In recent years, there has been a glimmer of hope in the battle against drug overdose deaths, particularly in parts of the U.S., where the number of deaths has started to decline for the first time in years. However, this progress comes with a critical caveat: the opioid epidemic is far from over. Despite these signs of improvement, significant barriers to effective treatment, discrimination in healthcare access, and ongoing struggles with insurance coverage remain formidable obstacles. As the opioid crisis continues to evolve, a pressing issue is the failure of health insurance companies to comply with state and federal parity laws, which prevent equitable access to treatments for opioid use disorder (OUD). This ongoing issue, as outlined in the American Medical Association’s (AMA) annual overdose epidemic report, reflects a healthcare system that, while making progress, still falls short in providing timely, effective, and accessible care for those struggling with addiction.
The Role of Medications for Opioid Use Disorder (MOUD)
One of the most significant tools in the fight against OUD is Medications for Opioid Use Disorder (MOUD). These medications, including buprenorphine, methadone, and naltrexone, have proven to be the most effective means of treating opioid addiction, significantly reducing the risk of overdose and enabling individuals to lead stable lives. The AMA’s report highlights how MOUDs are the cornerstone of treatment for opioid use disorder, yet access to these life-saving medications remains inadequate.
Buprenorphine, in particular, has shown promise in helping individuals overcome the physical dependence that opioids create. However, despite its proven efficacy, the AMA’s report notes that more than a third of substance use disorder (SUD) treatment facilities do not offer any form of MOUD. This startling statistic demonstrates the glaring gap in access to crucial care.
While the number of buprenorphine prescriptions dispensed from retail pharmacies increased between 2017 and 2021, that growth plateaued in 2021. This plateau remains a point of concern, as it suggests that progress in making these treatments accessible is not moving forward at the rate necessary to address the scale of the crisis. The reasons behind this plateau are unclear, but several barriers contribute to the stalling progress, particularly concerning healthcare policies and insurance barriers.
Barriers to Access: Insurance, Prior Authorization, and Racial Disparities
Access to MOUD is not simply about prescribing the medication; it is about ensuring that the right individuals can actually get it. One of the key barriers to accessing these medications is the refusal of many health insurers to comply with state and federal parity laws. These laws require insurers to provide the same level of coverage for mental health and substance use disorders as they do for physical health conditions. Yet, insurers often fail to comply, citing reasons such as prior authorization requirements, dosage restrictions, and limited access to prescribing physicians.
These barriers disproportionately affect marginalized communities. People of color, particularly Black, American Indian/Alaska Native, Asian, and Hawaiian/Pacific Islander populations, face significant disparities when it comes to accessing MOUD treatment. The AMA’s report emphasizes that these communities are at a disadvantage due to a lack of prescribers in racially and ethnically diverse areas, which severely limits their ability to receive life-saving treatment. Geographic location is also a critical factor, with rural areas experiencing an especially acute shortage of healthcare providers who can offer MOUD.
Adding to the complexity of the situation are the prior authorization requirements imposed by some insurers, which create further delays in the provision of necessary care. Many states have imposed these requirements for buprenorphine and other medications, and in some cases, insurers refuse to cover higher doses of buprenorphine or impose unnecessary dosage limitations. The report also cites concerns about the DEA’s role in regulating access to these medications, adding yet another layer of complexity and delay.
For many individuals, these barriers not only delay their treatment but also increase the likelihood of relapse, overdose, and death. While the opioid crisis is marked by its devastating toll on lives, these insurance-related obstacles only exacerbate the suffering and prevent access to the most effective solutions.
The AMA’s Call for Action: Policy Change and Expanding Access
The AMA has called for immediate action to address these barriers and expand access to MOUDs. One of the organization’s most critical recommendations is the removal of prior authorization requirements for medications used to treat opioid use disorder, including higher doses of buprenorphine. States are encouraged to implement these changes, ensuring that individuals who need treatment can access it without unnecessary delays.
The AMA also emphasizes the importance of providing MOUD treatment to incarcerated individuals throughout their sentences and ensuring that they are connected to community-based care upon release. The opioid crisis does not end with incarceration, and there is a significant opportunity to prevent relapse and overdose by continuing treatment for those incarcerated and ensuring a smooth transition to care after they are released.
Another key recommendation from the AMA is to address the glaring gaps in harm reduction strategies. Harm reduction involves strategies that aim to minimize the negative health impacts associated with drug use, such as providing clean needles, supervised consumption spaces, and education on safer drug use. These programs are critical in reducing overdose deaths, yet they remain underfunded and underdeveloped in many parts of the country.
Stimulant Use Disorder and the Need for Contingency Management
While the opioid crisis remains the primary driver of overdose deaths, there has been a growing concern about the rise of stimulant use disorder (StUD), particularly in relation to drugs like methamphetamine and cocaine. In 2023, approximately five million people used cocaine, nearly four million misused prescription stimulants, and 2.6 million people used methamphetamine, according to the AMA’s report. Stimulants are frequently used in conjunction with fentanyl, further complicating the overdose crisis.
However, unlike opioid use disorder, there are currently no FDA-approved medications for stimulant use disorder. Instead, the most effective treatment for StUD is contingency management, a behavioral therapy that uses positive reinforcement to encourage individuals to reduce or stop drug use. The AMA highlights that contingency management is twice as effective as other treatments for stimulant use disorder. Despite this, less than 10% of SUD treatment programs offer this evidence-based intervention.
The lack of access to contingency management is a critical gap in the current treatment landscape. The AMA calls for expanded access to this effective treatment method, emphasizing that policymakers must prioritize funding and support for programs that utilize contingency management. Without this, individuals with stimulant use disorder will continue to face significant barriers to recovery, contributing to the rising number of overdose deaths.
The Road Ahead: A Call to Action
The opioid epidemic is far from over, even as we see a slight decline in overdose deaths in certain parts of the country. The barriers to effective treatment, particularly in terms of access to MOUDs, remain a major challenge. As the AMA’s report highlights, we need unwavering commitment from policymakers, insurers, and healthcare providers to expand access to lifesaving treatments, enforce parity laws, and address the glaring gaps in harm reduction efforts.
“We cannot stand by as outdated policies and insurance barriers prevent patients from accessing evidence-based care,” said Dr. Bobby Mukkamala, president-elect of the AMA and chair of the AMA Substance Use and Pain Care Task Force. “Delays or denials of this care only result in increased suffering and death. Ending the epidemic is possible, but much more work must be done.”
In order to combat the opioid crisis effectively, we must confront these systemic barriers head-on. Removing prior authorization requirements, increasing the availability of MOUD treatments, expanding access to contingency management for stimulant use disorder, and holding insurers accountable for complying with parity laws are all critical steps. Only through comprehensive policy changes and unwavering dedication to expanding access to care can we hope to make lasting progress in the fight against this devastating epidemic.
