Understanding the Final Report of the President's Commission on Combating Drug Addiction and the Opioid Crisis: What They Got Wrong

The announcement of the Opioid Crisis as a National Emergency was an attempt by the White House to bring awareness and knowledge to this very urgent matter. On November 1, the appointed Commission on Combating Drug Addiction released their Final Report. Usually, recommendations given in task force commission reports are the guiding post for practice changes and are based on driven knowledge and proven protocols for best outcomes. Within the first several pages of the 138-page report, it is clear, as members of the practice industry, this report cannot be taken as a whole for practice change. 

On page 12 of the report, the SBIRT model is mentioned as a screening tool recommended for use:

"Opioid Addiction Prevention: The Commission recommends that Department of Education (DOE) collaborate with states on student assessment programs such as Screening, Brief Intervention and Referral to Treatment (SBIRT). SBIRT is a program that uses a screening tool by trained staff to identify at-risk youth who may need treatment. This should be deployed for adolescents in middle school, high school and college levels. This is a significant prevention tool."

For those experienced in the Addiction Medicine field and with a dedication to serving disparity population, this is a glaring problem. The SBIRT was developed for screening adults, NOT children. In the toolkit, there are guidelines on drinking misuse specific for only adults with risky drinking defined by age and number of alcohol consumed each day and week.

The Audit C and the DAST 10, which are part of the SBIRT model, were developed and standardized for adult screening. They were not developed and standardized for use with adolescents. Rather, the proper screening tool for adolescents is the CRAFFT. It has demonstrated high validity and reliability with disparity communities and can be implemented in a school setting. The SBIRT was developed to be used within a primary care or co-located care setting. To use an evidence-based practice model out of context of its indicated best outcome method is not sound practice. Using a screening tool outside of the indicated population the tool was standardized for will only lead to loss of true effective interventions, as well as false negatives equating to losses in dollars and most importantly, losses in lives. There would be continued frustration in care for those most vulnerable with the fewest resources.

Recommendation #18 of the Commission states:

"The Commission recommends that CMS remove pain survey questions entirely on patient satisfaction surveys, so that providers are never incentivized for offering opioids to raise their survey score. ONDCP and HHS should establish a policy to prevent hospital administrators from using patient ratings from CMS surveys improperly."

The pain survey developed and approved by the National Quality Form is to ensure follow-up and best practices in treatment protocol with the consumer's report on pain for good care. This measure, #131 (NQF 0420), required the treating physician to be responsive and responsible to pain treatment protocol. It does not require or is linked to a prescriptive opioid medication. The physician is penalized if they did not report follow-up; they are not penalized for not providing opioid. Taking this measure set away relieves the physician of the responsibility for pain management follow-up, and it actually increases the chance of self-medication which has been indicated as a major starting point for addiction. Taking away this measure only serves to stigmatize the treatment population for the experience and need of pain management treatment. The focus here should be on the pain protocols available and the engagement and knowledge of the treating physician for alternatives to opioid prescribing.

Recommendation #36 of the Commission mentions Parity as it relates to the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008:

"The Commission recommends that federal and state regulators should use a standardized tool that requires health plans to document and disclose their compliance strategies for nonquantitative treatment limitations (NQTL) parity. NQTLs include stringent prior authorization and medical necessity requirements. HHS, in consultation with DOL and Treasury, should review clinical guidelines and standards to support NQTL parity requirements. Private sector insurers, including employers, should review rate-setting strategies and revise rates when necessary to increase their network of addiction treatment professionals."

The work toward the implementation of MHPAEA across market products is essential. However, a survey design is not enough to hold insurers accountable for true access to care. Several states have been well advanced in Parity implementation with annual Parity compliance self-reports required for participating insurers in their state's marketplace; some of these states continue to have litigation cases for Parity violation litigation. Marketplace conduct cannot be assessed by self-report alone. Marketplace conduct must be more rigorously monitored and responsibility must be more clearly defined.

As much as there are concerns in this Report, it is necessary to read and understand it. Understanding where the Commission is lacking shines light on where we must develop effective strategies and build a shared dialogue on moving forward based on experience, expertise, commitment, and a drive to serve.