We all know the stats surrounding the opioid crisis. Between 2016 and 2017, drug overdose deaths involving synthetic opioids other than methadone increased 45% (see 70,000+ Drug Overdose Deaths Reported In 2017, Up 9.6% From 2016). Between 2008 and 2016, the national rate of opioid inpatient stays increased almost 79.2% (see National Rate of Opioid-Related Inpatient Stays Increased 79% Since 2008). And on average, 130 people die each day from an opioid overdose in the U.S. (see Understanding the Epidemic).
These stats are why a recent headline caught my attention – New Jersey is allowing paramedics to carry buprenorphine and to administer the drug after an overdose (see In A Nationwide First, New Jersey Authorizes Paramedics To Start Addiction Treatment At The Scene Of An Overdose). The goal of the program is to mitigate the symptoms of withdrawal.
The new initiative was issued via an executive order by the Commissioner of the Department of Health and adds buprenorphine to the optional formulary used by the state’s mobile intensive care units (MICUs) (see Commissioner Authorizes Paramedics to Carry Buprenorphine). This means that each of the state’s 21 MICUs can choose whether to carry and administer buprenorphine. In order for a paramedic to administer buprenorphine, they must first administer naloxone and have the permission of their physician supervisor who has the ability to prescribe buprenorphine. A bill is sent to the individual’s insurance for the administration and cost of the medication. Uninsured individuals will be on the hook for the cost. The order is effective immediately, but paramedics will have to be provided with training and take competency assessments before being able to administer the medication.
This certainly is an interesting approach, but there are a number of considerations to take into account. The first is the connection to treatment after initially administering buprenorphine. Under the program, individuals will be taken to the emergency room after administration. For individuals who refuse, they will be given educational materials. The idea, according to statements from the health commissioner, is that with the ability to administer buprenorphine, individuals will feel less of an urge to use right away because they won’t be experiencing severe withdrawal symptoms (see A Radical Way To Stop Heroin Overdoses).
Even for those individuals that make it to the emergency room, there is no guarantee that the hospital will be equipped to serve the individual and make the bridge to treatment. The lack of connection between emergency rooms and addiction treatment is well documented, although many hospitals are trying to fix that (see 30% Of Massachusetts Opioid Overdose ER Survivors Later Received MAT, Beyond survival: Hospitals closing gap in getting opioid patients addiction treatment, This E.R. Treats Opioid Addiction on Demand. That’s Very Rare., Could medication-assisted opioid treatment in the ED save money as well as lives?).
The second consideration is whether New Jersey has enough physicians who are able to prescribe buprenorphine to meet demand. First, physicians supervising paramedics must have a license with the DEA and have a waiver from SAMHSA to prescribe buprenorphine. Then there is the issue of connecting individuals to long-term treatment with a physician who is able to continue the treatment. Physicians and nurse practitioners are limited to the number of individuals they can serve and many treat well below that limit (see 20% Of Physicians Able To Prescribe Buprenorphine Treated Fewer Than Three People For Opioid Use Disorder, Two-Thirds Of Buprenorphine-Certified Physicians Have Waiting Lists, HHS To Expand Buprenorphine Prescribing).
I don’t bring these considerations up to be negative about the new initiative, rather to emphasize the number of people and systems that are required to have an effective addiction treatment program. Research in France has shown that easing restrictions can actually drop overdose related deaths significantly (see How France Cut Heroin Overdoses by 79 Percent in 4 Years). I think states, researchers, and policy experts will be keeping an eye on the New Jersey initiative to see if it can actually make a difference.
For even more on this topic, join us at The 2019 OPEN MINDS Management Best Practices Institute on August 14 in Long Beach California for the session, “Implementing Provider Rating Scales For Substance Use Disorders: Payer Pilot Results & Impact On Benefit Design” featuring Samantha Arsenault, MA, Director, National Treatment; Eric Bailly, LPC, LADC, Business Solutions Director, Anthem, Inc.; and Doug Nemecek, M.D., MBA, Chief Medical Officer – Behavioral Health, Cigna.