It’s nice to see that the author can clearly identify many of the problems. Things will work better for us when our legislative bodies do so
by Shannon Firth,Washington Correspondent, MedPage TodaySeptember 21, 2018
WASHINGTON — Despite numerous barriers to expanding access to treatment for opioid use disorders, bright spots are emerging, said clinicians, government officials, and policy experts at a workshop here.
Efforts to reduce stigma, properly train and reimburse physicians, and target special populations are underway, participants said. But they are currently falling short of the need.
“Of the estimated 2.1 million people with opioid use disorder, only 30% of those individuals received treatment at a specialty facility or private doctor’s office,” said Mark McClellan, MD, PhD, director of the Duke-Margolis Center for Health Policy, citing the recently released 2017 National Survey on Drug Use and Health from the Substance Abuse and Mental Health Services Administration (SAMHSA).
A lack of physicians trained to intervene, reimbursement problems, and stigma, all contribute to the low rates of treatment, said Janet Woodcock, MD, director of the Center for Drug Evaluation and Research at the FDA. (The workshop was hosted by the Duke-Margolis Center for Health Policy under a cooperative agreement with the FDA.)
But “the major problem … is that medical treatment is often not even tried,” she said.
“Failure to attempt treatment for a disease that is often fatal — that’s not something you see very often in medical care.”
On the one hand, there aren’t enough providers willing to treat patients with opioid use disorders. On the other, many patients with opioid use disorder don’t believe they need treatment, suggested experts at the workshop.
Panelists at the all-day workshop unpacked both sides of this issue — access to willing providers and engagement in care from reluctant patients — citing a web of complex factors including stigma, both external and internal, lack of provider training, lack of resources, and patients’ own fears.
Stigma often gets in the way of people seeking help for substance use problems or continuing treatment, said Sharon Stancliff, MD, associate medical director of the Harm Reduction Coalition for the AIDS Institute.
When the public calls opioid users “junkies” who are “immoral” and “responsible” for their own illnesses, that discourages would-be patients.
Finally, the all-too-common refrain that patients who use methadone or buprenorphine are “substituting one addiction for another” frustrates Edwin Salsitz, MD, associate clinical professor of psychiatry at the Icahn School of Medicine at Mount Sinai in New York City.
Physical dependence is not necessarily equal to addiction, he said, and stigma around evidence-based treatment for opioid use disorder does a disservice to patients.
One way to mitigate stigma is to raise awareness of success stories, through social media as well as in-person visits, for example, by former patients to the clinics where they first received treatment, Stancliff said.
Pregnant women with opioid problems are easy targets for stigma.
Universal screening for opioid use disorders is recommended by the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics. But Kaylin Klie, MD, founder of the Denver Health And University of Colorado OB Addiction Medicine clinics stressed that such screening should occur in the form of a conversation and not a demand for a urine sample.
Many women fear that if their opioid use is detected, they will lose custody of their children, which is not an irrational concern, Klie said.
“Some states have laws that protect women[‘s] toxicology information in pregnancy from being used in criminal charges, but child custody happens at the civil court level, not criminal,” she wrote.
Twenty-three states and the District of Columbia consider substance use during pregnancy to be child abuse, and 24 states and D.C. require healthcare providers to report “suspected prenatal drug use.” However, 17 states and D.C. give pregnant women “priority access” to drug treatment programs funded by the state, according to the Guttmacher Institute.
Still, research has shown that despite being a “priority” population, pregnant women in most states are not receiving treatment at higher rates than non-pregnant individuals.
Sarah Wattenberg, director of quality and addiction services at the National Association for Behavioral Healthcare, said payment policies are the biggest barrier to opioid use disorder treatment.
Some payers don’t cover medications for all forms of opioid use disorders, some don’t pay for the full continuum of providers, and some won’t pay for a sufficient number of counseling sessions a patient — despite research finding that counseling helps people stay in treatment. Payers can also limit medication duration, forcing patients to taper them in a “dangerous” way, she said.
One common problem is that the payment for office visits is insufficient to support the time required to diagnose and treat patients, explained Shawn Ryan, MD, MBA, president and chief medical officer for BrightView, an outpatient addiction medicine practice.
The American Society of Addiction Medicine and the American Medical Association jointly designed an alternative payment model, the Patient-Centered Opioid Addiction Treatment, which incentivizes non-face-to-face services including phone calls and email consultations and aims to improve care coordination among specialists, outpatient treatment programs, and other health providers.
The outpatient model involves a one-time payment for initiation of MAT along with monthly payments for maintaining both medical and psychosocial aspects of care.
Each physician’s practice is measured based on factors such as the percentage of patients who comply with their treatment plan and the risk-adjusted average number of opioid-related emergency department visits per patient.
Ryan views payment innovation as an urgent need, arguing that without proper reimbursement, physicians (many of whom already have heavy case loads) aren’t going to take the time to assess and treat patients with opioid use disorder.
Education, Provider Awareness
A final barrier to reducing stigma is physician and clinician awareness.
“We really have to get all health professionals to be able to screen, diagnose, and, if not treat, refer” patients with opioid use disorders, Kathryn Cates-Wessel, CEO and executive director of the American Academy of Addiction Psychiatry, told MedPage Today after speaking at the workshop.
She highlighted one initiative, the Providers’ Clinical Support System for Medication Assisted Treatment, which provides training in identifying and treating patients using MAT, as well as prevention of opioid abuse. Physicians can receive buprenorphine waivers for free and listen to webinars and podcasts.
The group also provides free mentoring either one-on-one or in a group, focused on specific clinical cases or other issues, and advice seekers can also post questions on a discussion forum anonymously, monitored by addiction specialists.
A second program run though a SAMHSA State Targeted Response-Technical Assistancegrant provides even more comprehensive, on-the-ground technical support from a pool of physicians with experience in MAT, recovery, and prevention.
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