Public Health Issues to Watch in 2017

January 12, 2017|3:35 p.m.| KT Kramer

As the 2017 state legislative sessions get under way, trends in proposed legislation are emerging. Responding to the opioid epidemic remains a major priority for lawmakers. Efforts in 2017 will build on policies adopted over the past few years, such as expanding access to opioid antagonists, improving prescription drug monitoring programs (PDMPs), and strengthening substance misuse treatment programs. Key challenges facing states as they address opioid misuse and abuse will include fiscal and budget pressures, the illicit trafficking of highly potent opioids like fentanyl, and the coordination of a multi-faceted, cross-sector response.

Funding Mechanisms for Opioid Antagonists - From 2001 to 2016, 45 states and Washington passed laws expanding access to opioid antagonists, such as Narcan. Getting the lifesaving drug into the hands of first-responders, community outreach providers, and friends and family members who can respond to an overdose has been instrumental in saving lives. However, prices for opioid antagonists have increased significantly over the past few years. States will look for ways to rein in these costs and ensure reasonable access to opioid antagonists, particularly with the rise in fentanyl and carfentinal overdoses, which can require multiple doses of opioid antagonists. Existing state models to purchase opioid antagonists include the Massachusetts’s Bulk Purchasing Program and price agreements negotiated between state attorney generals and drug manufacturers. In 2017, states may continue to identify alternative, sustainable financing mechanisms for opioid antagonists.
 
Improving Access to Medication-Assisted Treatment - Medication-assisted treatment (MAT) combines behavioral interventions and counseling with drugs like methadone, buprenorphine, and naltrexone to counteract opioid cravings. MAT has been found effective in treating substance abuse disorders, including opioid dependence. However, due to a scarcity of providers who are able to provide MAT and insurance coverage barriers, individuals who need treatment are not able to get it. States can play a key role in expanding access to MAT by modifying insurance coverage requirements and working with physician groups to expand the number of providers.
 
Additionally, the Comprehensive Addiction and Recovery Act of 2016 establishes a 5-year program to enable advance practice registered nurses (NPs) and physician assistants (PAs) to obtain a waiver from HHS to provide buprenorphine in MAT. NPs and PAs must complete 24 hours of education related to opioid addiction treatment, and they will be limited to 30 patients. HHS defers to state law about scope of practice requirements for prescribing controlled substances and collaborative practice agreements, so lawmakers may choose to modify these types of requirements in order to increase the number of MAT providers in their states, particularly in rural or underserved areas.
 
Improving Clinical Prescribing Practices - Seven states (Connecticut, Maine, Massachusetts, New York state, Pennsylvania, Rhode Island, and Vermont) adopted state-level opioid prescribing guidelines, and Arizona implemented prescribing guidelines for the state employee health insurance and the Medicaid program in 2016. In addition, CDC also provided prescribing recommendations
 
States will continue to experiment with new ways to improve prescribing practices. For example, a bill introduced in Utah for the 2017 legislative session would require health plans—including Medicaid and workers compensation—to implement policies mitigating the risk of prescribing controlled substances. The bill requires health plans to use evidence-based prescribing guidelines and cites the CDC prescribing recommendations and the 2016 Utah Opioid Prescribing Guidelines.  However, health plans would have flexibility to choose the specific guidelines to adopt. Beyond prescribing guidelines, the bill also includes language that would require health plans to facilitate access to non-narcotic pain treatment alternatives and MAT for plan enrollees with opioid dependency disorders.
 
Leveraging Data - Forty-nine states and D.C. have established prescription drug monitoring programs (PDMPs). Over the years, states have refined their PDMPs by mandating that healthcare providers use the state’s PDMP, allowing non-medical providers (e.g., coroners, judicial offices, or public safety officers) to access or input information into PDMPs, and allowing public health agencies and researchers to use PDMP data to identify unusual prescribing patterns. Legislators in Arkansas introduced a bill to allow access to the PDMP by the state’s Medicaid program. In addition, policymakers in states such as Massachusetts are tracking and reporting key indicators to better target resources.  

For his 2017 ASTHO President’s Challenge, Dr. Jay Butler (AK) has focused on public health approaches to preventing substance misuse and addictions. He outlined a tri-level framework focused on acute health event control and prevention, chronic disease screening and management, and environmental controls and social determinants. Within each of these broad levels, there are proven public health approaches and evidence-based policies that state health officials share with interested policymakers. For more information, see the 2017 President’s Challenge Factsheet.

KT Kramer

KT Kramer, JD, MHA is ASTHO’s director of state health policy. She supports state and territorial health agencies to advance and strengthen public health through laws and policies.