Effective treatments for opioid addiction using medications are being arbitrarily denied to patients by government and insurance companies, a comprehensive report from the American Society of Addiction Medicine (ASAM) shows. The report, prepared by Suzanne Gelber Rinaldo, Ph.D., of the Avisa Group and A. Thomas McLellan, Ph.D., of the Treatment Research Institute, is a scathing review of state Medicaid policies and private insurance coverage of medication-assisted treatment (MAT). The report was released in conjunction with a June 20 summit on MAT, sponsored by ASAM, in Washington, D.C.
Methadone, buprenorphine and naltrexone (including the extended-release form) are the only three medications approved by the Food and Drug Administration for the treatment of opioid addiction. Using them could help reverse the epidemic of opioid addiction and overdose deaths. But due largely to stigma, access to these medications is frequently and tragically denied.
Relapse rates for addiction, a chronic disease, are similar to those for other chronic diseases such as diabetes and hypertension, the report shows. Treatment for addiction is best managed by a combination, including behavioral interventions and medications, depending on the patient.
For the report, the researchers reviewed 642 reports on medication-assisted treatment and surveyed insurance companies and state Medicaid plans. “These reports show that we could be saving lives and effectively treating the disease of addiction if state governments and insurance companies remove roadblocks to the use of these medications,” said Stuart Gitlow, M.D., president of ASAM. “Treatment professionals need every evidence-based tool available to end suffering from this chronic disease. State lawmakers and insurance company administrators would never deny needed medication to people suffering from other chronic diseases, like diabetes and hypertension. But it happens every day to people with addiction.”
Long-term, not short-term, MAT
A key finding of the report is that the medications show clear evidence of effectiveness only when they are used on a long-term basis. There is little evidence that they are effective when used on a short-term basis. Yet that is exactly what policymakers in various states are trying to do — limit dosages, cap the time in treatment and, in some states, not have any coverage for treatment with certain medications at all.
Private insurance companies and state Medicaid agencies were reluctant to provide clear information on coverage of opioid addiction medications, according to the researchers. And the restrictions can be very complex.
“The fact that patients are frequently denied access to the full spectrum of treatment options for addiction is unethical and would constitute malpractice in other medical specialties and chronic disease treatment,” said McLellan. “This needs to be acknowledged by the treatment community, medical specialties, insurance companies and all levels of government.”
“There weren’t too many surprises in the findings,” said Nicholas Reuter of Reckitt Benckiser. “There are issues in the ways these medications are reimbursed,” he said. “And the literature review showing that the medications are cost-effective as demonstrated by peer review, that they keep people engaged in treatment, that they reduce criminality — that wasn’t surprising either.”
But the problem is getting the word out to policymakers and insurance companies. The report showed that, in fact, many people making Medicaid decisions aren’t aware of the medications, the differences between them and how they are used. They think that if something works on a long-term basis, it can work on a short-term basis — while there is absolutely no evidence to indicate that.
But what if policymakers are given the information but don’t want to believe it? “I’m not sure what else can be done,” said Reuter. “They’re all out there making short-term decisions with limited budgets. Those elements might reduce their ability to have careful reviews.” Stakeholders need to be available as resources to policymakers so they can see what the data say, he said. “They need to support this mission financially,” said Reuter.
The next step is informed guided advocacy to make sure policymakers have information available. “What ASAM heard at the summit is that we’re in a good position to do that,” he said. “They have chapters in every state, they can advocate that medications are effective and that arbitrary term limits are not.” And they can produce patients as advocates, as they did at the press conference announcing the report.
Insurance companies have different ways of paying for the three medications, noted Reuter. Vivitrol is often covered in the medical benefit stream because the injection must be administered by a physician. Buprenorphine, which is prescribed, is usually handled as a pharmacy benefit. Methadone is often carved into the carve-outs with a bundled reimbursement, with medication and medical services combined in one rate. “It’s been that way for a while,” said Reuter. “It would make sense if there were better communication among those silos to make those decisions.”
The report did not say that any one of the three medications was better than another, which may presage a new era in which Alkermes, which makes Vivitrol (extended-release naltrexone); Reckitt Benckiser, which makes Suboxone (buprenorphine-naloxone); and generic companies making methadone, generic buprenorphine and newer versions can all work together instead of competing for patients. “I got all three of them together at the ASAM meeting and said, ‘You have common interests; it’s time you formed an association of MAT organizations,” Rinaldo told ADAW.
Many states and insurance plans seem more generous toward buprenorphine than methadone, something that was known at the Substance Abuse and Mental Health Services Administration (SAMHSA) for years, said Reuter, who was at SAMHSA until joining Reckitt this year. “The individual differences between methadone and buprenorphine are tiny,” he said. The main difference is that buprenorphine can be prescribed by an office-based physician, while methadone can’t. But that one little difference completely influences how states include the medication in their benefits.
Another difference is whether patients get the extra services they need, such as counseling, said Reuter. In opioid treatment programs (OTPs), the only place where methadone can be dispensed for the treatment of opioid addiction, counseling is required. But that is not the case for buprenorphine or naltrexone — even though the evidence shows that counseling is essential to treatment. “There’s no consistency about counseling,” said Reuter.
“ASAM, SAMHSA and NIDA emphasize that it’s absolutely necessary to have counseling and other services with MAT,” said Reuter. “It’s required when methadone is done in OTPs.” But when physicians prescribe buprenorphine, all they need to do is certify that they have the capacity to refer patients to treatment. “The trick in regulating this is that people need different levels of these services, as they transition through treatment, so you can’t write that in a rule,” said Reuter. Once someone has been in MAT for years and is completely stable, counseling may not be necessary.
For the full report, go to www.asam.org/docs/advocacy/Implications-for-Opioid-Addiction-Treatment.
Medication-assisted treatment is effective when provided on a long-term basis, but states and insurance companies are denying access to it, according to a scathing report from the American Society of Addiction Medicine.