Throughout the past decade, the U.S. has seen a dramatic shift in addiction medicine research, clinical practice, and related stigma in seeking care. In a pair of blog posts, we will explore the top six trends related to treating the opioid crisis. And we’ll consider what may be next.
The Opioid Epidemic
Opioid addiction has existed for centuries. But deaths from opioid overdose in the U.S. have rapidly risen since the 1990s. This started as prescription opioids were prescribed more liberally for pain. A second wave of overdose deaths begin in 2010 with a rapid increase in deaths involving heroin. Then a third wave arrived in 2013, with an increase in deaths involving synthetic opioids, particularly fentanyl. In 2017, the U.S. federal government declared the opioid epidemic a public health emergency. Deaths have continued to climb, reaching as many as 128 everyday. And now, the opioid epidemic is has been made much worse by the COVID-19 pandemic.
With this context, let’s look at three trends that are driving improvement in treating the opioid crisis.
Trend 1: Medication for Opioid Use Disorder is Now the Standard of Care
The U.S. Food and Drug Administration (FDA) has approved three medications for treatment of opioid use disorder (OUD): methadone, buprenorphine, and naltrexone. Medication for opioid use disorder (MOUD) (previously referred to as medication-assisted treatment, or MAT) is now the evidence-based standard of care for treatment of OUD. You can read more about these medications in a previous post here at The Medical Care Blog.
For many decades, abstinence-only treatment, alongside behavioral health support was the de facto standard of care. This was largely due to the absence of evidence-based guidelines. However, the Substance Abuse and Mental Health Services Administration (SAMHSA) and American Society of Addiction Medicine (ASAM) have now taken authoritative stances that medication is the standard of care. MOUD has clear superiority as a first-line treatment when compared to behavioral intervention only. This ultimately paves the way for holding providers accountable for MOUD. And payers will need cover these services for patients.
The necessity to follow national and external standards of care was reaffirmed in Wit v. United Behavioral Health, a 2019 federal court decision in the Northern District of California. In this case, United Behavioral Health (the largest managed behavioral healthcare organization in the U.S.) rejected the insurance claims of thousands of patients seeking treatment for mental health and substance use disorders. The judge ruled that United Behavioral Health’s self-produced medical review criteria were flawed and did not meet generally accepted standards of care. The judge’s ruling further confirmed that standards of care are defined by medical societies through their guidelines, such as at ASAM.
Trend 2: Formalization of the Addiction Medicine Specialty
The past decade has seen dramatically increased focus on the field of addiction medicine, culminating in formalization of the addiction medicine specialty. In 2018, the Accreditation Council for Graduate Medical Education (ACGME) formally recognized addiction medicine as a subspecialty overseen by the American Board of Preventive Medicine. This allowed fellowship programs in addiction medicine to finally gain accreditation. Furthermore, by joining the ACGME, addiction medicine fellowship programs are now eligible to receive money from the Centers for Medicare and Medicaid Services (CMS). CMS allocates federal funds for graduate medical education.
As more physicians have become board certified, this has facilitated research and faster practice improvement. For example, we’ve seen the evolution of micro-starts, the process of starting medication at very low initial doses. We also now understand that stopping medication treatment is not necessary when patients undergo medical procedures. Disease and treatment nomenclature has also improved. For instance, we have transitioned from “substance abuse” to “substance use disorder” and from “medication-assisted treatment (MAT)” to “medication for opioid use disorder (MOUD).” This helps people understand that medication is part of treatment (not assisting treatment), and also decreases stigma.
Trend 3: Expanding the Availability of MOUD
There have been extraordinary restrictions on MOUD prescribing. Methadone can only be dispensed from specially licensed treatment programs where patients report daily. Providers can only administer extended-release naltrexone on-site. Buprenorphine is the only medication that patients can take home, but prescribers must complete buprenorphine training to become “waivered.” And buprenorphine is the only medication with a limit on the number of patients a clinician can treat at once. These overly-restrictive buprenorphine regulations have accordingly evolved in recent years:
- The Drug Addiction Treatment Act of 2000 allowed waivered physicians to treat 30 patients at a time. After one year, physicians could apply to SAMHSA to treat 100 patients.
- The Comprehensive Addiction & Recovery Act of 2016 expanded the definition of “qualifying other practitioner”. It allowed nurse practitioners and physician assistants to become waivered.
- In 2016, SAMHSA released its final rule on MOUD. It allowed physicians to request approval to treat up to 275 patients after prescribing at the 100 patient limit for one year. Clinicians have to be board certified in addiction medicine or addiction psychiatry, or provide MOUD in a qualified practice setting.
- The Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act of 2018 allowed clinicians to treat up to 100 patients in the first year of holding a waiver, if they met the above criteria.
On January 14, 2021, the U.S. Department of Health and Human Services announced that buprenorphine waivers would no longer be required to prescribe for up to 30 patients at once. However, neither SAMHSA nor the DEA have supported this. It is not in the federal register and does not have an effective date. The announcement was likely premature, but is part of a trend toward relaxing MOUD restrictions.
Much Improvement, but a Long Way to Go
These three trends–recognizing MOUD as the standard of care, formalizing the addiction medicine specialty, and expanding the availability of MOUD–reflect considerable progress in addressing the opioid epidemic. As a result, the treatment of OUD is gradually starting to look more like treatment of other chronic conditions.
But there’s still a long way to go. First, it’s crucial that HHS and every state regulatory body allow the prescription of buprenorphine without additional restrictions. Because education is vital to treating patients with addiction, as is the case with all medical conditions, this must be included in health professional education, rather than compulsory training from SAMHSA. And further, removal of patient caps for providers would significantly increase access to lifesaving MOUD. Lifting these restrictions would allow the U.S. to be more effective at treating the opioid crisis.
In our next post, we’ll review trends related to incarceration and MOUD, harm reduction, and the role of telehealth in addressing the opioid overdose crisis.
Latest posts by Rebekah Rollston (see all)
- Treating the Opioid Crisis: Current Trends and What’s Next, Part 2 - February 18, 2021
- Treating the Opioid Crisis: Current Trends and What’s Next - February 11, 2021
- After COVID-19, We Must Build Back Better - August 20, 2020
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