Massive spending bill includes huge changes for SUD field: No more x-waiver, increases for treatment

Some people called it “something for everyone.” Others just said “at last.”

The spending bill approved by Congress December 23 eliminates the x-waiver for prescribing buprenorphine for opioid use disorder, something that the field at large had been calling for for years. Who did not want this: OTPs, because it makes it much easier for misprescribing to take place in the hands of untrained physicians. Yes, when they have to renew their DEA licenses, these prescribers will have to get SUD training. These are the two main components of the MAT Act (no x-waiver) and the MATE Act (requiring training). This is the “something for everyone.”

The massive bill includes a lot more. Below are initial perspectives from the American Society of Addiction Medicine (ASAM) and the National Association of Alcohol and Drug Abuse Directors (NASADAD).

From ASAM

The American Society of Addiction Medicine (ASAM) today commended Congress for including several key provisions in an end-of-year legislative package that will strengthen the nation’s addiction treatment infrastructure. President Biden signed the bill on December 23, just in time to prevent a government shutdown.  The Consolidated Appropriations Act, 2023, as amended, will help improve Americans’ access to evidence-based addiction treatment and related support services at a time when overdose deaths are near record highs.

“The addiction and overdose crisis has accelerated in recent years, and bold, comprehensive measures are required to save lives,” said William F. Haning, III, MD, DLFAPA, DFASAM, president of ASAM. “Removing barriers to addiction care and expanding education for treating addiction are critical to expanding access to treatment. ASAM appreciates Congress’ leadership in eliminating some obstacles that are deadly for far too many Americans. With hundreds of thousands of lives on the line, this legislation comes at a critically important time.”

Key health provisions that will help increase access to addiction treatment and related support services include:

• eliminating the “X-waiver” to prescribe buprenorphine for opioid use disorder (and associated patient limits), as called for by the Mainstreaming Addiction Treatment (MAT) Act;
• requiring controlled medication prescribers to receive education on treating and managing patients with substance use disorder, as called for by the Medication Access and Training Expansion (MATE) Act;
• appropriating $40,000,000 for Fiscal Year 2023 for the Health Resources and Services Administration (HRSA)’s Substance Use Disorder Treatment and Recovery (STAR) Loan Repayment Program;
• appropriating $25,000,000 for Fiscal Year 2023 for HRSA’s Addiction Medicine Fellowship Program to foster robust community-based clinical training of addiction medicine or addiction psychiatry physicians in underserved, community-based settings;
• reauthorizing HRSA’s Addiction Medicine Fellowship Program through 2027;
• reauthorizing a grant program for screening, assessing, and treating maternal mental health conditions and substance use disorders, as well as continued funding of the Maternal Mental Health Hotline;
• authorizing $10,000,000 in grants for each of the first five fiscal years beginning after the date of enactment to support mental health and substance use disorder parity implementation;
• codifying regulations that allow opioid treatment programs (OTPs) to operate mobile medication components without separate DEA registrations, as called for by the Opioid Treatment Access Act;
• extending mental health and addiction parity requirements to nonfederal governmental health plans;
• authorizing $60,000,000 in grants for each of fiscal years 2023 through 2027 to improve uptake and patient access to integrated care services, including the psychiatric collaborative care model;
• extending critical Medicare telehealth flexibilities started during the COVID-19 public health emergency (including delaying the in-person requirements for telemental health services) through December 31, 2024;
• providing for the distribution of 200 additional Medicare-funded graduate medical education (GME) residency positions for Fiscal Year 2026, with 100 of those positions set aside for psychiatry or psychiatry subspecialty residencies;
• revising Medicare’s partial hospitalization benefit beginning on January 1, 2024 to provide coverage of intensive outpatient services;
• directing the Comptroller of the United States to conduct a study to compare the mental health and substance use disorder benefits offered by Medicare Advantage plans to traditional Medicare and to other benefits offered by Medicare Advantage plans;
• directing the Department of Health and Human Services to conduct a review on whether to establish a safe harbor related to the federal anti-kickback statute for evidence-based contingency management incentives for the treatment of substance use disorder and the parameters for such a safe harbor, followed by recommendations to Congress for improving access to evidence-based contingency management interventions while ensuring quality of care;
• establishing Medicare Part B coverage for services rendered by marriage and family therapists and mental health counselors beginning on January 1, 2024, and removing regulatory barriers that prevent physicians who are employed by a hospital from accessing mental health/substance use disorder programs offered by said hospital;
• facilitating consensus-based best practices, which may include model laws for implementing suggested minimum standards for operating, and promoting the availability of, high-quality recovery housing;
• making permanent the option for states to offer 12 months of postpartum Medicaid coverage; and
• amending the Medicaid Inmate Exclusion Policy to allow otherwise eligible juveniles to continue receiving Medicaid-funded health care while awaiting trial, at the option of the State.

The Centers for Disease Control and Prevention (CDC) predicts that there were 107,735 drug overdose deaths between July 2021 and July 2022, the latest statistics available. In addition to the heartbreaking loss of human life, the opioid addiction and overdose crisis has cost the United States $1.5 trillion in 2020 alone, according to a September report published by the U.S. Congress’ Joint Economic Committee. With over 41.1 million Americans aged 12 or older needing substance use treatment in the past year, yet only a relatively small percentage of adolescents and adults with substance use disorder (6.5%) receiving any substance use treatment, there is an urgent need to for the bipartisan legislation passed today.  

ASAM looks forward to working with the Biden-Harris Administration and the 118^th Congress on expanding today’s progress, including new efforts designed to strengthen the addiction treatment workforce, close the Medicare coverage gap for residential substance use disorder services, and responsibly increase access to methadone treatment for opioid use disorder.

NASADAD  

And from NASADAD, which represents state directors who have oversight over the SAPT block grant, as well as State Opioid Treatment Authorities, here is a summary with a slightly different focus.

• SUD Substance Abuse Prevention and Treatment (SAPT) Block Grant:  The proposed bill recommends a $100 million increase in the SAPT Block Grant. As a result, the total for FY 2023 would be $1,928,879,000.
• No recovery set-aside: The draft bill does not include a new mandate that would require State alcohol and drug agencies to spend at least 10 percent of SAPT Block Grant funds on recovery support services. 
• State Opioid Response (SOR) Grant: The bill proposes a $50 million increase for the SOR program. As a result, the total for FY 2023 would be $1,575,000,000.
• SAMHSA reauthorization bill included as part of the larger bill:  As expected, a bill to reauthorize a number of programs within SAMHSA – including the SAPT Block Grant – is included in the bill.

SOR grants

The agreement provides an increase and notes that large swings in funding between grant cycles can pose a significant challenge for States seeking to maintain programs that were instrumental in reducing drug overdose fatalities. The agreement directs SAMHSA to avoid significant cliffs between States with similar opioid mortality data, and to prevent unusually large changes in a State’s SOR allocation when compared to the prior year’s allocation. In ensuring the formula avoids such cliffs, the Assistant Secretary may consider options including, but not limited to, expanding the number of States that are eligible for the 15 percent set aside. The agreement continues to direct SAMHSA to conduct a yearly evaluation of the program to be transmitted to the Committees no later than 180 days after enactment of this Act and make such an evaluation publicly available on SAMHSA’s website.

SOR Overdose Data Report.—The agreement recognizes that drug overdose mortality data collection and reporting is complex, often with multi-substance use contributing to mortality. The agreement encourages SAMHSA to evaluate the data used to calculate SOR allocations, including whether accurate, State-level data exists for mortality rates for opioid use disorders and whether such data should be used to calculate the 15 percent set-aside within SOR.

Substance Abuse Prevention and Treatment Block Grant (SABG).—The agreement does not include a new set-aside within the SABG for recovery services, but urges SAMHSA to strongly encourage States to use a portion of their SABG funding for recovery support services.

Building Communities of Recovery.—The agreement provides an increase for enhanced long-term recovery support principally governed by people in recovery from substance use disorders. The agreement encourages SAMHSA to continue supporting recovery support programs principally governed by people in recovery from substance use disorders, including peer support networks.

First Responder Training.—The agreement urges SAMHSA to take steps to encourage and support the use of First Responder Training funds for opioid safety education and training, including initiatives that improve access for licensed health care professionals, including paramedics, to emergency devices used to rapidly reverse the effects of opioid overdoses. Within the increase, the agreement provides $10,500,000 to make awards to rural public and non-profit fire and EMS agencies as authorized in the Supporting and Improving Rural Emergency Medical Service’s Needs (SIREN) Act (P.L. 115-334). The agreement again encourages SAMHSA to allow the purchase of equipment, including naloxone and to continue to fund grants with award amounts lower than the maximum amount allowable.

Medication-Assisted Treatment for Prescription Drug and Opioid Addiction.—The agreement directs SAMHSA to ensure that these grants include as an allowable use the support of medication-assisted treatment and other clinically appropriate services to achieve and maintain abstinence from all opioids, including programs that offer low-barrier or same day treatment options. Within the amount provided, the agreement includes $14,500,000 for grants to Indian Tribes and Tribal Organizations.

Opioid Use in Rural Communities.—The agreement encourages SAMHSA to support initiatives to advance opioid use prevention, treatment, and recovery objectives, including by improving access through telehealth. SAMHSA is encouraged to focus on addressing the needs of individuals with substance use disorders in rural and medically underserved areas. In addition, the agreement encourages SAMHSA to consider early interventions, such as co-prescription of overdose medications with opioids, as a way to reduce overdose deaths in rural areas.

Opioid Use Disorder Relapse.—The agreement recognizes SAMHSA’s efforts to address opioid use disorder relapse within Federal grant programs by emphasizing that opioid detoxification should be followed by medication to prevent relapse to opioid dependence. The agreement encourages SAMHSA to continue these efforts.

Pregnant and Postpartum Women.—The agreement provides an increase and again encourages SAMHSA to fund an additional cohort of States under the pilot program authorized by the Comprehensive Addiction and Recovery Act (P.L. 114-198).

Recovery Housing.—In order to increase the availability of high-quality recovery housing, the agreement encourages SAMHSA to examine opportunities to provide direct technical assistance to communities in multiple states and promote the development of recovery ecosystems that incorporate evidence-based recovery housing for substance use disorder intervention. SAMHSA is encouraged to explore the establishment of a Center of Excellence with a non-profit, in collaboration with a college of public health, which has expertise and experience in providing technical assistance and research in recovery housing and focuses on homeless and justice-involved individuals utilizing blended funding and an intervention model with demonstrated outcomes.

Treatment Assistance for localities.—The agreement again recognizes the use of peer recovery specialists and mutual aid recovery programs that support Medication-Assisted Treatment. The agreement directs SAMHSA to support evidence-based, self-empowering, mutual aid recovery support programs that expressly support Medication-Assisted Treatment in its grant programs.

Youth Prevention and Recovery lnitiative.—The agreement includes funding for activities outlined in House Report 117-403.

Stay tuned for more on how this legislation will play out in the coming year.

Also in our sights: the the Part 8 NPRM from SAMHSA (see https://atforum.com/2022/12/samhsa-proposal-update-methadone-regulations/).