I read the American Medical Association's annual report on opioids so you don't have to

The AMA released its annual report on opioids and overdoses yesterday, and there was a theme throughout: harm reduction, harm reduction, harm reduction. There are too many legal barriers to treatments and harm reduction methods that we know to be effective. Read on to see highlights:

What's getting better?

• Overdose deaths are down in many states
• Telehealth and mobile treatment centers are helping more people access addiction treatmen
• Naloxone access is increasing. "From August 2021 to July 2023, the national harm reduction organization, Remedy Alliance For The People, sent 1,639,542
  doses of generic injectable naloxone to 196 harm reduction projects in 44 U.S. states, DC and Puerto Rico, of which 206,371 doses were provided at no-cost to 138 under-resourced harm reduction projects. If it was not for naloxone, it is likely that hundreds of thousands additional Americans would be dead today."

What's getting worse?

• Infection diseases that can be transmitted via IV Drug use including HIV, as well as hepatitis A, B & C are on the rise.
• Overdose death rates are rising disproportionately among Black, Latino and Indigenous communities, pregnant people, young people and LGBTQ people.
• Fatal overdoses involving stimulants like methamphetamine and cocaine are also on the rise. Approximately 40% of overdose deaths involving fentanyl also involved stimulants.
• Prescriptions for the opioid cessation drug buprenorphine have plateaued for unknown reasons, but various legal barriers may have played a role.
• Patients suffering from chronic pain face more restrictions for opioid medications, and non-opioid alternatives are often prohibitively expensive.

What barriers do we need to get rid of?

• Drug testing technologies, including fentanyl test strips, should be legal everywhere.
• Good Samaritan laws should protect anyone who helps reverse an overdose with naloxone.
• The AMA recommends removing legal barriers to overdose prevention sites (also known as safe injection sites and supervised injection sites.) OPS are one of the most controversial harm reduction services—they provide people with a safe place to inject drugs with safe supplies, and supervisors who have naloxone on hand in case of overdose. Political opposition, fear of federal intervention and lack of funding all prevent state governments from authorizing OPS. According to the AMA report, there are only two OPS in the United States at the moment, both in New York.
• Throughout the report, the AMA criticizes health insurance companies for violating the Mental Health Parity and Addiction Equity Act of 2008 which requires health insurance plans to cover mental health and substance use treatment. Some insurance plans include illegal treatment exclusions, "such as for autism spectrum disorder, eating disorders and substance use disorders." Providers need to comply with the law—and state governments need to start intervening if they don't.
• Restrictions on opioid and other pain medication prescriptions are hurting patients, without necessarily preventing overdoses. Opioid prescribing has decreased by more than half since 2012, yet overdoses have continued to rise. According to the report, "most states and national pharmacy chains continue to hold on to outdated, arbitrary dose and quantity restrictions that have led to harms for patients with chronic pain, sickle cell disease, cancer and for those in hospice or with palliative care need."
• People who are pregnant and people who are incarcerated should have access to medication assisted treatment for opioid use disorder.
• Public places, including schools, should have naloxone on hand. Young people should also have access to naloxone prescriptions.
• Governments should also get rid of restrictions on the opioid cessation drug buprenorphine, including by decriminalizing buprenorphine possession for people without a prescription.
• Doctors should be able to prescribe doses higher doses of buprenorphine than what the FDA recommends for patients, if they think it's what they need. Recent NIH resources shows that higher buprenorphine doses might improve treatment outcomes for opioid use disorder patients. Prior authorization requirements for buprenorphine should be done away with, including for larger doses.
• The Department of Health and Humans Services should permanently allow people to access addiction treatment via telehealth
• All drug companies that make overdose reversal drugs should submit those drugs for over the counter approval, and they should price their overdose reversal drugs responsibly.
• Policies that allow doctors to reduce opioid prescription doses without patient consent should also go away.
• The best known treatment for stimulant use disorder is contingency management. But "Fewer than 10% of substance use disorder treatment programs in the U.S. routinely use CM" in part because of federal restrictions.

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