Highlight on Wisconsin: As opioid overdose and deaths rise, state seeks $15.7 million in SAMHSA support

The rate of opioid overdose deaths in Wisconsin has risen approximately 81 percent from 2006 through 2015, according to a new Wisconsin Department of Health Services (DHS) report, titled “Select Opioid-Related Morbidity and Mortality Data for Wisconsin.” In response, the Wisconsin DHS has submitted an application for up to $15.7 million in federal funding to boost the state’s response to the growing misuse and abuse of opioids from the Substance Abuse and Mental Health Services Administration (SAMHSA). The amount of the grant is based on the unmet need for opioid-related treatment and the number of opioid-related deaths in the state. Wisconsin is eligible to receive up to $7,636,938 each year for the next two years under the 21st Century Cures Act.

The DHS report provides statewide and county-level data on opioid-related deaths and hospital visits, neonatal abstinence syndrome (NAS) (in which an infant is born with withdrawal symptoms from substances taken by the mother), and data on ambulance runs in which naloxone (a medication used to reverse opioid overdose) was administered. The report includes these data highlights:

  • The rate of opioid overdose deaths increased from 5.9 deaths/100,000 residents in 2006 to 10.7 deaths/100,000 in 2015.
  • Rates of drug overdose deaths involving opioids were higher among counties in the southeastern region of the state (Milwaukee area), and higher among men compared with women.
  • Drug overdose deaths involving opioids were highest among young men aged 25-34, and among women aged 35-54.
  • Hospital visits involving opioid acute poisoning (including overdose) increased from 25.3 to 52.0 per 100,000 between 2006 and 2014.
  • The rate of ambulance runs in which naloxone was administered rose from 51.2 to 67 per 100,000 from 2011 to 2015.
  • The rate of NAS increased from 2.0 to 8.7 per 1,000 live births from 2006 to 2014, a rate increase of 335 percent.

In 2016, DHS issued a Public Health Advisory due to the opioid epidemic. In 2017, Governor Scott Walker called for a special session of the legislature to consider recommendations presented by the Governor’s Task Force on Opioid Abuse. New legislative proposals will build on efforts already underway under the HOPE (Heroin, Opioid Prevention and Education) agenda, which includes 17 bills aimed at prevention and treatment of opioid addiction and overdose.

Pending approval from SAMHSA, the funds will be used to:

  • Support community coalitions focused on reducing the nonmedical use of opioids among people age 12 to 25.
  • Establish a hotline to provide information on treatment services and recovery supports.
  • Expand access to treatment for uninsured and underinsured individuals.
  • Establish new opioid-specific treatment programs to reduce the distance people have to travel for these services.
  • Establish a network of individuals in long-term recovery from the misuse and abuse of opioids trained to coach people through the treatment and recovery process.
  • Develop training for professionals on proven intervention and treatment strategies for opioid misuse and abuse.

 

HHS prescribes regulations for opioid addiction treatment reports

Medical practitioners who treat up to 275 patients in an office-based setting must provide various information to assist HHS in complying with newly established regulations regarding medication assisted treatment (MAT) of opioid use disorders. In an advance release of a Final rule set to publish in the Federal Register September 27, 2016, HHS requires information related to: (1) a practitioner’s annual caseload of patients to be reported monthly; (2) the number of patients provided behavioral health services and referred to behavioral health services; and (3) the features of the practitioner’s diversion control plan.

Background

Buprenorphine is used in MAT to help people reduce or quit their use of heroin or other opiates, such as pain relievers like morphine. Unlike methadone treatment, which must be performed in a highly structured clinic, buprenorphine is the first medication to treat opioid dependency that is permitted to be prescribed or dispensed in physician offices, significantly increasing treatment access.

HHS had increased access to MAT in an office-based setting by allowing eligible physicians to request approval to treat up to 275 patients if certain conditions are met in a previous Final rule titled “Medication Assisted Treatment for Opioid Use Disorders” (81 FR 44712, July 8, 2016) (MAT rule). The MAT rule had originally proposed requirements to ensure that patients received the full array of services that comprise evidence-based MAT and minimize the risk that the medications provided for treatment are misused or diverted (see Proposal could push up patient limit for opioid abuse treatment, Health Law Daily, March 29, 2016).

HHS also made changes to the original proposed reporting requirements based on earlier comments by adding a requirement proposing that practitioners provide reports to the Substance Abuse and Mental Health Services Administration (SAMHSA) to maintain their approval to treat up to 275 patients in a supplemental Notice of Proposed Rulemaking (SNPRM) (81 FR 44576, July 8, 2016). The purpose of the reporting requirements is to help HHS assess practitioner compliance with the additional responsibilities of practitioners who are authorized to treat up to the highest patient limit.

Reporting requirements

HHS recognized that asking practitioners to calculate and report average monthly caseload of patients receiving buprenorphine-based MAT each year could be could be burdensome and changed this reporting requirement in the Final rule. The revised text requires practitioners to report annual caseloads of patients by month. By seeking information on the annual caseload of patients by month, HHS noted that an appropriate balance between collecting valuable information needed to assess compliance with the rule and avoiding undue burden to practitioners would be struck.

In addition, the reporting requirement has been revised to request the practitioner report on the number of patients provided behavioral health services and referred to behavioral health services. By seeking information on the number of patients that were provided services and referred for behavioral health services will meet the needs of assessing compliance of the MAT rule.

HHS modified the third reporting requirement, which required that the practitioner report on the features of their diversion control plan, by striking requirements related to reporting the number of patients who: (1) completed a buprenorphine course of treatment; (2) were referred to a less intensive level of care; (3) no longer wished to take buprenorphine; or (4) no longer taking buprenorphine for reasons not listed.

Beyond scope

HHS declined to address comments requesting higher patient limits, access to buprenorphine, or SAMHSA audit practitioners to ensure compliance with the MAT rule because the comments did not relate directly to the reporting requirements of the SNPRM.

HHS marks Prescription Opioid and Heroin Epidemic Awareness week with $44.5M grant

The Health Resources and Services Administration (HRSA) and the Substance Abuse and Mental Health Services Administration (SAMHSA) will award more than $44.5 million in awards to training programs aimed at increasing the number of mental health providers and substance abuse counselors in the United States.  The funding includes 144 new and continuing grants through the Behavioral Health Workforce Education and Training (BHWET) program.

Behavioral Health Workforce Education and Training Program

 The BHWET program supports clinical internships and field placement programs for professional and paraprofessional behavioral health disciplines and occupations. The initiative serves children, adolescents, and transitional-age youth at risk for developing or who have a recognized behavioral health disorder by adding to the behavioral health workforce. Recipients of grants under this program are expected to expand the behavioral health workforce by participating in internships and field placements focusing on working with these at-risk individuals. Activities under the grant emphasize prevention and clinical intervention and treatment for those at risk of developing mental and substance abuse disorders and the involvement of families in preventing and treating behavioral health conditions.

Of the $44.5 million grant, more than $7.9 million will support a total of 34 new grantees, and the other $36.6 million will fund the program’s 110 existing grantees.

Prescription Opioid and Heroin Epidemic Awareness Week

President Barack Obama designated the week of September 18 – 23, 2016, Prescription Opioid and Heroin Epidemic Awareness Week. During this time, federal agencies focused on the work being done across government entities and announced new efforts to address the epidemic of prescription opioid and heroin abuse. In his announcement, Obama stated that he continues to “call on the Congress to provide $1.1 billion to expand access to treatment services for opioid use disorder.” The investments would build on the steps already taken to expand overdose prevention strategies and increase access to the overdose reversal drug naloxone.

HHS throwing water on the opioid epidemic fire

As the opioid epidemic in the United States continues, HHS announced a group of new actions to build on the HHS Opioid Initiative–which focuses on (1) improving opioid prescribing practices; (2) expanding access to medication-assisted treatment (MAT) for opioid use disorder; and (3) increasing the use of naloxone to reverse opioid overdoses–and the National Pain Strategy, the federal government’s first coordinated plan to reduce the burden of chronic pain in the U.S.

The new actions include a Final rule expanding access to buprenorphine, a medication to treat opioid use disorder, and other MATs. HHS also launched more than a dozen new scientific studies on opioid misuse and pain treatment and soliciting feedback to improve and expand prescriber education and training programs. The department took other steps on opioids in response to physician concerns about financial incentives to prescribe the drugs.

MAT Final rule

In a Final rule (81 FR 44712, July 8, 2016), the Substance Abuse and Mental Health Services Administration (SAMHSA) took action allowing more patients to receive buprenorphine prescriptions each year. Practitioners must have a waiver to prescribe buprenorphine–to be eligible for the waiver, the practitioner must have additional credentialing in addiction medicine or addiction psychiatry from a specialty medical board and/or professional society, or practice in a qualified setting. Under the waiver, the number of patients to whom they may prescribe the MAT is limited annually; under the Final rule, practitioners who have had a waiver to prescribe buprenorphine for up to 100 patients for one year or more, may now obtain a waiver to treat up to 275 patients. A supplemental notice of proposed rulemaking (81 FR 44576, July 8, 2016) asked for input on increasing the highest patient limit for qualified physicians to treat opioid use disorder under the Controlled Substances Act to 275. The proposal would help assure compliance with the MAT Final rule by adding reporting requirements for MAT prescribers.

Opioid misuse research and training

According to a request for information (81 FR 44640, July 8, 2016), deaths related to opioid analgesic–a class of prescription drugs such as hydrocodone, oxycodone, morphine, and methadone used to treat both acute and chronic pain–overdose have quadrupled since 1999. To fill knowledge gaps and improve the country’s ability to fight the opioid epidemic, HHS is launching more than 12 new scientific studies on opioid misuse and pain treatment. It released a related report and inventory on the opioid misuse and pain treatment research being conducted or funded by its agencies, which will help stakeholders and external funders of research avoid unnecessarily duplicating research. In addition, HHS developed activities that support opioid prescriber education, and seeks comment on current HHS prescriber education and training programs and proposals that would augment ongoing HHS activities.

Elimination of potential financial incentive to prescribe opioids

In an advance release of its Proposed rule for the hospital outpatient prospective payment system (OPPS), CMS suggested eliminating any potential financial incentive for doctors to prescribe opioids based on patient experience survey questions. The Hospital Value-Based Purchasing (VBP) Program ties payments to performance measures, including a pain management dimension. Providers and other stakeholders have told CMS that they are concerned about the pain management dimension putting pressure on staff to prescribe unnecessary opioids; the agency proposed removing the pain management dimension for purposes of the Hospital VBP Program “in an abundance of caution.” For more on the OPPS Proposed rule, see Patient-focused and physician-supporting changes proposed for OPPS and ASCs, Health Law Daily, July 7, 2016.