has a statewide PDMP, and many states make its use mandatory, integration between PDMPs and EHRs becomes more critical. Currently, most systems are separate, requiring a provider to log into both, adding more time constraints with a patient. A system that allows for customization and wide interoperability is required.
|Orange > Red|
|Prescription Medicine||The Drug Enforcement Agency should create new requirements that health care providers register with their state PDMP and complete training to prescribe opioids (similar to what is required to prescribe medication assisted treatment (MAT)) - using Center for Disease Control’s (CDC) prescribing guideline in training.||Red - No federal movement|
Some states have/have attempted mandates including: California, District of Columbia, Maryland, Georgia
|While some states have taken it upon themselves to mandate that providers in their state register with their PDMP, this has not happened on a national level. The DEA’s focus is law enforcement, not the quality of medical training. Currently, there are more bureaucratic hurdles for prescribing MAT than there are for prescribing the opioids themselves. This is at least one factor in a low number of providers prescribing medication for treating opioid use disorder. Education should be the focus here and that change has been initiated within the medical education community.||Orange > Red|
|Prescription Medicine||Health & Human Services should invest in additional research and evaluation of non-pharmacological therapies for pain and guidance to assist states in making appropriate coverage decisions in Medicaid and other state administered health programs.||Yellow - Signs of Progress|
June 2018: Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review
May 2019: Pain Management Best Practices Inter-Agency Task Force: Updates, Gaps, Inconsistencies, and Recommendations Final Report
|This is an important goal. The Pain Management Best Practices Inter-Agency Task Force, the National Institutes of Health HEAL Initiative, and the numerous new grants coming out of federal agencies, including the passage of H.R. 6 SUPPORT for Patients and Communities Act, have influenced and expanded research and evaluation. While these things take time, there are already clear efforts moving in that direction. What has not yet been seen are guidelines published with the stated intent of assisting states in making appropriate coverage decision.|
|Prescription Medicine||Pres. Comm. #12: The Administration should support the Prescription Drug Monitoring Program (PDMP) Act and mandate that states receiving grant funds comply with PDMP requirements, including data sharing||Yellow - Some Initiatives In Place||When mandates from the federal government are not accompanied with funding to implement them, the mandates can be problematic. In the absence of funding, states could end up shifting money to comply with the mandate, sacrificing money for more critical priorities and creating/increasing unresolved challenges. |
All but one state (Missouri) have a statewide PDMP, and many make its use mandatory.
Since 2017, several congress members have introduced legislation every year in an effort to pass the Prescription Drug Monitoring Act. (Links available for 2017, 2018, and 2019). However, these efforts have never gone passed being introduced into Congress, highlighting a low likelihood of passage.
|Red > Yellow|
|Prescription Medicine||Pres. Comm. #13: Federal agencies should mandate PDMP checks and consider amending requirements under the Emergency Medical Treatment and Labor Act (EMTALA), which requires hospitals to screen and stabilize patients in an emergency department, regardless of insurance status or ability to pay.||Red - Very Unlikely||Like Recommendation 12 - this requirement would not come with direct funding (EMTALA is an unfunded mandate) which means states have to shift money to a requirement like this. States should be making full use of their PDMPs and many, but not all, have mandates to check the PDMP. New grant money for the crisis could help states achieve this, mandate or not. |
HR 6 SUPPORT for Patients and Communities Act does provide some resources for hospitals and other entities to develop protocols to address the provision of an overdose reversal medication, such as naloxone, upon discharge, connection with peer-support specialists, and referral to treatment and other services that best fit the patient’s needs.
These efforts are still only happening on the state level, despite the constant federal attempts to pass legislation. FAQ #3 in the linked CMS guidance suggests that there will not me an amendment to EMTALA for the mentioned recommendation.
|Prescription Medicine||Pres. Comm. #14: PDMP data integration with electronic health records, overdose episodes, and substance use disorder-related decision support tools for providers is necessary to increase effectiveness.||Orange - Nonspecific/Non-Trackable||This recommendation is non-agency specific and more of a statement of principle. CMS has issued new guidance with information to help states leverage federal funding into approaches for PDMP and EHR integration and innovation in Health IT. Innovation in both the public and private sector here is a reason to be hopeful. (CMS guidance)|
|Prescription Medicine||Pres. Comm. #15: The Office of National Drug Control Policy and the Drug Enforcement Agency (DEA) should increase electronic prescribing to prevent diversion and forgery. The DEA should revise regulations regarding electronic prescribing for controlled substances||Yellow - Some Effort But Not Enough||Electronic prescribing is considered a vital tool in regaining control over prescription opioids. There are already some states that require it, and there is legislation that could incentivize it, federally. However, there are areas in rural America that don't even have consistent broadband internet access. |
Requiring new technology without funding the requirement, and without appropriate waivers, erects barriers to appropriate care even when well intended.
The SUPPORT for Patients and Communities Act made changes that support this commission suggestion. Firstly, while it raised some concerns, this law made it a federal mandate for physicians to electronically prescribe controlled substances by January 2021 for Schedule II, III, IV, and V controlled substances that are covered under a Medicare part D or Medicare Advantage prescription drug plan.
As of September 2019, the DEA had not revised its regulations that would require all prescribers to electronically submit prescriptions. However, this publication also suggests that several states (including Connecticut, New York, Massachusetts, Minnesota, and Maine) have mandated electronic prescribing through legislation while other states (California, Missouri, Vermont, Texas, and Ohio) have considered passing similar legislation.
|Prescription Medicine||Pres. Comm. #16: The Federal Government should work with states to remove legal barriers and ensure Prescription Drug Management Programs (PDMP) incorporate available overdose/naloxone deployment data, including the Department of Transportation’s (DOT) Emergency Medical Technician (EMT) overdose database. It is necessary to have overdose data/naloxone deployment data in the PDMP to allow users of the PDMP to assist patients.||Yellow - Long Way to Go||A PDMP is only as helpful as the quality and timeliness of the inputs. When information is excluded or delayed, there are missed opportunities to counsel, assist, and protect patients from the risks associated with the use of any prescription medicine. Naloxone prescriptions should be included in that. There is some progress in municipalities that have elected to engage in their own mapping.|
|Prescription Medicine||Pres. Comm. #17: Communities should utilize Take Back Day to inform the public about drug screening and treatment services. Hospitals/clinics and retail pharmacies should become year-round authorized collectors and explore the use of drug deactivation bags.||Green - Steady Progress|
DEA Public Disposal Locator
National Board of Pharmacy Drug Disposal Locator
|Take Back Days are an important tool in reducing the supply of prescription medicines to those who may misuse them. In addition to the two national Take Back Days (in April and October), sponsored by the Department of Justice and the DEA, many pharmacies have become year-round collectors. Communities should also, to the extent possible, consider deactivation bags where collection is less feasible.|
|National Coordination||Pres. Comm. #1: Congress and the Administration should increase block grant funding for opioid-related and substance use disorder (SUD)-related activities in the states.||Green - Some Considerations |
March 2019: HHS released an additional $487 million in its State Opioid Response (SOR) grant program
|Increased funding to states and communities is a great first step and has been realized through several initiatives such as through the HHS Five-Point Opioid Strategy. However, any funding initiatives should be paired with a national strategy focusing on bold ideas, promising practices, and evidence-based youth prevention efforts.|
|National Coordination||Congress and the Administration should increase federal funding to states for SUD related activities, streamline the grant process (extend duration), and increase flexibility in grants/funding.||Pres. Comm. #2: The Office of National Drug Control Policy (ONDCP), through support from Health & Human Services and the Department of Justice, should establish a coordinated system for tracking all federally-funded initiatives.||Yellow - Warning, Caution Ahead |
Oct 2018: SUPPORT Act Medicaid Provisions
September 2019: Trump Administration increases state funding to combat Opioid Crisis
|Tracking the effectiveness of grants made by the Federal Government is an important accountability measure. While there has been an increase in funding and grant measures, an increase should go along with an effort to make grants more flexible. States and individual recipients still struggle to meet overburdensome reporting requirements, while new actors in the field struggle to understand the grant-making process. There is an influx of money, but efficacy, coordination and tracking are to still be determined.|
|National Coordination||Increase coordination and communication between agencies - via inter-agency task force or executive agency.||Pres. Comm. #3: Congress should fund implementation of ONDCP review for every federal program and mandate federal and state cooperation.||Yellow - Some Coordination||Inter-agency task forces are a great way to accelerate progress on initiatives important to the Administration, but must be paired with the resources and accountability to drive action. ONDCP is a natural office to lead an inter-agency task force and should receive the resources and legitimacy to facilitate a review process. While ONDCP does coordinate federal agency actions, it does not have the funding and resources to do reviews at the suggested level. Reviews of federal programs should be based on measures appropriate to the program area; prevention and treatment programs must be evaluated by different criteria.|
In March 2019, the Bipartisan Policy Center released a report: Tracking Federal Funding to Combat the Opioid Crisis. They included the same recommendation that ONDCP should should enhance federal coordination, indicating a lack of progress. However, all of the states included in the report had coordinating bodies that improved communication and data-sharing.
Additionally, The Comprehensive Opioid Abuse Grant Program (COAP) administered by the DOJ. In FY2018, they included funding to improve the SUD response to those in the criminal justice system. It was intended to enhance coordination between criminal justice agencies and the single-state agency responsible for administering SUD grants. While this initiative shows some interest in increasing coordination, it falls short of meeting the national level discussed in the NGA and President's Commission.
|Full-Spectrum Prevention||Continue to coordinate with existing prevention programs in schools and avoid increasing stigma and fear around punitive approaches for those who need access to treatment. Expand federal support for new and additional resources to support training officers in schools, community engagements, and other educational activities.||Yellow - Limited Infrastructure||This recommendation will largely be helped by implementing universal screening programs for students, in addition to supportive environments and activities to keep students out of triggering situations for return to use. Funding without the infrastructure to support long-term prevention and support for those in recovery will reap few benefits. Our SAFE Campuses program will work to support and provide opportunities for those in recovery in higher education.|
|Full-Spectrum Prevention||Pres. Comm. #18: The Center for Medicare & Medicaid Services (CMS) should remove pain survey questions entirely on patient satisfaction surveys so that providers are never incentivized for offering opioids to raise their survey score. The Office of National Drug Control Policy (ONDCP) and Health & Human Services should establish a policy to prevent hospital administrators from using patient ratings from CMS surveys improperly.||Yellow - |
|According to research (such as this December 2018 study or this May 2017 study) it has been difficult to find agreement on what the right measures are for patient satisfaction and health outcomes, especially as they relate to propensity for opioid misuse.|
However, in August 2018, CMS announced a proposal to remove pain management questions from the HCAHPS Survey in response to the President's Commission. In July 2019, they also proposed removing pain question #10 from all HH CAHPS Surveys, but it was announced in November of 2019 that CMS would not be finalizing the removal of question #10 because of consumers gathered during the public comment period.
Research in these areas is key; ensuring that patients have access to the right treatment, rather than the easiest and cheapest treatment, which matters to the long term wellness of the patient.
NGA has a long history of working with states to tackle complex issues, including opioids. Their leadership helps states develop public policy options, and helps identify what is working in other states. Analysis of which states have policies that correspond to removing pain survey questions, as well as an analysis of what is working or not working would be helpful. The states then adopt their own state policy and regulations to align state systems with federal regulations.
The bureaucracy around changing state policy, internal systems, and effective implementation of those changes will slow this down.
|Full-Spectrum Prevention||Pres. Comm. #19: CMS should review and modify rate-setting policies that discourage the use of non-opioid treatments for pain, such as certain bundled payments that make alternative treatment options cost prohibitive for hospitals and doctors, particularly those options for treating immediate post-surgical pain.||Yellow - Attempts Have Fallen Short||There are few provisions for alternative pain treatments across federal and private insurers. Some states are convening "Payors" councils to examine service definitions and establish payment mechanisms. CMS included in its 2018 Roadmap: Strategy to Fight the Opioid Epidemic a plan to “disseminate best practices for state Medicaid agencies and other payers on alternative pain management strategies and other tactics to address the opioid crisis.” Although, reimbursement rates for alternative treatments remain an under addressed barrier to reducing opioid dependence.|
A March 2019 Mandated Report to Congress, examined how the SUPPORT ACT called on the Medicare Payment Advisory Commission to identify incentives specific to the Medicare Inpatient and Outpatient Prospective Payment Systems that might encourage providers to choose cheaper opioid pain treatment strategies over other non-opioid treatment strategies.
In October 2019, U.S. Senators Jeanne Shaheen (D-NH) and Shelley Moore Capito (R-WV) sent a bipartisan urging HHS Secretary Alex Azar and CMS Administrator Seema Verma to address Medicare’s payment policies to ensure that health care providers are not incentivized to use opioid-based pain management treatments over non-opioid alternatives.
|Treatment and Recovery||Pres. Comm. #4: The Department of Education should collaborate with states (Dept. of Ed) on student assessment programs, such as Screening, Brief Intervention, and Referral to Treatment (SBIRT) - to identify at-risk youth who may need treatment.||Yellow - Some Momentum, Needs More Results|
ONDCP released Substance Use Prevention: A Resource Guide for School Staff
|There are two sides to this - data sharing can save lives. However, without strong privacy protection, it can adversely affect one’s livelihood in and after recovery. Proceed with caution. SAFE wrote about this as legislation was being introduced, however, it did not make it into the final version of H.R. 6, SUPPORT for Patients and Communities Act.|
In May 2019, HHS the creation of a new committee to identify areas for improved coordination related to SUD research, services, supports and prevention activities across all relevant federal agencies. DOE will be part of the committee.
Schools are leary of doing any assessments on kids. They don't want to be held responsible for knowing something about a child and not addressing it. Assessment in schools by school staff is rare.
However, school districts do not need to wait for the Department of Education to implement SBIRT - there is a free tool available: CRAFFT Screening Tool
|Red > Yellow|
|Treatment and Recovery||Congress should align 42 CFR Part 2 with the Health Insurance Portability and Accountability Act (HIPAA) to bring substance use disorder (SUD) info with other types of health data||Yellow - Little Movement||In June 2018, The U.S. House of Representatives passed a bill designed to align 42 CFR Part 2 with HIPAA for the purposes of health care treatment, payment, and operations. |
However, in September 2018, Congress agreed to compromise opioid legislation. They did not align 42 CFR Part 2 with the HIPAA Privacy Rule, but instead permits the disclosure of substance abuse treatment on a patient's medical record with the patient's consent.
In October 2019, The Partnership to Amend 42 CFR Part 2 is calling on the SAMHSA to align the rule with HIPAA to ensure proper patient data access and protect patient privacy.
|Treatment and Recovery||The Administration should expedite approval of Medicaid Institute for Mental Diseases (IMD) waivers. Congress should enact legislation creating an exception to IMD exclusion for those receiving SUD treatment.||Green - Steady Progress||Waivers can currently be requested for opioid use disorder but not for broader SUDs. As part of the HHS effort to combat the ongoing opioid crisis, on November 1, 2017, CMS issued guidance describing additional flexibilities to help states improve access to, and quality of, SUD treatment through Medicaid section 1115 |
The Medicaid Innovation Accelerator Program (IAP) is available to support Medicaid agencies interested in strategic design support to develop their section 1115 SUD demonstration proposals and implementation plans. For more information, visit IAP SUD Individualized Technical Support Opportunities. H.R. 6, SUPPORT for Patients and Communities Act provides the option to cover care in IMDs, which may otherwise not be reimbursed, for treatment of SUD for patients aged 21-64 during fiscal years 2019-2023. However, this is still not a permanent solution.
|Treatment and Recovery||Health & Human Services (HHS) should strengthen federal oversight and ensure the Mental Health Parity and Addiction Equity Act (MHPAEA)/parity violations do not limit access to substance use disorder (SUD) treatment.||Pres. Comm. #33: HHS, The Centers for Medicare and Medicaid Services (CMS), the Indian Health Service (IHS), Tricare, the Drug Enforcement Agency (DEA), and the Veterans Administration (VA) should remove reimbursement and policy barriers to SUD treatment, such as patient limits, that limit access to any forms of FDA-approved medication-assisted treatment (MAT), counseling, inpatient/residential treatment, and other treatment modalities, particularly fail-first protocols and frequent prior authorizations. All primary care providers employed by the above-mentioned health systems should screen for alcohol and drug use, and provide treatment within 24 to 48 hours, directly or through referral.|
Pres. Comm. #35: Because the Department of Labor (DOL) regulates health care coverage provided by many large employers, the Commission recommends that Congress provide DOL increased authority to levy monetary penalties on insurers and funders, and permit DOL to launch investigations of health insurers independently for parity violations.
Pres. Comm. #36: Federal and state regulators should use a standardized tool that requires health plans to document and disclose their compliance strategies for non-quantitative treatment limitations (NQTL) parity. HHS, in consultation with DOL and
|There is a lot of confusing messaging from the government about parity rules and enforcement, healthcare insurance coverage for inpatient treatment, and substance use. Congress has been making progress on some areas, but overall, government action on this front shows a lack of coordinated effort.|
|Treatment and Recovery||Expand access to evidence-based SUD and mental health services for justice-involved populations. Specifically, medicaid coverage for medicaid-eligible individuals who are incarcerated pending disposition or nearing release. CMS should grant states (under 1115 authority) partial waivers of inmate exclusion otherwise barring states form receiving federal Medicaid funding in these circumstances.||Pres. Comm. #37: The Commission recommends the National Institute on Corrections (NIC), the Bureau of Justice Assistance (BJA), the Substance Abuse and Mental Health Services Administration (SAMHSA), and other national, state, local, and tribal stakeholders use medication-assisted treatment (MAT) with pre-trial detainees and continuing treatment upon release.||Red - |
Needs Funding, Culture and Attitude Change
|The most lethal time for any opioid user is the two weeks after release from jail or prison. Social and environmental factors as well as a decreased tolerance both increase vulnerability for return to use and overdose.|
The move to allow for Medication Assisted Treatment (MAT), also known as pharmacotherapy, for incarcerated individuals has been very slow, mostly due to funding, concerns over diversion of prescription medicine for illicit use within the facilities, and a general misunderstanding of the role of these medications and their effectiveness for longer term treatment of SUD. Even if inmates have access to MAT/pharmacotherapy, those with felony charges are not eligible for medicaid coverage upon release until their probation is complete, creating a dangerous gray area.
Public-Public and Public-Private partnerships must be formed in most cases so the correctional facility can make a warm handoff of medical services to the local managed care organization (MCO/Medicaid provider) or county health department. In 2016 Rhode Island launched a first of its kind program in the country to provide medically assisted substance abuse treatment for incarcerated individuals, as well as transition programs to connect with treatment providers upon release. Rhode Island is currently the only state that mandates the use of all three evidenced-based opioid withdrawal medications (Vivitrol, Suboxone, and Methadone).
All of these systems mentioned are working on incorporating MAT/pharmacotherapy into their programs and making it available to current incarcerated offenders. H.R. 6, Support for Patients and Communities Act requires Health and Human Services to convene a stakeholder group to report on best practices for states on this topic. This is an important, but tiny step in an area critical to impacting this crisis.
|Treatment and Recovery||Health and Human Services should revise Medicare coverage requirements to cover methadone at community outpatient treatment programs.||Green - Complete||H.R. 6, SUPPORT for Patients and Communities Act expands Medicare coverage to Opioid Treatment Providers and does not limit the coverage to methadone only. This is a big win for senior citizens using Medicare who struggle with opioid use disorder. However, there are still many barriers for Medicaid clients, who have to pay out of pocket for treatment in these programs.|
|Treatment and Recovery||The Health Resources and Services Administration (HRSA) should expand definition of approved sites where primary care providers can be reimbursed for providing medication assisted treatment (MAT) and other behavioral health interventions to include substance use disorder (SUD) treatment facilities.||Pres. Comm. #34: Health and Human Services (HHS) review and modify rate-setting (including policies that indirectly impact reimbursement) to better cover the true costs of providing SUD treatment, including inpatient psychiatric facility rates and outpatient provider rates.||Yellow - |
Needs More Work
|H.R. 6, SUPPORT for Patients and Communities Act works to increase the number of providers who can treat SUD with MAT. However, reimbursement rates will impact how many qualified providers actually provide the treatment, and the SUPPORT Act doesn't seem to address that. Once improved reimbursement demonstrates positive impact in the field then the rate will be justified. SAMHSA-HRSA promotes the use of integrated care for treatment of substance use disorder with tools and resources.|
|Treatment and Recovery||Pres. Comm. #32: Adopt process, outcome, and prognostic measures of treatment services as presented by the National Outcome Measurement and the American Society of Addiction Medicine (ASAM).||Yellow - Some Progress||Yes! We need more money for research of evidence based practices and recovery supports that work. Policies for outcome measurements have to be adopted by insurers, providers, healthcare systems, and government to enable real change in treatment models.|
As of November 2019, Some states have used their SUD waivers to formally implement the ASAM Criteria to promote consistency in client placement for SUD treatment
|Treatment and Recovery||Pres. Comm. #39: The federal government should partner with appropriate hospital and recovery organizations to expand the use of recovery coaches, especially in hard-hit areas. Insurance companies, federal health systems, and state payers should expand programs for hospital and primary case-based SUD treatment and referral services.||Green - Progress at the State Level||Great recommendation - doable and affordable. The model can save lives and money. Rhode Island - RI-CARES - was one of the first states to use recovery coaches in the emergency room (ER). They are collecting data about their work and now other states are adopting this practice. This model can be utilized in any ER.|
|Treatment and Recovery||Pres. Comm. #40: The Commission recommends the HRSA prioritize addiction treatment knowledge across all health disciplines.||Yellow - Slow Progress||Psychiatric/medical academic programs have an average of 8 hours of total education for students about substance use disorders. Information in this area should be much more available and more intensive for health care providers. Medical schools, boards, and healthcare systems can all help make this a reality today.|
HRSA has an Opioid Crisis Webpage that incorporates resource, training, and assistance opportunities to address the opioid epidemic
|Treatment and Recovery||Pres. Comm. #46: The Commission recommends that HHS implement guidelines and reimbursement policies for Recovery Support Services, including peer to peer programs, jobs and life skills training, supportive housing, and recovery housing.||Green - On The Right Track||These recovery support services were included in the first piece of legislation called CARA (Comprehensive Addiction Recovery Act), however, they were not funded. Some states have added recovery coaches to their formulary but it is hit and miss. When someone successfully stops misusing, but can't find employment, or housing, or a community of support, they are more likely to re-engage in misuse. Recovery Support Services are part of treatment.|
H.R. 6, SUPPORT for Patients and Communities Act requires HHS to issue best practices for recovery housing, and to identify common indicators in fraudulent recovery housing operators. The Building Communities of Recovery program was reauthorized and modified by the law to include peer support networks and funding for community organizations focused on long-term recovery support services. H.R. 6 also requires HHS to establish a National Peer-Run Training and Technical Assistance Center for Addiction Recovery Support to facilitate expansion of comprehensive recovery support programs in communities, as well as provide a program to support transition to independent living and return to the workforce.
|Treatment and Recovery||Health & Human Services (HHS) should issue guidance encouraging universal screening of pregnant women as part of comprehensive obstetric care. HHS should also issue comprehensive standards for treating neonatal abstinence syndrome.||Pres. Comm. #47: HHS, the Substance Abuse and Mental Health Services Administration (SAMHSA), and the Administration on Children, Youth and Families (ACYF) should disseminate best practices for states regarding interventions and strategies to keep families together, when it can be done safely (e.g., using a relative for kinship care). These practices should include utilizing comprehensive family centered approaches and should ensure families have access to drug screening, substance use treatment, and parental support. Further, federal agencies should research promising models for pregnant and postpartum women with substance use disorders (SUDs) and their newborns, including screenings, treatment interventions, supportive housing, non- pharmacologic interventions for children born with neonatal abstinence syndrome, medication-assisted treatment (MAT) and other recovery supports.||Green - Moving Forward||When screening laws lead to separation of families with a charge of "neglect and abuse," the safety and health risk increases for mothers and children. The opioid crisis has caused a dramatic increase in the number of children in foster care. Communities and states must ask (if children can be kept safe with their parents); does investment in finding ways to keep families together and healthy make more fiscal and emotional sense than foster care?|
H.R. 6, SUPPORT for Patients and Communities Act has several provisions to improve care for infants with neonatal abstinence syndrome and their mothers - an important step in reducing the impact of this crisis to next generations. The law includes a study to identify gaps in Medicaid coverage for pregnant and postpartum mothers, clarification for states on provision of Medicaid to infants with NAS, and provision of support for their mothers. It also provides funding for HHS to test a “recovery coach” program for parents with children in foster care, along with an increase of funding to increase capacity for family-focused residential treatment.
|Treatment and Recovery||Pres. Comm. #48: ONDCP, the Substance Abuse and Mental health Services Administration (SAMHSA), and the Department of Education (DOE) identify successful college recovery programs, including “sober housing” on college campuses, and provide support and technical assistance to increase the number and capacity of high-quality programs to help students in recovery.||Yellow - Some Momentum, Needs More Funding||Great idea but there has been no money for this. Technical assistance and services for Collegiate Recovery Programs has not previously been funded by the federal government and there is no current legislation to support it.|
In March 2019, the U.S. Department of Education, Office of Safe and Supportive Schools (OSSS) and the National Center on Safe Supportive Learning Environments (NCSSLE) in coordination with the White House ONDCP hosted a webinar to explore the role of Collegiate Recovery Programs (CRPs) and similar initiatives in supporting students in recovery. In this transcript, it is mentioned that the federal government supports the development of CRPs bu hosting webinars, hosting panels with experts, passing policies, and funding preliminary research. However, there are no direct links included in this transcript to point people towards more information on these investments.
There are several organizations that do support the development, creation, and maintenance of CPR, including Transforming Youth Recovery and The Association of Recovery in Higher Education
|Red > Yellow|
|Pres. Comm. #51: ONDCP, federal agencies, the National Alliance for Recovery Residences (NARR), the National Association of State Alcohol and Drug Abuse Directors (NASADAD), and housing stakeholders should work collaboratively to develop quality standards and best practices for recovery residences, including model state and local policies. These partners should identify barriers (such as zoning restrictions and discrimination against MAT patients) and develop strategies to address these issues.||Green - Consistent Progress||NARR has done a great job to move this initiative forward with support from many partners. Standards have been developed and housing all over the country is implementing better quality according to these standards. Continued work must be done but work to date must be applauded and recognized. In May 2018, the National Council for Behavioral Health and NARR partnered in creating a Recovery Housing Toolkit to help state policy makers move forward|
|Law Enforcement and Medical Response||The Administration should issue guidance to facilitate more open data sharing. Congress should provide the Department of Justice (DOJ) with increased federal funding for trainings and technical assistance that support state law enforcement and public health data and information sharing initiatives.||Green - New Funding Available||New federal funding through the 21st Century Cures Act and DOJ Comprehensive Opioid, Stimulant, and Substance Abuse Program (COSSAP) is available to states. These programs can and should be used to help states better integrate public health and public safety data sharing initiatives.|