Treatment Works

September 21, 2018 | Mark O'Brien

KY DC web of treatment

Like other chronic diseases, there are treatments that have been proven to be effective for substance use disorder. Different treatments will work for different people, and patients require individualized treatment planning. It is critical for people to have access to a system of care that has adequate capacity to provide all levels of treatment and address all levels of severity. Ideally, systems of care should include coordination among components of the addiction treatment system and other healthcare providers. They should offer multiple access points for treatment so that people can enter treatment as soon as they are ready.

Addiction is a disease of the brain that can make it difficult to be motivated to engage in treatment, and delays in treatment access can mean that an opportunity to improve health is missed and a person with addiction remains at risk for death and other harms associated with substance misuse.

Increase Capacity for Medication-Assisted Treatment

Medication-assisted treatment (MAT), the combination of medications and counseling for treating addiction, is the “gold standard” of care for opioid use disorder and has been shown to decrease the risk of relapse and increase the likelihood that an individual will remain in treatment. There are three FDA-approved medications for treating opioid use disorder—methadone, buprenorphine, and naltrexone—as well as several medications for the treatment of alcohol use disorders and tobacco use disorders. A patient-centered approach to treating substance use disorders requires widespread availability of all medications so that providers can work with patients to tailor treatment and give patients the best chance of improving their health.

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According the National Institute on Drug Abuse, medication-assisted treatment for opioid use disorders has been shown to “reduce opioid use and opioid use disorder-related symptoms” and “the risk of infectious disease transmission as well as criminal behavior associated with drug use.” MAT increases the likelihood that a patient will remain in treatment. People receiving treatment with medications are up to 75% less likely to die from a causes related to substance use.

States can consider a number of strategies for increasing capacity for MAT:

  • Reducing state regulations that limit access to Opioid Treatment Programs (programs authorized under federal law to dispense methadone for the treatment of opioid use disorder);
  • Expanding the availability of naltrexone and injectable naltrexone to address gaps in capacity, such as for criminal justice populations;
  • Ensuring adequate Medicaid reimbursements for substance use disorder services, including medications;
  • Supporting primary care, OB-Gyn, pain management, and other providers treating patients with opioid use disorder by offering free buprenorphine waiver training and training on treating patients with naltrexone and mentoring from experienced providers;
  • Ensuring opioid detoxification is linked immediately to treatment engagement.

Improve Insurance Coverage for Substance Use Disorder Treatment

A significant barrier to treatment access for many people is a lack of insurance coverage or poor coverage for substance use disorder services. Insurance policies may include provisions that limit access to substance use disorder treatment, or patients may be unable to find treatment providers that accept their insurance.

For many but not all health plans, federal law prohibits health insurance carriers from imposing treatment limitations for substance use disorder or mental health services that are more restrictive than benefits for medical and surgical services. But federal law also contains policies that create barriers to treatment like the Institute for Mental Disease (IMD) exclusion that limits access to residential treatment by excluding residential facilities with more than sixteen beds from receiving Medicaid reimbursement.

States should expand and improve insurance coverage of substance use disorder treatment by:

  • Aggressively enforcing insurance parity requirements and make it easy for patients and providers to file complaints about non-compliant plans;
  • Requiring adequate coverage for behavioral health services in health benefits packages and benchmark plans;
  • Ensuring Medicaid plans cover all needed substance use disorder services, including medications and peer recovery support;
  • Ensuring Medicaid plans comply with parity requirements and do not create barriers to addiction services like inequitable prior authorizations requirements;
  • Promoting provider network adequacy through incentives and other means;
  • Ensuring Medicaid plans cover all evidence-based substance use disorder treatment options without fail first requirements or limitations on medication dose or duration;
  • Applying to the Centers for Medicare and Medicaid Services (CMS) for 1115 waivers to cover additional substance use disorder services like residential treatment;
  • Ensuring adequate Medicaid reimbursement levels for substance use disorder services.

Support Families in Crisis

There is a profound lack of accurate information and guidance available for patients and families who are in crisis and need proper treatment and care. Families consistently describe desperate, agonizing attempts to get help, turning to Google to search for treatment options and other basic information, reaching out to physicians or local contacts who have neither answers nor referrals, and not knowing who to call without being judged. Policymakers should support families experiencing addiction-related crises by making government agency locations places where people can seek treatment and offering telehealth and treatment location services.

Access points for treatment

Several jurisdictions have experienced success implementing programs that turn fire and police stations into places where people in the community can seek treatment. Individuals seeking assistance at these locations are permitted to surrender drugs and paraphernalia without fear of arrest or prosecution. They receive a short health screening, and if no somatic conditions require immediate attention, they receive a rapid warm handoff to addiction treatment.

Building on these models, state and local governments should consider implementing programs to make government locations like police and fire stations, child welfare agencies, and social services offices entry points to treatment.

Telehealth and treatment locators

Treatment can be difficult to access because it is unavailable in some locations or because it is hard to find the right treatment option. Many jurisdictions have developed online treatment locators or hotlines for referrals to treatment that can be powerful resources for a patient or family in crisis. Telehealth can provide counseling services to patients in locations where treatment in inaccessible. Policymakers should ensure that residents in their jurisdiction have access to a high-quality and up-to-date treatment locator as well as telehealth counseling services for patients in underserved areas.

One option is  Addiction Policy Forum’s Addiction Resource Center (www.addictionresourcecenter.org), which offers a comprehensive website for those seeking assistance for themselves or a loved one, including information about available treatment that is searchable by location, levels of care, payment type, medication, and patient population. The Addiction Resource Center telehealth phone line is staffed by trained counselors and peer support specialists who can provide counseling, grief support, and treatment referrals. 

Enhance Integration and Coordination

Unlike other chronic diseases, addiction prevention and treatment has historically been conducted outside of the somatic healthcare system. This has contributed to confusion about ways to access care, uncertainty and unfamiliarity with effective treatment options within the healthcare system, and reduced coordination among providers. This fragmented system of care is harder to access and less effective than it would be if it were better integrated with other healthcare specialties.

Policymakers can improve outcomes by encouraging emergency departments to adopt post-overdose protocols and supporting coordinated referral systems of addiction treatment and healthcare.

Emergency department post-overdose protocols

People with substance use disorder may have little or no interaction with the healthcare system. A hospital or emergency department may be the only place they receive care. In some cases, this will be for an overdose, and in other cases, it may be for an injury or infection related to their substance use. This makes the emergency department a critical intervention point for engaging people with substance use disorder and linking them to treatment.

Policymakers should encourage health systems to adopt post-overdose protocols that support long-term health for patients with opioid use disorders. These can include:

  • Training for providers about the disease of addiction;
  • Connections to case managers, social workers, or peer support specialists for treatment planning and navigation;
  • Referrals to treatment and hot handoffs of patients to community-based treatment providers;
  • Initiation of medication-assisted treatment within the hospital.

Coordinated systems of care

A coordinated system of addiction treatment includes not only specialty substance use disorder treatment providers but also health systems and primary care. Many patients will initially need a high level of care for an addiction. This care should be coordinated with their primary care provider if they consent. As the patient is stabilized, they may need a lower level of care for their addiction that can be provided within the primary care setting.

Policymakers should incentivize substance use disorder providers to work closely with primary care and other healthcare specialties to facilitate seamless transitions between levels of care and coordination of care for behavioral and somatic health.

One good model is the Vermont Hub and Spokes system that weaves together existing infrastructure already dispensing substance use disorder medication including Federally Qualified Health Centers, methadone clinics, Office Based Opioid Treatment and more. The “hubs” located throughout the state are specialized addiction treatment centers and prescribe medication-assisted treatment (MAT) and connect patients directly with their “spoke”. The “spokes” include multipronged services to address opioid addiction, bringing in general medicine along with a continuum of care for recovery support.

Conclusion

The United States is experiencing an unprecedented epidemic of opioid addiction and overdose and continues to confront high levels of addiction to other substances. Increasing access to high-quality evidence-based treatment is a critical component of a comprehensive response to this crisis. Policymakers can have a major impact on addiction by focusing on increasing treatment capacity and improving insurance coverage in their jurisdictions, making the system more transparent and accessible, and enhancing integration of addiction treatment into healthcare.

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