Effective Opioid Recovery Is Unobtainable for Many: Urgent Action Is Needed
Drug overdoses have surpassed car crashes as the number one cause for accidental death in America, with a staggering 47,000 lives lost to addiction in 2014 alone. However, the systems largely responsible for combatting the disease of opioid addiction – public policy, insurance and criminal justice - are just beginning to publicly address the problem, and in some cases, even hinder the pursuit of safe and effective treatments.
One step forward in the fight against opioid addiction occurred just this July, when the Comprehensive Addiction and Recovery Act (CARA) was passed by Congress and signed into law by President Barack Obama. While it is by no means a permanent solution, CARA represents a desperately needed push in the right direction. Unfortunately, the bill has only received $37 million through the continuing resolution funding measure – far short of the $181 million specified in the bill and even further below the threshold of what’s needed to keep pace with the scope of the opioid epidemic. It is absolutely essential that this legislation be fully funded to succeed—the funds that, as of now, it has been denied.
Even worse, existing healthcare budgets are left with the burden of repeated futile attempts at defeating the disease of addiction without the most effective means to treat it.
But the treatment does exist. Many who need it just can’t get it.
Medication assisted treatment, or MAT, is the use of FDA-approved medicine in concert with behavioral counseling for opioid addiction that has proven efficacy. Multiple studies have shown that MAT is essential to effective long-term recovery, by reducing cravings and the risk of fatal overdose and increasing abstinence and time in treatment. And we have known this for a long time. In 2003, a multicenter clinical trial published in the New England Journal of Medicine (NEJM) found that buprenorphine reduced the craving to use an opiate by roughly 50 percent and increased the odds of not taking an opiate by about 3.5 times. MAT is the widely accepted and scientifically proven method for successfully treating opioid addiction – and the National Institute on Drug Abuse, the World Health Organization, UNAIDS and many other physician groups all recommend it as the standard of care.
However, despite the wealth of scientific knowledge surrounding MAT, public and private insurance barriers prevent many from getting access to treatment. They set up a series of redundant hurdles including, but not limited to, preauthorization, buprenorphine quantity limits, network requirements, step therapy requirements and duration limitations. In many cases, patients are forced to ‘fail first’ using an alternate treatment before they can begin the application process for MAT, even though the existing data tells us that MAT is the evidence based care according to clinical guidelines.
Only 3 percent of physicians in the entire country are even certified to prescribe recovery medications such as buprenorphine, and these physicians are placed under a restriction mandating that they can only treat up to 275 patients at a time. This means that, assuming a person has managed to navigate the web of prerequisites and qualify for MAT, they’ll still end up sitting on a waiting list for weeks, months or over a year before they can start treatment. The heartbreaking truth is that too many people are dying while waiting to access treatment.
In a recent IMS Health Institute report commissioned by Advocates for Opioid Recovery, we examined how medication assisted treatment is used and paid for by each individual state and found that coverage is inconsistent and suboptimal in many parts of the country. The share of MAT prescriptions paid for by state Medicaid programs ranges from less than 5 percent in Alabama, Florida, Mississippi, and Utah to 68 percent in Vermont. The huge variability is an indicator of the erratic decision-making around MAT.
Moving forward, public and private insurers need to start covering substance use disorder treatment programs that incorporate both medicine and behavioral therapy. No insurer could get away with refusing coverage for cholesterol medication or post-injury physical therapy, yet that is what is happening with opioid addiction. No one suffering from a substance use disorder should be forced to wait for an insurance decision or be required to do counseling alone first, when the harsh reality is that the cost of the delay to recovery medication could be a fatal overdose.
Lastly, drug courts must allow and encourage these same treatment programs. As recently as last year, some drug courts banned the use of treatment with medicine, requiring defendants to cease treatment for their addiction before going to court. Once again, we are astounded at the blatant disregard for the proven science behind these programs. While there has been recent progress to remove these outright bans in federally-funded drug courts as well as innovative programs being piloted in the criminal justice system, the cultural change is slow. The combination of some judges’ personal bias and the fear of the recovery drugs ending up on the streets instead of for their intended use is hindering medically-necessary treatment.
The urgency of the opioid crisis demands that we act immediately to remove the barriers to recovery medication, and give people living with addiction the treatment they need to survive, and ultimately thrive, in long-term recovery.