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15 Articles in Volume 18, Issue #5
Chronic Pelvic Pain: The Need for Earlier Diagnosis and Diverse Treatment
Cross-Linked Hyaluronic Acid for the Management of Neuropathic Pelvic Pain
Fentanyl: Separating Fact from Fiction
Gender Bias and the Ongoing Need to Acknowledge Women’s Pain
Letters to the Editor: 90 MME/day Ceiling; Ehlers-Danlos; Redefining Pain
Post-Menopausal MSK Pain and Quality of Life
PPM Welcomes Dr. Fudin and Dr. Gudin as New Co-Editors
Practitioner as Patient: Understanding Disparities in CRPS
States Take Action to Manage Opioid Addiction
Step-by-Step Injection Technique to Target Endometriosis-Related Neuropathic Pelvic Pain
The Many Gender Gaps in Pain Medicine
The Need for Better Responses to Vulvar Pain
Topical Analgesics for Chronic Pain Conditions
Topical Medications for Common Orofacial Pain Conditions
What’s the safest, effective way to taper a patient off of opioid therapy?

States Take Action to Manage Opioid Addiction

Model programs that address gaps in professional training, treatment access, and insurance coverage are popping up across the country.

With Lindsey Vuolo, JD, MPH, Paul George, MD, MPHE, Josiah Rich, MD, MPH, and Jeff Gudin, MD

By now, the numbers are familiar but still sobering. Every day in the United States, 116 people die from opioid-related overdoses, including not only prescribed opioids, but also illicit and pharmaceutical fentanyl, as well as heroin, counterfeit drugs, and the mixture of drugs that often lead to fatalities.1 These deaths are just part of the opioid epidemic problem, of course. In 2016, more than 2 million Americans had an opioid use disorder, and another 2 million misused prescription opioids for the first time.1

The opioid crisis is being fought on federal and state levels, with the US Department of Health and Human Services (HHS) focusing efforts on five priorities:

  • Improving access to both addiction treatment and recovery services (view PPM's new PainScan Lit Review on this subject)
  • Promoting the use of medications such as naloxone to reverse overdose
  • Strengthening the understanding of the epidemic through better public health surveillance
  • Providing support for cutting-edge research on pain and opioid addiction
  • Advancing better pain management practices.2

To help the states wage war on the opioid crisis, HHS released a second round of funding in April 2018. In all, 57 grant awards totaling $485 million were parceled out to 50 states, four US territories, and the free associated states of Palau and Micronesia.3 These grants were in addition to the nearly $900 million in opioid-specific funding issued in fiscal year 2017, to states, local governments, and civil society groups.4 Known as the Opioid State Targeted Response Grants, the funds were made possible by the 21st Century Cures Act. The Substance Abuse and Mental Health Services Administration (SAMHSA) within HHS administers the grants, and by September, new funding from a separate $1 billion grant is expected to be awarded.3

While a successful program to combat the crisis has numerous components, three areas are often mentioned by experts as crucial for individual states to address and for practicing physicians to know about. These include: professional training; access to treatment and recovery; and insurance access and coverage.

As the states’ efforts accelerate, and programs become operational, “clinicians are being forced into changing behavior,” said Jeff Gudin, MD, director of pain management and palliative care at the Englewood Hospital and Medical Center in New Jersey and incoming Co-Editor-at-Large for PPM. States’ efforts are already translating into clinical practice changes, he said. For instance, in his state, a new law mandates that prior to an initial prescription for opioids the physician have a discussion with the patient about the risks and alternative treatments.5

Following is a look at the three key ways states are working to improve opioid addiction, misuse, and overdose challenges, including highlights of some model programs.

Professional Training

Professional medical training must include opioid addiction facts, experts concur. “For doctors, the issue has long been that they get little training in medical school about addiction, how to screen for it, how to manage it,” said Lindsey Vuolo, JD, MPH, associate director of health law and policy for the Center on Addiction (formerly the National Center on Addiction and Substance, Abuse), a national nonprofit devoted to solutions for the US addiction crisis.

She was the lead author of a comprehensive report from the center, titled “Ending The Opioid Crisis: A Practical Guide for State Policymakers,” released in October 2017.6 The report lays out what needs to be done, with examples of model programs interspersed throughout.

The challenge is particularly difficult, said Vuolo, for primary care providers (PCPs) managing a large population of patients with a wide range of health conditions. They lack the extent of day-to-day experiences that many pain specialists encounter. However, pain specialists, too, even those who see large numbers of patients for addiction issues, face snags.

According to the Center on Addiction, professional training should educate healthcare professionals to be capable of predicting risky substance use and addiction, and include prevention, intervention, treatment and management; how to handle co-existing conditions; and how to work with populations with special needs, such as incarcerated individuals with co-existing mental health problems, repeat offenders, and juveniles.

Professional training must be provided not only to already licensed physicians, the Center report suggested, but also to physician assistants, nurses, nurse practitioners, dentists and clinical mental health workers. The training, if it is to be effective, must be mandated and made a condition of not only licensure but also for continuing education (CE) credits. In addition, non-healthcare professionals, such as educators, law enforcement, and criminal justice personnel, should be educated about substance use and addiction.6

Another important part of professional training, Vuolo said, is learning how to effectively screen patients and knowing when to provide brief interventions, as well as referrals for treatment – a process known as SBIRT. “Patients should be having that [SBIRT] with any encounter with the healthcare system,” Vuolo said.

Model Training Programs

Vuolo pointed to a program at Brown University as a model of professional training. “They are integrating a comprehensive training program for providers,” she explained. The program also offers opportunities for CME and CEU credits, said Paul George, MD, MHPE, assistant dean for medical education and associate professor of family medicine and medical science at the university’s Alpert Medical School.

Dr. George said the program, launched in September 2016, has “integrated more than 24 hours of curriculum around substance misuse/opioid misuse into our curriculum. Beginning with the MD class of 2019, all students who graduate from Alpert Medical School will be data waiver trained and be able to provide medication-assisted treatment (MAT) in Rhode Island.”7 He further noted that the program has been well received not only by students but also by key stakeholders such as the Rhode Island Department of Health, patients and physicians. The program includes annual faculty training on opioid misuse, tailored to healthcare workers from a wide variety of professions, he said—including nurses, pharmacists, and social workers. More than 200 health professionals per year have attended.

Overcoming physicians’ resistance to data waiver training will be a crucial step, added Josiah (Jody) Rich, MD, MPH, professor of medicine and epidemiology at the Alpert Medical School and director of the Center for Prisoner Health and Human Rights at The Miriam Hospital in Rhode Island. Dr. Rich is a long-time advocate of, and expert on, public health policy changes to improve the lives of those with addiction.

As for SBIRT, SAMHSA currently funds 32 state cooperative agreements.6 One noteworthy program is its own partnership with Northwell Health and the New York State Office of Alcoholism and Substance Abuse Services, which incorporates SBIRT into Northwell’s primary care practices and emergency departments. The goal is to build a model so that SBIRT can be incorporated into healthcare settings that may be replicated throughout the state.

Access to Treatment

The Center on Addiction report included quite a blunt statement about treatment: “Most individuals who receive addiction treatment do not receive evidence-based care or do not receive it in sufficient intensity and duration to promote long-term recovery.”6

The number of facilities offering substance abuse services is vast—more than 14,500, according to the National Institute on Drug Abuse.8 However, the quality of those programs varies widely, and patients and their caregivers often do not know how to search effectively. They rely heavily on the internet or word of mouth, often avoiding requests for a referral by their pain specialist or primary care physician and often finding less than reputable centers.9

In 2016, a grand jury in Palm Beach County, Florida, issued a report citing offenses that reflect nationwide problems with accessing addiction treatment. Among the issues, the report found, is that online marketers would route callers to inept or even dangerous centers, sometimes resulting in not just ineffective treatment but, in rare cases, human trafficking.9

Effective, evidence-based care, according to the Center on Addiction, should include:

  • Comprehensive assessment to develop an individualized treatment plan
  • Stabilization and detox as a precursor to treatment
  • Pharmaceutical and/or psychosocial therapies
  • Chronic disease management after the treatment course
  • Comprehensive support services.

Improvement can only occur, the Center report concluded, if the approach includes increasing treatment capacity and helping people find it, increasing the availability of MAT and improving quality of care, including recovery.6

“We treat people with this disease horribly,” said Dr. Rich. “We have effective therapy but we are not rolling it out [effectively]. Can you imagine having a patient come in with a heart attack and saying, ‘Here is the number for rehab. You need to call’?”

Physicians who want to do better by their patients “can get the data waiver training,” he added. Physicians registered with the US Drug Enforcement Administration as practitioners may apply to be qualified as a Data Waiver Physician, or DWP, to conduct maintenance and detoxification treatment using specifically approved Schedule III, IV, or V medications. Under the 2000 Drug Addiction Treatment Act (DATA), physicians need eight hours of training to get the waiver to prescribe and dispense buprenorphine, for example.10 “That’s the number one thing they can do. They can also find out where the methadone treatment [center] is in their community. We have a lot of people who would benefit from getting on MAT. We need to find them, wherever they are, and make sure the MAT is high quality.”

Among ways to improve access, the Center report authors suggested, are to require all healthcare professionals in all states to receive addiction care training, including training in providing MAT. A loan-forgiveness program could be used as an incentive to encourage providers to serve as addiction treatment providers, at least for a certain period of time (some early-stage Congressional bills propose this type of program).6

Model Treatment Access Programs

The moment an addicted person decides to get help is a pivotal time, as healthcare providers know. If patients and their families are unsure where to turn, the desire to seek help can vanish quickly. To seize this window of opportunity, several states have created resources available on demand, 24/7.6

In 2018, Maryland will create a crisis treatment center available every day, 24 hours a day. It will set up a Health Crisis Hotline to help callers get screenings and referrals. Massachusetts Behavioral Health Access bed finder, a website, helps practitioners find available capacity in addiction treatment and mental health programs. In New Hampshire, the state’s Health and Human Services Department Statewide Addiction Crisis Line operates 24 hours as a resource for professional counselors to find emergency care, treatment programs, support groups, MAT services, and more. In addition to a 24-hour hotline, New Jersey has created a searchable online directory of treatment services through its Division of Mental Health and Addiction Services.6

In Connecticut, Yale New Haven Hospital launched a buprenorphine program to start treatment in the emergency department after an overdose, negating the need to wait for a referral to treatment. These patients were more likely to stay in treatment, the experts involved found than those who got a brief intervention or referral after their overdose.11 Every dollar spent on MAT saves society $1.80, research shows.12

Vermont stands out as well, noted Vuolo, due to its “Hub and Spoke” model. “It’s really fantastic,” she said. The state’s Care Alliance for Opioid Addiction uses the model, which focuses on expanded access to MAT while creating a framework to integrate treatment services via a managed care approach. The hubs provide methadone treatment programs and the spokes serve as outpatient providers that prescribe buprenorphine. The model also provides home healthcare services. The payoff? The state’s capacity to provide MAT rose by about 50% in a year-and-a-half and patients were more likely to stay in treatment.13

Coverage and Insurance Challenges

Providing comprehensive insurance coverage for MAT is crucial to increase access to the quality and quantity of care needed. Inability to pay is a chief reason those with addiction issues do not get care.14

The Affordable Care Act and the Mental Health Parity and Addiction Equity Act are the two major federal laws that protect those seeking addiction treatment that is covered by health insurance. “On paper, the laws hold promise,” said Vuolo. However, while the laws are federal, the primary authority to enforce them lies with the states. And the reality of parity is not optimal, she explained. What’s needed instead, she offered, is prospective regulatory review to better enforce the law and protect patients’ rights. Vuolo is hopeful that the Parity at 10 Campaign, a multi-year effort, will change the situation. “We are currently working in five target states and one of the goals of the campaign it to improve education about the parity among providers,” she said. Among the other organizations are the Kennedy Forum and Partnership for Drug-Free Kids.15

Even with the legislation intact, and the states defining benefits by identifying an Essential Health Benefits (EHB) benchmark plan, no plan offers coverage of all the critical addition benefits, according to the Center on Addiction’s own survey.6 So that is, obviously, a major recommendation—that states select an EHB benchmark plan with good and thorough coverage of the benefits known to work for addiction care.

Among the numerous other suggestions for improving access to care and insurance coverage is outlawing prior authorization for treatment admission and MAT. Some headway has occurred. In 2017, for instance, Aetna dropped requirements for physicians to obtain prior authorization from the insurer before prescribing medication to treat opioid addiction. The change applies to all of the company’s private insurance plans.16 In a 2017 letter to the National Association of Attorneys General (NAAG), the American Medical Association encouraged all attorneys general to work with insurers to end prior authorization on MAT.17 Also, the American Academy of Family Physicians (AAFP) adopted a policy in 2017 urging correction of the problem of prior authorization.18

Model Insurance Coverage Programs 

New Jersey prohibits the use of prior authorization both for FDA-approved medication to treat addiction and for the first 180 days of addiction treatment deemed medically necessary, both inpatient and outpatient, at in-network facilities.6

In Virginia, Medicaid managed care plans and behavioral health organizations must use the ASAM Criteria when they complete assessments to get the appropriate level of care and when recommendations are made about the length of stay in a residential treatment center.6

Moving Forward

While there has been progress by the states, it is clearly not yet enough, according to the National Safety Council, who issued a report in April 2018, finding that seven states were failing in efforts to address the opioid crisis, 30 lagging, and just 13 improving.19 The “report card’’ was based on how each state measured in six key areas, including prescription drug monitoring programs, prescriber education, and treatment of overdoses.

Even so, with a variety of organizations — including the Center on Addiction, the National Safety Councils — continuing to monitor and track progress and to provide concrete actions known to stem the epidemic, the hope is that things will continue to improve nationwide.

Last updated on: March 1, 2019
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