Now more than ever, we need a sensible, unified, national response to the opioid epidemic; a response that recognizes the gravity of the situation and the reality that opioid use disorder (OUD) is a chronic – and treatable – condition.
While there are many preventive measures that could pay dividends down the line, such as abuse-deterrent formulations for prescription opioids and reducing the length of opioid pain treatment, there are approximately 2.6 million Americans with OUD. These are real people who need help now. Macro-level public health initiatives, such as expanding Medicaid to ensure coverage of all evidence-based treatments for OUD, are a direct and logical route to address the opioid epidemic.
OUD is treatable. Currently, three evidence-based treatments are recognized by the medical community as effective:
- Buprenorphine is a maintenance medication that can be prescribed by specially licensed office-based physicians. It is available in oral, sublingual, and depot-injection (long-acting for 1 or 4 weeks). It is also sometimes used in combination with naloxone.
- Methadone is an effective maintenance medication that has been used for decades, but requires daily visits to specialty clinics.
- Extended-release naltrexone is an opioid blocker and anti-craving medication that can be prescribed by any physician, although it is underutilized.
Unfortunately, these treatment options can be costly, and there are large geographic discrepancies in availability of medication-assisted treatments for OUD.
The Affordable Care Act and Mental Health Parity and Addiction Equity Act included special provisions aimed at treating substance use disorders like other chronic illnesses. Perhaps the most important aspect of these laws was to expand Medicaid, which currently covers about 73.5 million Americans. Yet states that were resistant to Medicaid expansion under the Affordable Care Act tend to cover fewer treatment options and have more barriers to OUD treatment.
In some states, Medicaid does not cover some medication-assisted treatments. States can leave medications off their Preferred Drug Lists, which makes it extremely difficult for persons on Medicaid to get access. Indeed, there are 20 states that do not cover methadone, 19 states that do not cover extended-release naltrexone, and only 13 states that cover all medical options for substance use disorders via Medicaid. Not covering certain treatment options drives underutilization of OUD treatment.
Expanding Medicaid to cover all forms of OUD treatment might be the simplest and most effective way to get people into treatment right now. It is hard to imagine restrictions on medications for other chronic diseases (like restricting insulin for diabetes), but many states have adopted policies that make it less likely that persons with OUD will get into treatment.
People at lower socioeconomic positions are at greater risk of OUD, and often cite barriers to treatment, such as lack of insurance or means to pay for treatment, as a significant barrier to recovery. Out-of-treatment individuals with OUD are already a vulnerable population, and in a recent survey of prescription opioid misusers, my colleagues and I found that about 23% of respondents were uninsured. This is nearly double the national rate.
As the opioid overdose death rate continues to rise, only about 20% of people that need OUD treatment actually receive it. Public health officials should be thinking about how Medicaid, among other resources, could help close the treatment gap for the remaining 80% of persons with OUD.
Part of the argument against expanding Medicaid is ideological; some lawmakers argue that we need less government involvement in our health care system and that free market forces will ensure that Americans have affordable options for health insurance. This line of thinking is fundamentally flawed, as the health care market does not behave like other markets, mainly because the barriers for market entry are incredibly high and there is practically no transparency regarding price at the time of treatment.
In an attempt to curtail Medicaid enrollment, some states are now calling for a work requirement to gain access to Medicaid, arguing that many of the people that benefited under Medicaid expansion are capable of working and therefore the government should require they work to gain access to health care. Kentucky will be the first state to implement the work requirement, while Arkansas, Arizona, Indiana, Kansas, Maine, Mississippi, New Hampshire, Utah, and Wisconsin have all applied to implement the work requirement. Only Kentucky, Arizona, and Kansas would not exempt people in treatment for substance use disorders, but it is unclear how states would define treatment and whether there would be time limitations or contingencies on this exemption.
Regardless, a recent study of Medicaid expansion in Michigan found that only a small portion of Medicaid enrollees are physically able to work yet remain unemployed, and including a work requirement would disproportionately affect vulnerable populations, such as those with chronic disease or functional limitations.
The federal government’s plan to combat the opioid epidemic remains unclear under the current administration, as talk of addressing the epidemic is undermined with legislation and policy aimed at shrinking Medicaid enrollment. Research has shown that Medicaid expansion is linked to increased utilization of buprenorphine to treat OUD, and many women rely on Medicaid coverage for access to treatment while pregnant. Likewise, individuals with OUD are more likely to use health services if they have insurance and medication-assisted treatments are locally available and reimbursed.
The national opioid crisis will not go away on its own, and lip service will not solve the problem. Government policies can make a substantial impact, and the nationwide public health response should include coverage of medical treatments for all individuals that suffer from OUD. Expansion of Medicaid is probably the most straightforward and effective means to reach out-of-treatment persons with OUD.
By increasing the number of individuals eligible for Medicaid, public health initiatives can more effectively attract individuals to OUD treatments. At the same time, increasing Medicaid coverage for medication-assisted treatments – both the number of treatment options covered and the duration of coverage – would help to increase treatment adherence as individuals could be matched to treatment regiments that are guided by physicians instead of insurance companies.
There are few other ways to curb the incidence of OUD and the rate of opioid overdose deaths in the United States aside from getting more people into treatment. Until our lawmakers recognize that the only way out of the opioid epidemic is through a paradigm shift in our approach to healthcare coverage, this health crisis will continue to devastate Americans from all walks of life.
[Ed. note: This blog post is an extended version of this Letter to the Editor from the author, published ahead-of-print on Feb. 2, 2018.]