The AMA’s Approach to Ending the Overdose Epidemic

Announcer:
Welcome to Perspectives with the AMA on ReachMD, produced in partnership with the American Medical Association. Here’s your host, Dr. John Russell.

Dr. Russell:
This is Perspectives with the AMA on ReachMD. I’m Dr. John Russell and joining me to discuss how the American Medical Association is working to end the nation's drug overdose epidemic is Dr. Bobby Mukkamala, a board-certified otolaryngologist and Chair of the AMA Substance Use and Pain Care Task Force. Dr. Mukkamala, thank you so much for being on the program today.

Dr. Mukkamala:
Oh, thank you so much for having me. It's an honor to be here. Thank you.

Dr. Russell:
So, doctor, let's start by level-setting our understanding of the overdose epidemic amid the COVID-19 pandemic. How has the pandemic influenced this ongoing epidemic?

Dr. Mukkamala:
You know, honestly, not in a good way. It was already hard for patients to get access to care for their substance use disorder, due to a lack of robust infrastructure for this type of care, period. You know, kind of a pre-existing to COVID. And COVID’s only made that more difficult. That, combined with what everybody is going through, but particularly those with substance use disorder. On top of that disorder, having to deal with the added stresses of work, exposure to the virus, subsequent personal illness, family illness. All of these things are just making life even harder for a group of people that already had challenges.

One ray of light in the midst of all that darkness that is COVID is the increasing awareness and appreciation of telemedicine as a very useful tool to help us take care of our patients. As an otolaryngologist, there's very limited utility for me with telemedicine because I've got to look into ears and noses. But it's wonderful for a patient and their physician when discussing management of their pain or substance use disorder.

Dr. Russell:
And, doctor, based on your experience, what are some of the obstacles preventing us from treating the millions of patients affected by this epidemic?

Dr. Mukkamala:
Workforce is one of the main obstacles. It's slowly getting better, with more people getting trained for their waivers. Good changes in law about not necessarily needing a waiver to take care of patients with medications like that. But stigma is still an issue. Our collective understanding about substance use disorder as a medical condition, and not simply a bad choice is still an issue. The legacy of the war on drugs remains in the form of this residual stigma.

And finally, the insurance system, right? Coverage for the care that's required and the barriers to get that care, like prior authorization, and not enough physicians in the network to take care of patients, these are all realities that we face. And also for our patients suffering from pain. While opioid prescriptions have dropped by 44 percent in the past 10 years, there's been minimal to no increase in access to non-opioid pain care, or this multimodal therapy that's available. But if you don't have coverage, it might as well not be available.

And then finally, another big challenge is the prevalence of illicit drugs like fentanyl and its analogs in counterfeit pills, where one pill contains a lethal dose of this stuff. And mortality from things like cocaine and methamphetamines at historic highs. These are all examples of some of the obstacles and challenges that we face.

Dr. Russell:
So Dr. Mukkamala, you know one of the issues, and I'm a primary care doctor, is we've kind of gone from pain being the fifth vital sign to now any doctor who orders any opioid pain medicine really to be evil. Where do we need to figure these things out?

Dr. Mukkamala:
Yeah, you’re absolutely right. And I vividly remember being a surgeon walking into a patient room in the hospital and seeing a whiteboard on the wall with a smiley face or a sad face and having that be part of it. And then the pendulum, as you've said, has sort of swung the other way where now any treatment of pain is something that meets so much scrutiny. And really where we need to be is somewhere in the middle, right? We need to be aware of the consequences of the treatment of our pain and the presence of pain in our patient. And I think we have sort of settled in the middle there. And we just need to have the punitive side of that removed so that patients can have conversations with their physician. And their pain can be managed in a way without worrying about repercussions from the administrative suite in a hospital or from an insurance company or from the law.

Dr. Russell:
So now that we have an understanding of many of the obstacles that you just talked about, can you give us a sense of what the AMA taskforce is currently doing to help increase access to evidence-based care, improve outcomes, and reduce drug-related overdose and death?

Dr. Mukkamala:
Yeah, absolutely. So, this taskforce, we've convened around 25 people from all the organizations you would expect to have an expertise on the subject, as well as several states that have been bold in taking initiative to address these issues. The AMA’s work started with two groups the Opioid Task Force, and then the Pain Care Task Force. And as the epidemic has changed to a less prescription drug-related and more illicit drug-related epidemic, our groups have merged and now are working collectively on measures to address these issues that face our country. And we're also advocating that decisions about how to treat a patient with pain should be a shared decision between them and their physician. And these external, arbitrary restrictions and the pressure to comply with those restrictions have resulted in a lot of patients just simply being cut off from access to proper treatment of their pain. And then of course, what happens is that they will go into withdrawal, die by suicide, all of these negative consequences of cutting people off from proper pain management. And we have to do better and get beyond the stigmatization of these patients with pain.

Dr. Russell:
For those just tuning in, you're listening to Perspectives with the AMA on ReachMD. I’m Dr. John Russell, and today I’m speaking with Dr. Bobby Mukkamala about the American Medical Association’s effort amid the ongoing drug overdose epidemic. 

Now Dr. Mukkamala, what are some of the recommendations the taskforce has provided to help remove barriers and increase access to evidence-based care for these patients and increase access to harm reduction services?

Dr. Mukkamala:
It’s a great question and really one of the main outputs of our task force. So, building a sustainable, resilient infrastructure with appropriate data collection and workforce to care for these patients. Instead of constantly putting out fires in crisis mode, we need these patients to have a medical home for this care that isn't an emergency room or a 911 operator. And then also removing barriers to care, like medication-assisted therapy, particularly those that are at a high risk. Those that are involved with the criminal justice system, youth, women who are about to give birth or have just given birth, these are particularly high-risk individuals, and removing barriers to care for medication-assisted therapy for these subsets is going to be critical. In coverage for comprehensive multidisciplinary multimodal care that's based on conversations that we physicians are having with our patients, the individualized care and treatment plans, not something that is sort of passed in a legislature that attempts to sort of fix all of this with one law, but instead allowing these conversations to take place for treatment plans to be developed and then executed and covered.

And then the harm reduction strategies you mentioned from overdose to spread of infectious disease. So, naloxone is a critical piece of the strategy, but not the only one. Communities need help with resources to distribute it, as well as needle and syringe services and drug-checking supplies – supplies that are meant to detect the presence of illicit fentanyl. You know, it's something that if it was available, we could reduce the number of deaths associated with illicit fentanyl. So, these are just some examples of recommendations that the taskforce has made.

Dr. Russell:
You mentioned medication-assisted therapies. How do we demystify that so primary care clinicians are going to feel comfortable discussing that and implementing that for their patients?

Dr. Mukkamala:
I think about my medical training, and you probably experienced the same thing, where a generation ago, physicians were reluctant to treat psychiatric diagnosis, right? They would just automatically refer to a psychiatrist. But now, pretty much every primary care physician in the country would feel comfortable talking to their patients about depression and starting medication for depression. And it's a generational change that's happened. And what I would love to see, and I think what we're going to see, is a similar shift in a comfort level in treating patients with substance use disorder. Where now, physicians that are coming out of training and starting their primary care practices will talk to their patients about substance use disorder, perhaps feel comfortable starting them on a prescription for buprenorphine, and managing that until it gets complicated and then referring. So, in the same way, we've evolved our treatment of psychiatric diagnosis, I think we will also evolve our treatment of substance use disorder because of an increased comfort level.

Dr. Russell:
So, doctor, you outlined a very complex problem. And it really sounds like it's going to take a village for us to work together to end this epidemic. So, what can physicians, policymakers, health insurance companies, and other healthcare providers do to combat this crisis?

Dr. Mukkamala:
Yeah, I think we need improved collaboration inside that village, right? Doctors, judges, hospital C suites, law enforcement, employers; we will do better for our patients in need, we all need to be on the same page about how to help them. We shouldn't be meeting in isolation, right? It shouldn't be physicians talking about it in the physician’s lounge, and attorneys talking about it in their offices, and police departments and officers, they're talking about within their own buildings. We shouldn't be meeting in isolation. And instead, we should try to address these issues as a community, right? As that village. And so, when police chiefs are talking to judges about the trend and the number of cases or the difficulty in how to care for patients when they leave an emergency room and go back to their neighborhoods, doctors and other members of the healthcare team need to be there as well for that conversation. And our insurance companies, some of whom are the dominant payers in these communities with 70 percent of the market share sometimes need to be brought into that conversation about how to fund this higher level of care for these patients in need.

Dr. Russell:
Well, based on our discussion today, it's clear there are many barriers left to overcome in order to end the drug overdose epidemic. But it's also clear that these barriers can be removed if policymakers, healthcare providers, key stakeholders, and organizations like the AMA take action and work together. And with that, I want to thank my guest, Dr. Bobby Mukkamala, for sharing his perspective on the overdose epidemic and giving us some insight on what the AMA is doing to help increase access to evidence-based care and reduce drug-related overdose and death. Dr. Mukkamala, it was great having you on the program today.

Dr. Mukkamala:
Thank you very much. It was an honor to be here. I enjoyed the conversation. Thank you.

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This was Perspectives with the AMA on ReachMD, produced in partnership with the American Medical Association. To access other episodes in this series, visit reachmd.com\AMA where you can Be Part of the Knowledge.