Policy News Roundup: September 12, 2024

Youth vaping hits decade low

The 2024 National Youth Tobacco Survey found that vaping among middle and high schoolers declined in the past year and reached its lowest level in a decade.

• Half a million fewer youth reported current e-cigarette use in 2024 than 2023, and that number is a third of what it was at its peak in 2019.

However: 1.63 million students still reported vaping in the past 30 days. And while the number of students using nicotine pouches remained steady, growing sales of products in appealing flavors raises cause for concern.

The findings:

• E-cigarette use: 5.9% of middle and high school students reported current e-cigarette use. Of those, 38.4% reported frequent use and 26.3% reported daily use.
• Nicotine pouch use: 1.8% of middle and high school students reported current nicotine pouch use. Of those, 29.3% reported frequent use and 22.4% daily use.
• E-cigarette device types: The device types used most often were disposables (55.6%). 21.8% were unsure of the device type used.
• Brands: Elf Bar was the most popular e-cigarette brand (36.1% of those who currently used e-cigarettes), followed by Breeze, Mr. Fog, Vuse and Juul. There was a drop in youth reporting use of Elf Bar products in the past year. ZYN was the most popular nicotine pouch brand (68.7%), followed by on!, Rogue, Velo and Juice Head ZTN.
• Flavors: 87.6% of those who currently used e-cigarettes used a flavored product (mostly fruit, then candy and mint). 85.6% of those who currently used nicotine pouches used a flavored product (mostly mint, then fruit and menthol).

The reactions: Food and Drug Administration (FDA) Center for Tobacco Products’ Director King attributed the decline in youth vaping in part to increased FDA enforcement against illegal vape sales, and he said they plan to monitor the nicotine pouch market while considering potential benefits to adult smokers.

Our thoughts: The decline in youth vaping is an encouraging sign that underscores the importance of effective prevention, but there are still many kids who vape, often frequently or daily, and new flavored, high-nicotine products continue to flood the market. Read Senior Vice President of Prevention Research and Analysis Linda Richter’s full response.

Source: Youth E-Cigarette Use Drops to Lowest Level in a Decade (Centers for Disease Control and Prevention)

The Biden administration finalized new parity rules, the most significant action on parity in a decade.

Why it’s important: Too many Americans still cannot access affordable mental health and substance use disorder (MH/SUD) treatment, even if they have insurance.

• This is despite the Mental Health Parity and Addiction Equity Act, which for over 15 years has required health plans that cover MH/SUD benefits to do so at the same level as physical health care benefits.
• Insurers continue to put up barriers to care and violate the law.

The new rule would:

• Require plans to evaluate their provider networks, reimbursement rates and how often they require and deny prior authorizations, and to make changes to come into compliance if needed. Such changes could include adding more MH/SUD professionals to their networks, reducing red tape for providers, boosting payment rates, etc.
• Reiterate/reinforce parity requirements, particularly surrounding utilization management restrictions. For example, plans cannot use more restrictive prior authorization requirements for MH/SUD benefits and have to use similar factors in setting out-of-network payment rates for MH/SUD providers as for medical providers.
• Close a loophole that had allowed non-federal governmental health plans (for state/local government employees) to opt out of parity.

The Centers for Medicare and Medicaid Services also developed a set of templates and instructional guides to help state agencies document compliance with parity requirements in Medicaid.

The reactions:

• “Health care, whether for physical or behavioral conditions, is health care. No one should receive lesser care for one or the other. That’s the law. The rules we issue today make that clear.” — Department of Health and Human Services Secretary Xavier Becerra
• Partnership to End Addiction, in partnership with several leading mental health and addiction organizations, released a statement applauding the rule.
• But: Insurers said the new requirements would be unworkable and a costly mandate. They have claimed that the new rules could cause employers to stop covering behavioral health services and could have unintended consequences, including putting patient safety at risk by forcing plans to accept lower-quality providers. They cite workforce shortages as the main reason for barriers to care.

What’s next:

• Most of the rules will go into effect next year, but some parts will go into effect when insurance plans renew in 2026.
• Insurers are likely to mount a legal challenge to stop the rules from taking effect, claiming the administration does not have the authority to create the new requirements. Recent Supreme Court decisions that weakened federal agencies’ regulatory discretion (e.g., Chevron) could give insurers an upper hand in court.
• As the rules come at the end of the Biden administration, a future administration could also opt to scrap or dial back the rule.

Source: Biden aims to boost mental health coverage (Axios); Fact Sheet: Final Rules under the Mental Health Parity and Addiction Equity Act (MHPAEA) (White House)

Lawmakers and mental health/substance use disorder experts and advocates are hammering a draft Drug Enforcement Administration (DEA) proposal that would significantly limit the prescribing of controlled substances via telemedicine.

The proposed rules would:

• Allow no more than half a provider’s prescriptions to be given virtually, which would be a substantial blow to many telemedicine providers who rely mostly or exclusively on virtual care.
• Prohibit virtual prescribing of Schedule II drugs, including Adderall for ADHD and methadone for opioid use disorder (OUD), without an in-person visit, unless the prescriber is a specialist.
• Allow patients to get Schedule III-V drugs, including buprenorphine, without an in-person visit.
• Require providers to check prescription drug monitoring programs (PDMPs) in all 50 states, which could be a major barrier, as the system linking the programs does not connect every state.

However: The proposal has not yet been released and could still change. DEA backed off its first proposal on virtual prescribing rules following a flood of protests.

The reactions:

• Currently, extended pandemic-era rules allow Schedule II-V drugs to be prescribed without an in-person visit, and advocates are worried that reverting to in-person requirements will cause many patients to lose access to treatment.
• Sen. Warner said the proposal is an “arcane approach” and would be a “significant step back.” He has proposed the TREATS Act to permanently allow providers to offer virtual treatment for OUD without an in-person visit.
• Telehealth advocates are pushing Congress for a two-year extension of current rules, which apply to a broader range of medications.
• OUD treatment providers and advocates are disappointed by the potential new rules, saying far too few people with OUD get treatment and that studies have shown that telehealth increased the likelihood that patients get treatment.

Source: ‘Arcane’: Lawmakers, addiction treatment advocates hammer new DEA telehealth proposal (Politico)

A Centers for Disease Control and Prevention (CDC) study found that in 2022, 21.9% of persons who died of a substance-related overdose had a reported mental health disorder.

The findings:

• The most frequently reported mental health disorders were depressive (12.9%), anxiety (9.4%) and bipolar (5.9%) disorders.
• Higher proportions of deaths among decedents with a mental health disorder involved antidepressants (9.7%) and benzodiazepines (15.3%) compared with those without a mental health disorder (3.3%, 8.5%).
• Nearly one-quarter of decedents with a mental health disorder had at least one recent potential opportunity for intervention — approximately 1 in 10 were undergoing substance use disorder treatment, and 1 in 10 visited an emergency department or urgent care facility within 1 month of death.

The conclusion: Expanding efforts to identify and address co-occurring mental health and substance use disorders (e.g., integrated screening and treatment) and strengthen treatment retention and harm reduction services could save lives.

Source: Reported Non–Substance-Related Mental Health Disorders Among Persons Who Died of Drug Overdose — United States, 2022 (Centers for Disease Control and Prevention)

National Institute on Drug Abuse (NIDA) Director Nora Volkow wrote a blog highlighting the impact of the overdose crisis on older Black men.

The trends:

• Although white and Black people use substances at similar rates, fatal overdoses have escalated in Black people at a much higher rate than in other groups over the past decade. Multiple studies have shown especially high rates of overdose deaths among older Black men.
• The overdose rate for older Black men is markedly higher than that for Black men overall. An increase in substance use and problems is being seen in older people of all races/ethnicities.
• In all groups, men are at greater risk of overdose than women, but additional factors, including age, social isolation and lifetime exposure to structural racism, may be colliding to produce the rise in overdoses among older Black men especially.

Contributing factors:

• The risk of problematic opioid use is raised by chronic illness and pain, which are more common in old age.
• As people age, they may start to lose partners and social contacts, and loneliness and isolation are risk factors for substance use.
• Health and other social disparities likely contribute to escalating overdose rates among Black men (e.g., discrimination in health care settings, social determinants of health, other chronic conditions).
• Discrimination takes a toll on mental health.
• Black people are less likely to engage/remain in SUD treatment, experience greater delays and are less likely to receive buprenorphine.

What’s needed: More research is needed to understand the disproportionate impact on this population. Prevention research has mainly focused on children, adolescents and young adults, but there is a need for other interventions targeted at older adults.

Source: Older Black men are disproportionately affected by the overdose crisis (National Institute on Drug Abuse)