By Barbara Goodheart, ELS
Almost 90% of Medicare Part D insurance companies covered at least one buprenorphine product without restriction back in 2007—but in 2018, only 35% did so.
Yet prescription opioids are covered—with no restrictions—in 93% to 100% of recently surveyed plans.
The culprit appears to be controls insurance companies impose to hold down costs, such as prior authorization or step therapy.
Does this make sense? Why restrict access to medication to treat opioid use disorder, in the face of an opioid epidemic? An epidemic that during those ten years—2007 to 2017 (final data for 2018 are not yet in)—saw overdose deaths for all opioids, including heroin and prescription opioids, soar from 18,515 to 47,600?
The graph shows the number of U.S. overdose deaths involving prescription opioids, methadone, and synthetic narcotics, including heroin and fentanyl. Adapted from CDC Wonder.
The data cited above are from a research letter published February 12 in JAMA. The letter assesses prior authorization requirements for buprenorphine products in Medicare Part D prescription drug plans.
Insurance companies commonly use preauthorization rules to manage or limit access to certain drugs, Daniel Hartung, PharmD, MPH, lead author of the study, explained in an Oregon Health & Science University (OHSU) news release. Dr. Hartung is an associate professor at the OHSU/Oregon State University College of Pharmacy.
A coauthor on the paper, Todd Korthuis, MD, MPH, professor of medicine and public health, chief of the addiction medicine section at OHSU, commented in the same news release: “Medicare insurance companies are making it increasingly difficult to prescribe buprenorphine, while making it easy to prescribe the opioid pain medications that contributed to the opioid epidemic.”
Fulfilling a preauthorization requirement doesn’t sound arduous, but in fact it’s “so cumbersome that many doctors choose not to prescribe” the medications at all, Brian Barnett, MD, an addiction specialist at Harvard Medical School, commented in a Washington Post article last year. Each prior authorization request takes 30 to 60 minutes to complete, and afterwards he’s usually told, “a decision will be rendered in several days.”
While he waits for approval, his patient is “at high risk of relapse due to the horrific effects of opioid withdrawal”—when one relapse can mean death.
In short, Dr. Barnett said, insurers are “conducting a war of attrition against the addiction treatment community, to reduce their short-term costs.”
Could the hassle involved in getting prior authorizations explain why many practitioners fail to prescribe buprenorphine, after undergoing the trouble and expense of training and qualifying for a waiver?
Previous Calls for Reform
In 2017, the AMA and 16 other health care organizations called for reforms in prior authorization requirements. An AMA survey had found that the average physician received a total of 29 prior authorizations (for prescriptions and medical services) per doctor per week, requiring an average of 14.6 hours—two working days—per week of the physician’s and office staff’s time. And 79% reported they had to repeat the procedure—even for stable patients on a previously approved regimen.
Opioid Crisis Triggers a Massive Call for Reform: The SUPPORT Act
Last fall, President Donald Trump signed into law the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (the SUPPORT for Patients and Communities Act), a massive piece of legislation—250 pages.
Starting in 2020, the Act will broaden Medicare coverage to include methadone treatment through opioid treatment programs. A provision within the Act mandates—by January 1, 2021—the use of electronic prior authorization for drugs covered under Medicare Part D. Details vary by state. (See Electronic Prior Authorization Bill for Medicare Part D, under References, below.)
Will the SUPPORT Act Have an Impact?
We wondered if the Act would help reduce the prior authorization problem.
We asked an expert, Barbara Andraka-Christou, JD, PhD, an assistant professor in the department of health management and informatics at the University of Central Florida.
She agreed with our idea that prior authorizations are a primary reason buprenorphine isn’t prescribed more often. But she added that under-prescribing isn’t limited to buprenorphine; it’s a problem with medications for OUD in general. And, from her research, she had some idea why this was happening.
Three Problems Underlying Prior Authorizations
Dr. Andraka-Christou’s research has uncovered three problems underlying prior authorizations
of OUD medications:
1. They are time-consuming. Dr. Andraka-Christou said that this is the only problem of the three that the SUPPORT Act addresses, and it does so only indirectly, “by requiring the government to create standards for electronic submission of prior authorizations.”
Paperwork, even when electronic, gets in the way of gathering information about health history and current treatment progress. An addiction medicine physician she’d interviewed hired a billing specialist whose sole task was to complete prior authorization paperwork. Dr. Andraka-Christou noted: “Not every physician has the luxury of hiring additional staff, especially when the physician serves low-income populations.”
2. They are dangerous when they delay the start or continuation of medication treatment
for OUDs. Delays can cause relapse, a potentially deadly response. At a minimum, they “can quash a patient’s motivation or feelings of self-efficacy.”
3. They are inequitable, and possibly violate federal parity laws—if applied to medications for OUD, but not to opioids to treat chronic pain. (See the adjoining short article in this issue.)
And whatever good will come from the SUPPORT Act is almost two years away.
In the news release mentioned earlier, Dr. Korthuis recommended: “Require Part D plans to eliminate coverage-related barriers, such as prior authorization.” This single step, he said, would immediately improve access to treatment for many Medicare beneficiaries.
We asked Dr. Andraka-Christou what steps she would like to see.
“In addition to standardization of prior authorization for all medications, I want to see federal legislation banning prior authorization requirements for typical dosages of evidence-based and cost-effective medications for OUD. Sure, insurance companies should continue to require prior authorizations for atypical dosages of evidence-based medications, for medications with a smaller or emerging evidence base, or for medications not yet shown to be cost-effective. But typical dosages of methadone, oral buprenorphine, and extended-release naltrexone do not meet these criteria.”
# # #
“Real-time Benefit Check,” a tool for prescribers from covermymeds, provides information on prior authorization and patients’ out-of-pocket prescription costs. According to author Kim Diehl-Boyd, it may help physicians select medications that do not require prior authorization. For information: https://www.covermymeds.com/main/insights/rtbc-scorecard/.
“2019 ePA National Adoption Scorecard,” another electronic publication from covermymeds, explains and clarifies some key aspects of the prior authorization process. Go to https://www.covermymeds.com/main/insights/scorecard/ and click on the nine subheads on the right.
Hartung DM, Johnston K, Geddes J, Leichtling G, Priest KC, Korthuis PT. Buprenorphine coverage in the Medicare Part D Program for 2007 to 2018. Research Letter. JAMA. February 12, 2019;321:6:607-609. PMID:30747957. doi:10.1001/jama.2018.20391.
Opioids more accessible than addiction treatment. OHSU study finds opioids are easy to get, but medication-assisted addiction therapy is not. Erik Robinson. February 12, 2019 Portland, Oregon. Available at https://news.ohsu.edu/2019/02/12/insurance-rules-make-it-harder-to-treat-opioid-use-disorder. Accessed 4/4/19.
Barnett, Brian. Insurers are making it harder for me to treat my opioid-addicted patients.
The Washington Post. OpEd. April 25, 2018.
http://blog.petrieflom.law.harvard.edu/2018/04/25/insurers-are-making-it-harder-for-me-to-treat-my-opioid-addicted-patients/. Accessed 4/4/19.
Wilson, F. Perry. Docs Rebel Against Prior Authorization. Prior authorization gets terrible reviews from practicing doctors, in a wakeup call to the insurance industry. The Methods Man. Methods Man Blog. March 19, 2018. https://www.methodsman.com/blog/prior-authorization. Accessed 4/4/19.
Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act, (the SUPPORT for Patients and Communities Act). https://www.congress.gov/115/bills/hr6/BILLS-115hr6enr.pdf. Accessed 4/4/19.
Diehl-Boyd, Kim. Electronic Prior Authorization Bill for Medicare Part D Passes in Senate:
Legislation Update. October 08, 2018. https://www.covermymeds.com/main/insights/articles/electronic-prior-authorization-bill-for-medicare-part-d-passes-in-senate/. Accessed 4/4/19.
By Barbara Goodheart, ELS
The SUPPORT for Patients and Communities Act—the massive piece of legislation signed into law on October 24, 2018—is not going to take care of the prior authorization problem. That means countless patients with opioid use disorders (OUDs) will still be unable to access treatment when they need it. Some will relapse; some will die.
That’s the opinion of Barbara Andraka-Christou, JD, PhD, assistant professor in the department of health management and informatics at the University of Central Florida.
The Act, known formally as the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (the SUPPORT for Patients and Communities Act), is a massive piece of legislation that has some positive features. But it falls far short in dealing with the opioid crisis, especially in helping patients with OUDs who need buprenorphine.
Where the SUPPORT Act Falls Short
In an accompanying article in this issue of AT Forum, Dr. Andraka-Christou, who has published extensively in the field, and is an attorney as well, discusses three problems related to prior authorizations for OUD medications: they are time-consuming; they are dangerous (when causing treatment delays); and they are inequitable—possibly violating federal parity laws.
In sharing with AT Forum her thoughts on the last point—the parity laws—she went into some detail. “Insurance requirements for prior authorizations are inequitable. In my opinion, such insurance requirements sometimes violate federal parity laws if applied to medications for OUD, but not to opioids for chronic pain management.”
She also stressed the difference between the two types of medications. “Ironically, medications for OUD, especially methadone and buprenorphine, are the most effective treatment for OUD, in combination with psychosocial support, while opioids for chronic pain management have questionable efficacy. Yet the OUD medications are more likely to be subject to prior authorization requirements.
“Furthermore, buprenorphine is a schedule III controlled substance, according to the Controlled Substances Act, meaning the government has already recognized in another law that it should have lower regulatory barriers than do schedule II controlled substances, like oxycodone or hydrocodone.”
The Answer: Federal Legislation
Dr. Andraka-Christou wants to see federal legislation banning prior authorization requirements for typical dosages of evidence-based and cost-effective medication for OUD. She acknowledges that insurance companies should continue to require prior authorizations for atypical dosages of evidence-based medication, for medication with a smaller or emerging evidence base, or for OUD medications that have not yet been demonstrated to be cost-effective. But, as she points out, typical dosages of methadone, oral buprenorphine, and extended-release naltrexone do not meet these criteria.
The discrepancy between treatment access for OUD and chronic pain management is the focus of Dr. Andraka-Christou’s academic research, and the topic of her forthcoming book, Opioid Naïve: America’s Addiction to Failing Treatment, Johns Hopkins University Press. Publication is scheduled for 2019.
By Alison Knopf
There are moves—important and funded ones—to support the expansion of medication-assisted treatment (MAT), but those moves apply mostly to office-based opioid treatment (OBOT) providers, not to opioid treatment programs (OTPs).
“I suspect that the OBOTs are already the beneficiary of increased access to MAT, since they keep expanding the number of providers, who can be DATA 2000 waived,” said Mark Parrino, president of the American Association for the Treatment of Opioid Dependence (AATOD). “To some extent, buprenorphine appears to be used as a harm reduction approach in expanding access to treatment,” he added.
However, the question is what constitutes treatment, after medications are used.
“Unintended Challenges” to Expanding Access to Treatment
In a paper published this winter (http://www.aatod.org/wp-content/uploads/2019/01/2019-Policy-Paper-5.pdf), Mr. Parrino cited “unintended challenges” that are developing as legislators and policymakers move to expand access to treatment for opioid use disorders (OUDs). One major barrier is developing a workforce. “Based on the history of OUD treatment, it is clear that comprehensive services are necessary for the majority of people in treatment, especially when treatment begins,” Mr. Parrino wrote. Methadone can help the patients become stabilized, but then the focus is what services are needed to continue recovery—which will differ from patient to patient.
However, said Mr. Parrino, it is “clear that increasing access to care and treatment requires quality of care assessments and monitoring, as well as continuous quality improvement at the provider/facility level.”
AATOD: “A Diverted Opioid Is Not a Therapeutic Opioid”
Medication diversion is another issue—but one that does not seem to trouble the harm-reduction community. “A number of public-health proponents have described the street diversion of buprenorphine as ‘therapeutic,’ because its use by individuals not in treatment amounts to an attempt at lay treatment of OUD,” said Mr. Parrino. However, he noted that injectable and depot formulations will restrict diversion.
“AATOD’s public position on this topic is that the diversion of any opioid at any time, and particularly during an opioid epidemic, is unwise. Our argument has always been that one cannot define a diverted opioid as being therapeutic.”
According to SAMHSA and the Drug Enforcement Administration (DEA), there are approximately 1,600 licensed and accredited OTPs in the United States, with an estimated 400,000-plus patients receiving treatment at OTPs. By 2017, SAMHSA had approved more than 45,000 DATA 2000 prescribers, but only half were prescribing any buprenorphine, a phenomenon attributed partly to low reimbursement by health insurance. “Comprehensive treatment protocols are critical as patients progress to maintenance therapy and recovery, especially in light of the focus on increasing access to medications, with or without support services, and the limited availability of support services,” said Mr. Parrino.
How Primary Care Providers Can Help
Sometimes, primary care allies itself with harm reduction in looking at reforming the OUD treatment system—basically, in getting rid of OTP regulations. As for the idea of methadone prescribed by primary care practitioners either for maintenance or detox, AATOD said such practices would be “countertherapeutic and dangerous.”
Citing the unintended consequences of prescription of methadone for pain—overdoses by patients who didn’t understand the long-term nature of the medication (and lack of prescribers’ education on the medication)—Mr. Parrino did, however, suggest that primary care practitioners, working in conjunction with OTPs, could help in treating fully stabilized patients.
OTP Hubs; Primary Care Extensions
In this model, the OTPs would be the addiction “hub” and the primary care practices their extension. “Linkage back to the hub site would provide accessibility to patients and providers for re-stabilization and increased recovery services and support as needed,” said Mr. Parrino. “Clearly, this model would need to be developed as treatment protocols are put into place to ensure safety and to protect patients from exposure to unintended danger. Additionally, it is worth considering the prospect that some entities, such as Johns Hopkins, may utilize pharmacies to treat even more stabilized patients, as they do when patients pick up medications to treat any other chronic disorder.
Harm Reduction Policies, AATOD, and OTPs
“I do not think that OTPs will change significantly through a harm reduction focus,” Mr. Parrino told AT Forum. “I know that a number of harm reduction policy groups would like to see the OTP regulations removed, to expand access to care. AATOD does not support this, and my recent paper explains why. The impediment to OTP expansion has been rooted not in the regulatory structure, but instead in zoning Board ordinances, community opposition, and occasional legislative moratoria on opening OTPs. I believe that West Virginia still has its moratorium in place.”
The Harm Reduction Coalition, however, does want to collaborate with OTPs. “Harm reduction programs also serve methadone patients. Harm reduction program staff should include methadone patients, and OTP staff include members of the harm reduction community,” said Daniel Raymond, deputy director of planning and policy for the Harm Reduction Coalition, based in New York City.
“Harm reduction advocates have attended and presented at AATOD’s conference, and OTP staff participate in our National Harm Reduction Conference,” Mr. Raymond told AT Forum. “We have a lot of common interests—not the least of which are struggles with NIMBY concerns—and among the broader SUD treatment field, OTPs were often the first to recognize the value and role of harm reduction. Ultimately, there are still far more OTPs than harm reduction programs, but the harm reduction community is clear on the value and role of methadone; indeed, in much of the world, methadone treatment is considered a central part of harm reduction.”
It should be noted that harm reduction forces are not the only ones who favor a deregulation of the system. The belief seems to be that if regulatory barriers are eliminated, access to treatment will be increased.
It’s important to add that harm reduction groups would like to see OTPs expanded—but that there is a basic lack of understanding that regulatory issues are not the real obstacle. The real obstacle is zoning boards and community groups.
By Alison Knopf
One of the most important initiatives occurring in methadone treatment for opioid use disorders (OUDs) is taking place in prisons and jails. In many states, a person who was addicted to opioids and then became incarcerated was left to undergo cold-turkey withdrawal, with no treatment.
Now, states and localities are starting to recognize the cruelty and lack of logic of this kind of plan. Because while most—but not all—of those people survived, when they were released from jail or prison and went back to using opioids, as was likely, they were also more likely to overdose. The dose they had been used to before the abstinence period was enough to make them overdose. And when illicit fentanyl entered the scene, a few years ago, the overdose became even more likely to be lethal.
So, states—starting with Rhode Island (see http://atforum.com/2018/02/moving-ahead-on-methadone-in-corrections/)—are gradually realizing that they need to have treatment behind the walls. Most recently, HB116/SB846 is working its way through the Maryland legislature. This bill would have opioid treatment programs (OTPs) operate within prisons and jails to provide methadone to addicted inmates.
AT Forum spoke with Babak Imanoel, DO, about how the program, which is expected to become law in October, would work. Dr. Imanoel, who is medical director of opioid treatment programs with the Anne Arundel County Department of Health, has been running just such a program in the local jail.
“We know that roughly 70 percent of people behind bars have an opioid use disorder,” Dr. Imanoel told AT Forum. “By starting them on buprenorphine, methadone, or Vivitrol behind bars, their chances of staying in treatment when they leave go up.” Before the program in Anne Arundel County started, the jail there had only abstinence-based treatment, he said. Of 350 people treated in that program, only 1 showed up for treatment after release. Close to 50 percent relapsed within two weeks. “We don’t know what happened to them,” said Dr. Imanoel, of the released inmates. Once the jail started using methadone instead, 85 percent of the people who were released showed up at treatment.
The county health department, where Dr. Imanoel is an independent contractor, is in charge of the treatment program in the jail. “We work with the correctional facility, but we are running the program,” he said.
Reductions in ODs
The Rhode Island OTP-corrections program, on which the Maryland program will be based, showed a 65% reduction in overdose deaths. In Anne Arundel county, there hasn’t been a single OD death in a patient treated with methadone: a 100% reduction in deaths.
In addition, jail staff report—not surprisingly—that inmates getting treatment “are calmer, less likely to get into fights, and use less medical resources,” said Dr. Imanoel.
The current Maryland bill would have an OTP inside every jail system. The OTP could be freestanding, or could be contracted by the jail system. The three approved medications—naltrexone (Vivitrol), buprenorphine, and methadone—would all be offered.
If only Vivitrol or buprenorphine were offered, an OTP wouldn’t be necessary, Dr. Imanoel conceded. “But Vivitrol doesn’t take the craving away to the extent that methadone does, and neither does buprenorphine—it doesn’t keep people in treatment as long as methadone does.” In addition, Vivitrol and buprenorphine are much more costly than methadone. However, the costs of an OTP, which would be needed under federal law if methadone were dispensed—are high, as well. Either way, the bill is going to cost the taxpayer.
The bill would require all three medications to be available. “We don’t want to force everyone to take methadone,” said Dr. Imanoel.
There are two obstacles to the bill: one is the price tag, and the other is that the correctional facilities are fighting it. “They say, ‘We are corrections, people should be punished,” said Dr. Imanoel. “But it’s treatment, it’s just like somebody with diabetes—they should get treatment.” So, while OTPs are 100% in favor of the bill, the jails themselves are not.
For the text of the bill as introduced, go to https://legiscan.com/MD/text/HB116/id/1860222/Maryland-2019-HB116-Introduced.pdf
By Alison Knopf
As authorities start recognizing the need to treat opioid-dependent detainees in jails and prisons, rather than let them detox cold turkey, the importance of opioid treatment programs (OTPs) to corrections is growing.
Last fall, a federal court granted a preliminary injunction giving methadone treatment to an incarcerated patient.
This was the first federal court—it was in Massachusetts—to find that denying medication can violate both the Americans with Disabilities Act and the prohibition against cruel and unusual punishment of the U.S. Constitution. The American Civil Liberties Union (ACLU) of Massachusetts, along with the law firm Goodwin Procter, brought the case on behalf of Geoffrey Pesce, a methadone patient. In March, another Massachusetts patient sued the federal Bureau of Prisons, demanding that she be able to stay on methadone when she begins serving her sentence.
States are continuing to consider legislation to require jails and prisons to offer methadone to detainees, based on successful work done in Rhode Island and Connecticut.
In fact, it looks as if corrections—which has in the past been interested in Vivitrol—is going to be a growth area for OTPs.
“The overwhelming majority of jails and prisons in this country fail to provide any of the three life-saving medications to treat opioid use disorder,” said Sally Friedman, vice president of legal advocacy at the Legal Action Center, referring to the Massachusetts decision. “This decision makes it clear that these practices are not only harmful, but illegal. Jails and prisons need to offer all three FDA-approved medications to treat opioid use disorder.”
Voices From New York
Indeed, New York State is considering such a move. “With up to 25 percent of the country’s incarcerated population suffering from opioid use disorder, it is time for jails and prisons to provide life-saving medication,” said Paul Samuels, president and director of the Legal Action Center. “We urge New York lawmakers to act quickly to ensure that the Department of Corrections is offering all three FDA-approved medications to incarcerated individuals with OUD across the state,” added Samuels. Legislation proposing that all three medications (methadone, buprenorphine, and naltrexone) be available in all lockups in the state has been offered in New York.
But it costs money, and it’s a battle. The state is not putting up enough money, meaning that counties—already strapped in many cases—would need to pay for methadone treatment for jail and prison detainees. That could be a heavy lift.
At a meeting in February, which was in part a protest against the budget and in part a rally for medication-assisted treatment (MAT) in jails and prisons, legislators and others spoke loudly.
“Throughout New York State, we have a critical opportunity to help fight the opioid epidemic, by establishing comprehensive addiction-treatment programs within correctional facilities; programs that include all three FDA-approved medications to treat opioid use disorder,” said Allegra Schorr, President of the Coalition of Medication-Assisted Treatment Providers and Advocates of New York State (COMPA).
“What’s more,” she added, “we need to provide connections to effective services, and treatment upon reentry into the community. Rhode Island and Connecticut have demonstrated the effectiveness of these life-saving programs. New Yorkers deserve a similar chance.”
OTPs and others have called on the state to urgently pass and fully fund A833/S2161–the bill to establish MAT in all New York State jails and prisons. At a press conference after Gov. Andrew Cuomo released his budget, speakers criticized the allocation of only $3.75 million to finance 50 county MAT programs in county jails across the state, forcing the counties themselves to bear much of the cost.
“More than 75 percent of incarcerated individuals in New York State have a diagnosed substance use disorder, yet just a few state prisons offer a comprehensive medication-assisted treatment program,” said Assembly member and bill Sponsor Linda B. Rosenthal. “Our state prisons and local jails provide medication to individuals with other medical disorders. To ignore the needs of those with substance use disorders, especially at a time when overdose rates are skyrocketing, is simply inhumane. My legislation would right this wrong and require all state prisons and local jails to make all FDA-approved forms of MAT available to those who need them.”
“Every person deserves to be treated in a humane manner, whether they are incarcerated or not,” said Senator and bill Sponsor Jamaal Bailey. “New Yorkers who are incarcerated should have access to adequate medical treatment—especially when we are suffering through an opioid crisis. It is unfortunate that instead of rehabilitating those who suffer from drug abuse, in New York’s prisons, individuals have been allowed to suffer on their own, often leading to their death. This is why I am proud to support the Medication Assisted Treatment bill, and hope to see it come to fruition.”
“Prison and jail inmates are at high risk for illnesses related to poverty, addiction, or mental illness, and we have a constitutional obligation to provide health care to people in our custody,” said Assembly Health Committee Chair Richard N. Gottfried. “Medication-assisted treatment is the professional standard of care on the outside and should be equally accessible within prisons and jails. We should also expand the very successful 2009 law giving the Health Department oversight of HIV/AIDS and Hepatitis C services in prisons and jails to include substance use disorder.”
Program “Addresses the Cycle of Arrest and Incarceration”
“At the Albany County jail we’ve implemented this program because we know it will reduce the rates of overdose among people recently released, improve people’s ability to stay in treatment and live the lives they want, and will address the cycle of arrest and incarceration that many people with opioid use disorder face,” said Albany County Sheriff Craig Apple. “It took me a while to get on board with this, but we’re already seeing early success with our program. I wholeheartedly support the expansion of these efforts and dedication of resources being asked of our state leaders. I also encourage my fellow law enforcement leaders to get behind this.”
“Politicians have long ignored overdose deaths in black communities like mine. Despite the rhetoric of a kinder, gentler drug war as the overdose crisis spreads into white, rural and suburban communities, these same politicians still have not enacted basic, life-saving interventions. I have met many of these white families, and they feel just as stigmatized, ignored, and angry, as my community,” said Will Robertson, Leader at VOCAL-NY. “If the blue wave that hit New York State does not take action to end our state’s overdose crisis, it will mean nothing to any of these families, white, black or Latino.”
“I am a person that was arrested for just having a possession of a needle and it wasn’t even on me it was in a car however I was sent to the county jail while I was 8 months pregnant and ended up having a premature birth with my daughter because I was detoxing and didn’t have methadone,” said Stephanie, a member of the Katal Center for Health, Equity and Justice. “I didn’t have access to the methadone from the program that I was attending for a year! As a result of this my daughter was in the NICU for two weeks which was very terrifying and traumatic. If I was able to have this treatment while I was incarcerated at the county jail things may have been different. This may not help me today but I’m sure that it would help many people that are and will be in the same situation that I have been through and I hope that they don’t have to suffer the same traumatic and terrifying situation.”
“At Friends of Recovery-New York (FOR-NY), we hear time and time again stories of people in the NYS Justice System who did not receive medication-assisted treatment (MAT), which is evidence-based,” said Interim Executive Director, Allison Weingarten, adding, “This lack of treatment and connection to treatment or recovery support services leaving a correctional facility tragically often leads to overdose and death. MAT is shown to reduce cravings for opioids and is a proven pathway to addiction recovery, which is why FOR-NY strongly supports this legislation making MAT available in all jails and prisons throughout New York State.”
NYASAP: “Ensure a Smooth Transition When They Return Home”
“A comprehensive range of patient-centered prevention, treatment, recovery, and harm reduction services should be made available to all residents of New York’s prisons and jails who suffer from the disease of addiction,” said John Coppola, Executive Director of New York Association of Alcoholism and Substance Abuse Providers (NYASAP). “While providing all available treatment options to people in prison—we also need to ensure a smooth transition when they return home which includes making sure they maintain easy access to the medications they are taking.”
“The criminalization of substance use has pushed people in need of care into jails and prisons that are not equipped to provide effective medical care. Lack of sustained state resources, medical bias, and misinformation surrounding medication-assisted treatment, have created a massive treatment gap in New York’s jails and prisons,” said Dionna King of the Drug Policy Alliance. “The funding allocated through the 2019-20 budget will not adequately address the significant treatment need in resource-strained counties struggling to provide care to people who cycle in and out of jail. New York state leaders must move beyond rhetoric, ending the overdose crisis requires a commitment to providing care to everyone.”
By Alison Knopf
The federal Center for Medicare and Medicaid Services (CMS) and the Substance Abuse and Mental Health Services Administration (SAMHSA) have started preparations for setting a rate for Medicare payment for people 65 and over, AT Forum has learned. Thanks to the “SUPPORT for Patients and Communities Act” signed into law last year by President Donald Trump, opioid treatment program (OTP) patients will be covered by Medicare, starting in 2020. This means that when patients turn 65 and lose their Medicaid or commercial insurance, getting Medicare instead, they will be able to stay in treatment.
“With regard to Medicare implementation, CMS/Medicare and SAMHSA representatives recently visited two OTPs to get a better sense of how they function and the services that are rendered,” Mark Parrino, MPA, president of the American Association for the Treatment of Opioid Dependence (AATOD), told AT Forum.
As we reported last fall, CMS is developing a weekly bundled rate. First, said Mr. Parrino, “they have to identify what the basic benefits will be and what the rate will be.” As the method of reimbursement becomes clearer, AATOD will offer an implementation webinar. It would be premature to do this at the present time, he said. But patients in treatment now, nearing their Medicare-eligible status, need not fear that they will lose coverage and have to drop out of treatment. AATOD spent more than a decade working to get this Medicare rate implemented.
The law creates a bundled payment for medication-assisted treatment (MAT), which by definition is a combination of medications and behavioral therapies to provide a holistic approach. The bundled payment will include the dispensing of methadone.
The law also requires private insurers who offer Medicare Part D prescription drug plans to implement “lock-in” programs, starting in 2022, that limit the number of pharmacies and prescribers used by enrollees identified as at risk of opioid misuse.
In adding OTPs to its covered programs, Medicare has to go through the same growing pains as all insurance companies. It will use the bundled approach, something Medicare already does for some other services. In the “bundled” approach, CMS combines payments for the physician and hospital or other services into a single amount, based on the expected costs during an episode of patient care.
Medicare covers items and services included in broad categories, such as hospital care, physician services, prescription drugs, and many other categories, but doesn’t explicitly list all reasonable and necessary items and services that treatment might require.
More to the point: until now, Medicare did not offer any explicit benefit to treat opioid use disorder (OUD), although many services considered part of OUD treatment are indeed covered under other categories, such as prescription drugs, psychologist services, physician services, and hospitalization.
Until now, Medicare did not recognize OTPs for reimbursement. And because methadone for OUD can be provided only in OTPs, it has not been covered by Medicare. Finally, it’s unusual for Medicare to group treatments to treat specific conditions or diagnoses in a bundle. But now, it will.
“Beginning on or after January 1, 2020, Medicare will pay OTPs 100% (less any beneficiary copayments) of a bundled payment for OUD treatment provided to Medicare beneficiaries during an episode of care (as defined by the Secretary),” according to the Congressional Research Service report on the SUPPORT Act’s Medicare implications. “The Secretary [of the Department of Health and Human Services] may implement one or more OTP payment bundles based on the medication dispensed, the scope of furnished services, beneficiary characteristics, and other factors the Secretary determines appropriate. In developing payment bundles, the Secretary may consider OTP payment rates for comparable services paid by Medicaid or TRICARE.”
Payment bundles for OTPs will be updated every year.
By Barbara Goodheart, ELS
With opioid overdoses now killing more people than traffic accidents or HIV infection—more than 45,000 lives were lost to overdoses in 2017—you’d think that most people with opioid use disorder (OUD) could easily access treatment. But that’s not the case. Only a minority receive any substance use treatment, such as counseling or inpatient treatment; even fewer receive medication treatment (MT).
With an eye to better understanding MT dynamics, and in hopes of helping policy makers “identify and close critical gaps in the opioid treatment infrastructure,” a team headed by Ramin Mojtabai, MD, MPH, PhD, at Baltimore’s Johns Hopkins Bloomberg School of Public Health, examined data from the National Survey of Substance Abuse Treatment Services. Study results covered 2007 through 2016, and were published in the January issue of Health Affairs.
Buprenorphine and XR Naltrexone Use Is Up; Methadone Lags
The percentage of facilities offering any MT increased from 20% in 2007 to about 36% in 2016; in the latter year only 256 facilities (6.1%) carried all three medications; almost two-thirds provided none.
As the Table below shows, driving the increase in treatment availability were buprenorphine and extended-release (XR) naltrexone. Virtually left behind: methadone—up less than one percentage point over the nine-year period. Yet methadone is “the only medication requiring a federally certified opioid treatment program,” the authors noted; and “methadone may be more effective in retaining patients in treatment and may be especially beneficial for patients with prior treatment failure.”
Medication Availability at OUD Facilities, 2007-2016
|Increase in % of facilities offering each medication type||14.9 to 25.4||9.6 to 20.7||9.4 to 10.3|
|Facilities offering each medication type among 4,218 offering any of these medications in 2016 (%)||2,968 (70.4)||2,429 (57.6)||1,208 (28.7)|
Factors Influencing Patient Access
Limits on Availability of Medication
In 2016, only 256 facilities (6.1%) offered all three MT medications; almost two-thirds provided none. Because each medication has pros and cons, the authors view the limited availability of all three at one facility as a “barrier to the optimal use of MT.”
Some likely benefits of full availability: some patients do better with the “structured treatment and accountability offered by methadone maintenance programs, while others may perceive treatment at a methadone clinic as stigmatizing or find the required daily travel overly burdensome.” As for naltrexone, some patients aren’t able or willing to complete naltrexone’s mandatory induction period.
States most likely to offer MT in their facilities were New York and Vermont; least likely were Hawaii, Arkansas, and Idaho. Offering MT was more common in:
- Department of Veterans Affairs facilities, compared to private for-profit facilities
- Facilities located in or operated by a hospital
- Facilities with residential and inpatient services, compared to those without these services
- Large facilities
- Facilities accepting health insurance, especially those accepting Medicaid in states that had expanded Medicaid eligibility
- Facilities in states that accepted Medicare, private insurance, and self-payment or cash
- Facilities in states with higher opioid death rates
- Facilities in states whose Medicaid plans offered more comprehensive coverage of MT
These findings, noted the authors, “highlight the persistent unmet need for MT nationally and the role of expansion of health insurance in the dissemination of these treatments.”
Type of Funding
Medicaid expansion has made MT available to more people, such as those treated in facilities that accept Medicaid. This is especially true in expansion states, where coverage under Medicaid is broader. Still, as the authors point out, many people don’t have easy access to facilities accepting Medicaid.
The Bottom Line
Financing has shifted from state and local general revenues to Medicaid and private insurance—thus, more money has gone into treatment in general medical settings, with prescription medications. This has dimmed the outlook for methadone, given the federal requirement for treatment programs.
Noting the typically slow pace of “changes in policy, financing of care, and insurance coverage,” the authors expressed concern that these changes “might not be extensive enough to meet the present urgent need for the expansion of MT.” They suggest governments may be able “to leverage block grants and other local funding mechanisms to promote more expeditious implementation of MT in substance use treatment facilities.”
Addiction Treatment Forum contacted Tami L. Mark, PhD, MBA, senior director, Behavioral Health Financing, at RTI International. Dr. Mark, an internationally known expert on behavioral health care financing and delivery, agreed with Dr. Mojtabai and colleagues about the need for better access.
“Dr. Mojtabai and his colleagues should be commended for providing data on access to MAT [medication-assisted treatment] in specialty addiction treatment programs,” she said. “The trend is moving in the right direction but we still have a ways to go to improve access to these life-saving medications. A critical next step is to give consumers easy to access and understand information on which providers offer MAT and other aspects of high quality addiction treatment, such as use of effective behavioral therapies for substance use disorders for which there are no medication-based treatments.”
In reply to Dr. Mark’s comments, Dr. Mojtabai agreed that provision of such information to consumers is a critical step, adding that it “should be accompanied by provisions at the federal and local level to increase availability of these treatments, improving patient access through expansion of public insurance and greater integration of these treatments in general health and specialty mental health services.”
(A grant from the National Institute on Drug Abuse supported the authors in this work.)
Mojtabai R, Mauro C, Wall MM, Barry CL, Olfson M. Medication treatment for opioid use disorders in substance use treatment facilities. Health Affairs. 2019;38(1):14-23. doi:10.1377/hlthaff.2018.05162.
For Additional Reading
Mark TL, Yee T, Levit KR, Camacho-Cook J, Cutler E, Carroll CD. Insurance financing increased for mental health conditions but not for substance use disorders, 1986-2014. Health Affairs. 2016;35(6):958-965. doi:10.1377/hlthaff.2016.0002.
“Where Multiple Modes Of Medication-Assisted Treatment Are Available.” Health Affairs Blog, January 9, 2018. doi:10.1377/hblog20180104.835958.
By Alison Knopf
There have been significant changes at Acadia Healthcare Company, which operates many opioid treatment programs (OTPs) among its 600 facilities. Last December, amid reports that the Nashville, Tennessee-based publicly traded company was possibly for sale, Joey Jacobs was fired as CEO and chairman of the board, replaced by Debbie Osteen, formerly with Universal Health Services. This is all very high-level wheeling and dealing, so what does it have to do with treatment in Acadia facilities?
To what extent do such high-level moves affect patients? For an answer to this question, we went to Jerry Rhodes, who was CEO of CRC Health Group when Acadia acquired it in 2014, and is no stranger to such changes.
The basic answer is: patients should not be affected at all. “To a large degree, patients are identifying with the facility at which they’re receiving treatment,” Mr. Rhodes told AT Forum. “A leadership change shouldn’t have any impact on a patient at all.”
Continuity of treatment is assured by the “quality of the program and the clinical abilities of the team,” said Mr. Rhodes. “Those traits are only indirectly attributable to the leadership changes of a company.”
There is a “ripple effect” on patients and staff, when headlines appear–which generally focus on the geographic area in which corporate is headquartered (in Acadia’s case, Nashville, Tennessee). But outside of Nashville there are few programs throughout the United States that have the Acadia brand. “From my perspective–and I’ve gone through this many, many times–if it’s a good quality program, which delivers good care and is well-managed, the impact at the facility will be negligible,” said Mr. Rhodes.
Transparency Is Key
There is one circumstance that worries patients and staff, and rightly so. It’s if a program is not performing and rumors abound that it may be shut down. “You have to be very direct and transparent about the intentions of a company,” said Mr. Rhodes. Otherwise, fear alone could adversely affect care. It’s up to corporate to be transparent with facilities, and up to facilities to be transparent with patients and staff.
In fact, Acadia issued a press release about the changes, when they took place (http://www.acadiahealthcare.com/investors), with the main audience being investors.
Importantly, in the OTP world, the main growth has been in the proprietary sector. This means a lot of mergers and acquisitions, and people are used to it. “Whether it’s being bought as a company or as a facility, this has been a facet of the business for a long time,” said Mr. Rhodes.
And it’s doesn’t really matter whether the investor is private equity, venture capital, or a hedge fund, he said. “The expectations are pretty much the same.”
Finally, Mr. Rhodes did express frustration that OTPs are not seeing more growth and acceptance in the past few years, with the stress on opioids front and center in the health care world. “This is because of the lingering stigmas associated with methadone,” he told AT Forum. “Over the years, it’s delivered the best results and most demonstrable, and yet, the industry does a terrible job of promoting itself and in public relations.” This is why the addiction field is gravitating toward integration with general health care. In the meantime, however, OTPs–including those with the Acadia brand–continue to move forward. Most recently, Acadia announced plans to open a new OTP in Vermont. Stay tuned.
By Alison Knopf
The world of addiction has a deeply embedded image of the oft-cited elephant in the room: substance use disorder in a family member, a fellow employee, a loved one; bigger than life, but not mentioned. The elephant in the room.
For opioid treatment programs (OTPs), the elephant is often alcohol, which, when combined with opioids (including therapeutic methadone or buprenorphine) can be dangerous, and even deadly. AT Forum talked about this problem with Lorenzo Leggio, MD, PhD, Chief of the Section on Clinical Psychoneuroendocrinology and Neuropsychopharmacology, a joint NIAAA (National Institute on Alcohol Abuse and Alcoholism) and NIDA (National Institute on Drug Abuse) laboratory.
Alcohol kills 89,000 people a year in the United States—double the rate of opioid overdoses, Dr. Leggio noted.
The problem isn’t only that the combination of alcohol and methadone or buprenorphine is a bad one—it’s the high comorbidity rate of alcohol use disorder and opioid use disorder, Dr. Leggio said. “Roughly 30 to 40 percent of patients who are on agonist maintenance also drink an excessive amount of alcohol—maybe even 50 percent.” And this may be a low estimate—the actual percentage may be much higher. This is based on epidemiological data from the United States and Europe. “It’s a remarkable number, unfortunately,” he said.
From a clinical perspective, the numbers are concerning. First, alcohol has an effect on the way the body metabolizes many drugs. Here’s how it works: the alcohol prevents the methadone from being metabolized, so the levels of methadone in the blood rise.
There is also the problem of sedation. In the case of methadone, alcohol would potentiate the effect of the medication—and in turn, the methadone would potentiate the effect of the alcohol. “Think about someone who is on methadone and is also drinking and is driving,” he said. “There’s the risk of sedation,” even if the methadone alone is not sedating (and it isn’t, for stable patients in OTPs). Alcohol, on its own, has a risk of sedation, of course. “By mixing methadone and alcohol, you can have an amplification of this effect,” said Dr. Leggio.
Sedation is a known side effect of methadone. Central nervous system (CNS) depression is also a side effect, and combining methadone with alcohol could be lethal because the person stops breathing—just as they do after an opioid overdose.
“The best way to explain alcohol to patients is to make it clear: this is not trivial,” said Dr. Leggio. “We are talking about the effect of these drugs in your body that may lead to respiratory depression—your brain is not able to handle this, and you can die.”
Be clear to the patient who is taking methadone or buprenorphine that they are increasing their risk of death by drinking alcohol, he said.
On the bright side, methadone and buprenorphine patients, by definition, have been bought into treatment. “They are already committed to try to improve their health,” said Dr. Leggio.
So what can an OTP do? According to Dr. Leggio:
- Screening. First, the assessment must be clinically oriented and comprehensive, including alcohol screening. “You can use CAGE, you can use AUDIT, but you need to use some well-validated tool.”
- Patient education. “Patients may not recognize that alcohol is problem for them.” Lorenzo Leggio,
- Treatment. Depending on the level of care needed, providing brief intervention, motivational interviewing, or contingency management may be effective. Cognitive behavioral therapy is more complex and requires more time, but is also effective. “Try to do the treatment as part of a comprehensive approach,” said Dr. Leggio. For example, if the patient is coming into the OTP for methadone dosing, perform the alcohol counseling at the same time. And remember, it could be as simple as a brief intervention; if patients learn about the dangers, they may stop drinking, or at least reduce their drinking.
- Medications. This can be a complex issue, said Dr. Leggio, moving on to discuss three medications indicated for alcohol use disorder: naltrexone, acamprosate, and disulfiram. Patients on buprenorphine or methadone can’t take naltrexone, a medication that is only for patients who are opioid-free, but does reduce alcohol cravings. However, the patient may want to taper off methadone and buprenorphine (this is unlikely, but just in case a patient is interested in doing that, the naltrexone would be a good solution to prevent opioid use and reduce or prevent alcohol use). However, it’s important to remember that naltrexone reduces alcohol cravings in only 30% of patients—and nobody knows ahead of time which 30%.
There are no studies in which acamprosate, indicated for alcohol use disorders, has been studied in the context of methadone, said Dr. Leggio, but it would also be a possible treatment. He flatly ruled out disulfiram (which causes the patient to become very ill temporarily when combined with alcohol). “I would be concerned about the disulfiram syndrome in the context of opioid use disorder,” he said.
Finally, Dr. Leggio pointed to the fact that so few people get treatment for substance use disorder. “If we provided treatment to only 10 percent of people with breast cancer, it would not be accepted, but with addiction, it is accepted,” he said. “At the end of the day, we tend to put our head under the sand, until we are hit personally” by addiction. “It doesn’t help that we are so far beyond other medical fields, like cancer and infectious disease; it doesn’t help that there is so much we don’t understand.”
And criticism is more pointed in addiction than in the rest of the field. A Nobel Prize in Physiology or Medicine was awarded for cancer immunotherapy, a treatment that helps one-third of patients—the same success rate as naltrexone for alcohol, noted Dr. Leggio. However, for the cancer treatment, a molecular analysis can be done to predict whether a patient will respond or not. “For naltrexone, we don’t have that knowledge yet,” he said.
NIAAA is currently funding clinical trials looking at ondansetron and topiramate for alcohol use disorder. “But a trial is very expensive, with multiple sites needed,” said Dr. Leggio. Of course, physicians are free to use approved medications off-label.
If the most an OTP can do is get a patient to reduce his or her drinking, that would be a “clinical success,” said Dr. Leggio. “If a patient were to drop from five drinks a day to one, would that be a success?” we asked. “That would be a wonderful success, I would sign off on that,” he said. “You have to be practical and compromise, and sometimes do baby steps. Abstinence should be the real goal, but reduction is an important goal.”