ONDCP’s Michael Botticelli on the Importance of OTPs in Treating Opioid Use Disorders

Michael Botticelli, acting director of the Office of National Drug Control Policy (ONDCP) and a longtime friend of medication-assisted treatment (MAT), dating from his years heading the Massachusetts Bureau of Substance Abuse Services, gave AT Forum an exclusive interview this summer on how opioid treatment programs (OTPs) effectively treat their patients who have opioid use disorders. The current epidemic has put Mr. Botticelli in the spotlight as the top federal official on drug policy, and treatment advocates are depending on him to help improve access to treatment.

“It has always been the policy of this office to support access to the full spectrum of evidence-based treatment for substance use disorders,” he said. “We have been particularly diligent about making sure that people who have an opioid use disorder have access to MAT—one reason is that patients on MAT have better treatment retention.”

Comprehensive Services and Reduction in Overdoses

Mr. Botticelli singled out OTPs for their comprehensiveness. “We’re not talking about just drug administration—we want to make sure patients get the full continuum of other services,” he said.

MAT should be available wherever it’s needed, including primary care and criminal justice settings, said Mr. Botticelli, who himself is in long-term recovery from an alcohol use disorder. The benefit of the OTP, regardless of what medication (methadone or buprenorphine) is given, is that it is required to offer other behavioral therapies, he said. “The challenge is making sure patients who are getting MAT in non-OTP settings have access to full services. They need all of their health care attended to.”

Another reason that the ONDCP strongly supports MAT for opioid use disorders is to reduce overdoses (ODs). “Studies have shown that patients who are engaged in MAT have significantly lower rates of ODs,” he said, citing as an example Baltimore, which, after it expanded methadone maintenance treatment, saw a drop in OD rates. OTPs are a “proven OD prevention strategy,” he said. (A study published last year in the American Journal of Public Health showed that increasing access to methadone and buprenorphine resulted in a decrease in heroin overdoses: (http://www.ncbi.nlm.nih.gov/pubmed/23488511).

Stigma Challenges

The ONDCP is working to change the stigma associated with addiction, in particular the language associated with opioid use disorders. “We don’t say ‘addict,’ we say ‘person with a substance use disorder,’” he said. “We have to stop talking about ‘clean’ and ‘dirty’ in urine testing. Our language needs to change so that we are not stigmatizing people.”

The Need to Expand Addiction Treatment

Even before Mr. Botticelli joined the ONDCP, the office’s national drug strategy was focusing on expanding addiction treatment. Now the ONDCP has convened a treatment workgroup from federal agencies looking at the need for treatment expansion in the context of the changing environment—the Affordable Care Act and the building prescription opioid and heroin crisis. “As a group, we’ve chosen increasing the access to MAT as the top priority,” he said.

ONDCP’s Treatment Coordination Group (TCG) is chaired by Mr. Botticelli (see participant list below).The TCG is working to:

• Coordinate and synchronize efforts of Federal partners who play a role in supporting the National Drug Control Strategy for substance use disorder treatment services;
• Increase understanding of the “state of the art” of treatment for substance use disorders;
• Ensure the adoption of quality, evidence-based services and systems of care across Federal agencies and contractors;
• Develop and promote opportunities among Federal partners to expand access to treatment services for substance use disorders;
• Ensure agency, programmatic, and interagency data (performance, research, etc.); inform discussions and decisions; and
• Share insight and experience to address issues pertaining to treatment for substance use disorders.

“There is no one silver bullet” when it comes to increasing access to MAT, he said. “We are open to a variety of ways” as long as care is high quality and minimizes diversion. “We get a tremendous amount of satisfaction in the number of patients who are able to access good, high-quality treatment through our OTPs. We want to make sure people have access to medications, and some way of decision-making for what medications are good for them—we believe a patient should be part of the decision making process.”

Goal to Increase Medicaid Coverage

Meanwhile, the ONDCP is trying to encourage states that don’t allow Medicaid to pay for OTP treatment to do so. “We participate in many state policy academies,” he said. “And we have always talked about access to MAT as part of any state strategy to appropriately respond to the opioid problem.” The ONDPC wants to make sure that states consider access to MAT as a response to the heroin and prescription opioid crisis, he said.