As stories and statistics of the opioid crisis become increasingly prevalent in our national discourse, we are seeing a stronger, more innovative, and more aligned push for interventions across communities, government agencies, and the public, social, and health services sectors.

Much of the current response—shifting legislative mandates, a focus on the development and dissemination of clinical guidelines, and new funding opportunities—directly affects the practices of primary care providers and pharmacy providers. This article explores federal, state, and commercial initiatives affecting practitioners on the front lines of the effort.

The President’s Commission on Combating Drug Addiction and the Opioid Crisis – Recommendations

On July 31, 2017, the Commission on Combating Drug Addiction and the Opioid Crisis—a taskforce formed by President Trump in March of this year—issued an interim report (“Interim Report”) that included several recommendations. On August 10, 2017, the President responded with action that the Commission identified as “the first and most urgent recommendation”: declaring the crisis a national emergency.

Other recommendations of the report, the fate of which remain to be seen, include to:

• Expand the capacity for drug treatment under Medicaid and Medicare;
• Establish and fund a federal incentive to enhance access to medication-assisted treatments, such as buprenorphine and suboxone;
• Mandate medical prescriber education initiatives;
• Enforce the Mental Health Parity and Addiction Equity Act with a standardized parity compliance tool to ensure that health plans cannot impose less favorable benefits for mental health and substance use diagnoses (versus physical health diagnoses); and
• Support interstate data sharing among state-based prescription drug monitoring programs to better track patient-specific prescription data and support regional law enforcement in cases of controlled substance diversion.

We are also seeing more federal initiatives making their way through the legislative branch, and dollars flowing down to states in connection therewith. The 21^st Century Cures Act of 2016, signed into law by President Obama in December 2016, implements a proposal to provide nearly one billion dollars in new funding to combat the opioid epidemic. The first of two rounds of funding was announced by Tom Price, Secretary of the Department of Health and Human Services, in April 2017.^[1] The grants “aim to increase access to treatment, reduce unmet need, and reduce overdose related deaths.”^[2]

States are Stepping in to Curb Prescriptions

A spate of state legislation seeks to more strictly limit prescriptions, through mechanisms such as dosage and duration limits. These laws appear to follow guidance issued last year by the Centers for Disease Control and Prevention (the “CDC”), which states that three days or less will often be sufficient; more than seven days will rarely be needed. Generally, these rules establish exceptions, such as for the treatment of cancer, as well as hospice and palliative care. ^[3]

A primary target of these laws is first-time opioid prescribing, driven by concerns that more generous prescriptions for acute pain situations (such as following outpatient surgery) risks longer-term addiction. Detractors argue that such laws can be overly burdensome and / or too restrictive, leaving patients without adequate pain relief.

Another state-based intervention, reflected in the Interim Report highlighted above, is an expanded role for drug reporting and monitoring. Prescription monitoring programs collect information on patients who receive controlled substances, such as opioids. Typically, state law requires the pharmacy or other dispenser to upload information to a database within a certain time after dispensing a prescription to a patient. Prescribers and dispensers alike can utilize the database, whether to review a patient’s history of treatment with a controlled substance, identify “doctor shopping” (i.e., where patients seek prescriptions from multiple physician offices) and diversion, and review the legitimacy of prescriptions.

Currently, many states establish usage of the database—the act of obtaining a report or otherwise reviewing the database—as voluntary, or mandate usage only in certain situations. This feature may limit the effectiveness of the intervention. Legislation that targets uptake and utilization may be on the horizon, especially in the face of grants such as last year’s “Data-Driven Prevention Initiative,” from the CDC, which funds data and planning components of state prescription drug overdose prevention programs with the expectation that states improve data collection and analysis.

The Private Sector Takes Aim, Too

From solo practices to industry giants and entities in between, diverse healthcare system actors are revisiting approaches to opioid prescribing and addiction prevention and treatment.

For example, on February 21, 2017, CVS Health announced enhanced efforts that include changes to CVS Caremark’s utilization management program. Consistent with the Guideline for Prescribing Opioids published by the CDC, the pharmacy benefit manager will, among other measures: (i) limit to seven days the supply of opioids dispensed for certain acute prescriptions; (ii) limit the daily dosage of opioids dispensed based on the strength of the opioid; and (iii) require the use of immediate-release formulations of opioids before extended-release opioids are dispensed. ^[4] Targets for the pharmacy innovation company also include strengthening counseling for patients filling opioid prescriptions, and expanding its Medication Disposal for Safer Communities Program.

It Is Concurrent, But Is It Coordinated?

As the federal government, states, and private sector stakeholders work through their priorities, it will be critical to consider how the initiatives engage with, complement, supplement, or even compete with one another.

To date, there appear to be several common and aligned themes, such as stricter prescribing practices and oversight thereof. This is a positive trend. In light of the complexity and severity of the opioid epidemic, the response likely requires significant coordination across communities, government agencies, and the public, social, and health services sectors. Notably, any such collaboration and coordination is likely to rely heavily on front-line practitioners such as primary care providers and pharmacists.

_{[1] HHS Press Office, Trump Administration awards grants to states to combat opioid crisis (April 19, 2017), available here.}

_[2] Id.

_{[3] Thomas R. Frieden and Debra Houry, “Reducing the Risks of Relief – The CDC Opioid-Prescribing Guideline,” The New England Journal of Medicine (April 21, 2016), available here.}

_{[4] CVS Health Responds to Nation’s Opioid Crisis (September 21, 2017), available here.}