There’s a question on the minds of everyone who is involved with opioid treatment programs (OTPs) and reads the headlines: If we’re in such a dire opioid epidemic, why hasn’t methadone treatment, proven effective for more than 50 years, been expanded?
We contacted Robert Lubran, MS, MPA, director of the division of pharmacotherapies at the Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration (SAMHSA), and Mark Parrino, MPA, president of the American Association for the Treatment of Opioid Dependence (AATOD), and asked for an answer.
“Clearly, access to OTPs now is fundamental,” said Mr. Lubran, whose agency regulates OTPs. “At least support for OTP expansion exists at the federal level. We’ve made the process of applying for federal certification relatively efficient, and we’re streamlining more of our processes.”
Specific Barriers
But a number of barriers exist. Here are the main ones, according to Mr. Lubran:
- Many states still do not allow Medicaid to pay for treatment in an OTP.
- Many commercial insurance plans will not reimburse for treatment in an OTP.
- Providers are consolidating, rather than expanding.
- Many states will not use the Substance Abuse Prevention and Treatment (SAPT) Block Grant for treatment in an OTP.
- Most OTPs offer only one medication—methadone; they don’t offer buprenorphine and extended release naltrexone (Vivitrol).
It’s the philosophical opposition to OTPs and methadone in some states which prevents them from allowing government funds – Medicaid or SAPT Block Grant – for reimbursement. In these states, there either are no OTPs, or there are only self-pay proprietary OTPs.
Mr. Parrino agreed with Mr. Lubran about reimbursement barriers—Medicaid, commercial insurance, Medicare, and the SAPT Block Grant. States with philosophical opposition to OTPs and methadone don’t allow any government funding to be used for it.
Expanding OTPs and Making All Three Medications Available
“We want OTPs to be capable of offering all three medications,” said Mr. Lubran. However, the fact that reimbursement problems exist even with methadone, a very inexpensive medication, means that it would be even more difficult to get payers to cover buprenorphine or Vivitrol, which are far more costly.
It’s not clear that patients are asking for buprenorphine or Vivitrol. “But they’re not going to ask for something if they don’t know what it is,” said Mr. Lubran. “I think buprenorphine is pretty widely covered by insurance companies and Medicaid, but until every OTP in the United States offers patients multiple choices, the three choices that we have, we can’t call the care comprehensive.” But he acknowledged that a relatively small number of people seek buprenorphine or Vivitrol, compared to methadone, based on N-SSATS (National Survey of Substance Abuse Treatment Services) data.
NIMBY
Mr. Lubran didn’t mention a sixth barrier—NIMBY (Not in My Back Yard), something which Mr. Parrino said was a major barrier to OTP expansion. Even in states that do favor expansion, local opposition from law enforcement and residents has prevented siting.
For example, the state of North Dakota is supporting OTPs, but localities—where the clinics would be sited—are not. “The state wants it,” said Mr. Parrino, referring to constructing OTPs. “But the sheriffs say no, and the communities say no.”
We spoke with Mr. Parrino as he was planning to meet with officials from the Department of Health and Human Services (Assistant Secretary for Planning and Evaluation Richard Frank, PhD), SAMHSA (acting director Kana Enomoto), and the Office of National Drug Control Policy (director Michael Botticelli).
“They know I’m going to point out that the main focus for the past two years has been on buprenorphine and Vivitrol,” and he wants to add methadone expansion to that list.
Specifically, he wants to know: “If you really think OTPs are addiction hub sites, and you want to go from 1,400 OTPs to 2,000, how do we do that? What strategy do you, as federal agencies, need to follow?”
Whether it’s a matter of SAMHSA talking with alcohol and drug directors about block grant usage, or Health and Human Services (HHS) talking with Medicaid and Medicare officials about reimbursement, something has to be done, Mr. Parrino emphasized. “We have to kick out all the stops, make sure there’s coverage, expand OTPs.”
For the past five years, the only OTP expansion has been in the private for-profit sector. “You can’t just hope that the proprietary sector is continuing to increase expansion,” Mr. Parrino said, indicating the need for additional public expansion.
Need for Public Support at State and Local Levels
Mr. Parrino pointed to the real problem, which lies in states and communities within the states, not with the federal government.
Mr. Parrino recalled a state director who approached him 20 years ago at a NASADAD (National Association of State Alcohol and Drug Abuse Directors) meeting. The director, from a southeastern state, said, “‘I’m worried about the expansion of OTPs in my state by the proprietary sector. They’re increasing sites, and we have to give them licenses.’”
Mr. Parrino’s response was: “Increase public support for OTPs in your state.” The response, from the state director: “That’s not realistic.”
It would be helpful, according to Mr. Parrino, for the ONDCP (the Office of National Drug Control Policy at the White House) to talk with governors about the need to support OTPs. Likewise, HHS should send out an advisory on how to set up an OTP, and provide startup funding, he said.
“SAMHSA, HHS, and ONDCP have smart, hardworking people,” said Mr. Parrino. “The question is, can they marshal resources?”
Finally, Mr. Parrino hopes that the forthcoming recommendations from the federal Center for Disease Control and Prevention on opioid prescribing will be a wake-up call for public health officials. “To what degree will these guidelines trigger a reaction in the medical community?” he asked. If indeed the result is that many current opioid users—whether legitimate pain patients or abusers—no longer have access to opioids, the need for treatment will escalate.
Many who abuse drugs already inject prescription opioids, said Mr. Parrino. It will not be a big jump for them to start injecting heroin instead. “At some point, the individual loses any sense of being engaged in risky behavior.” He emphasized that coordination with the treatment community is essential, to make sure OTPs are available to people who need them.