It appears that the more than 650 psychiatrists and other health professionals who attended this month’s American Academy of Addiction Psychiatry (AAAP) annual meeting are expending more energy trying to excel in the current drug treatment system than projecting whether a new system altogether might soon emerge.
Prospects of major policy shifts under a new president and Congress affected but did not dominate the discussion at the Dec. 8–10 AAAP annual meeting in Bonita Springs, Fla. “There was more of a push to understand the current system, so that providers can be more effective regardless of what might happen in the future,” Carla Marienfeld, M.D., an addiction psychiatrist and co-chair of the AAAP’s Program and Scientific Committee, told ADAW.
Discussions at the conference conveyed a sense that the opportunity of the Affordable Care Act (ACA) has not been fully realized for many individuals with substance use disorders, and that too few people in need have access to the most evidence-based treatment approaches, particularly medication treatments for opioid use disorders.
“Although coverage rates have dramatically improved for some populations, many patients with severe [substance use disorders] have yet to receive care due to lack of providers and a fragmented treatment system,” Arthur Robin Williams, M.D., fellow at the Columbia University Division on Substance Use Disorders and a conference co-presenter, told ADAW. “Many patients with [opioid use disorders] who receive treatment do not receive evidence-based care with maintenance treatment such as buprenorphine or methadone.”
Thinking more broadly
Marienfeld, an associate professor at the University of California, San Diego, said that while she senses attitudes among physicians shifting, doctors haven’t traditionally seen themselves as agents of understanding the workings of a system of care. “The opioid epidemic represents a really important challenge to the traditional ways of providing care on an individual level,” she said.
Addiction psychiatrists, Marienfeld says, are uniquely positioned to address the commonly seen substance use and mental health comorbidities that integrated approaches to care can successfully treat. That is why there was some disappointment, she said, that the recent U.S. surgeon general’s report on substance use didn’t address the mental health comorbidity issue to a great degree.
More than 650 professionals attended the regular AAAP meeting, with another 200 participating in an addictions and treatment course. Marienfeld said participants were particularly energized by the opportunity to apply current data to their everyday practice needs. Some of the more clinically oriented sessions at the meeting addressed research on attempts to quit cannabis use and progress in understanding how the use of appetitive hormones could assist in the treatment of alcohol use disorders.
The symposium for which Williams copresented was titled “How to Realign the Drug Treatment System Under the ACA in Response to the Overdose Epidemic.” He said that one of the key takeaways from his presentation was that attempts to integrate behavioral health and primary care services might not be sufficient to help individuals with the most severe opioid use disorders and the highest level of disruption in their lives.
“Specialized provider networks such as those developed under Vermont’s hub-and-spoke system and Massachusetts’ nurse care management model likely hold more promise for connecting with patients with [opioid use disorders] and stabilizing their opioid use,” Williams said.
Williams focused his symposium remarks on a systems perspective on the ACA. Other topics addressed by his co-presenters included the integration of medication treatment into systems-based practice, combining medication-assisted treatment and 12-Step approaches, and sociocultural factors that affect access to treatment.
Williams cited several recent statistics that illustrate the magnitude of the overall access problem. He stated that only between 20 and 40 percent of patients with an opioid use disorder have received treatment in the past year. Access to maintenance medications is similarly limited.
In addition, he said that according to a study published this year, “the average patient received buprenorphine for only 53 days despite the evidence suggesting buprenorphine maintenance of a minimum one to two years is most effective at preventing relapse.”
What the future holds
Asked what he communicated to the AAAP audience about what it could expect from an incoming administration that has vowed to dismantle the ACA, Williams said that President-elect Trump and his nominee to head the Department of Health and Human Services, U.S. Rep. Tom Price, “both have made comments about giving states more control over experimenting with health care reform.”
Williams continued, “If so, the states can build on prior efforts under Medicaid waivers to loosen restrictions on reimbursement for substance abuse treatment and better incentivize quality care.” Examples of such quality variables could include the percentage of opioid use disorder patients on a form of medication-assisted treatment, or the percentage of patients retained in treatment at six months, he said.
Marienfeld said the conference audience appeared to be mainly focused on the present. Regarding the impact of possible policy shifts in Washington, “It takes a long time for these things to trickle down to everyday changes,” she said.
She added that rather than hearing much buzz about expanded capacity to prescribe buprenorphine, she heard more addiction psychiatrists expressing concern that appropriate education be provided to the physician extenders who now will be allowed to prescribe the medication.
“The increase to 275 [patients] will be meaningful in those systems that are already capable of handling that volume,” Marienfeld said. “An individual physician cannot handle 275 patients on their own.”
With an estimated 1,400 addiction psychiatrists practicing across the country, the AAAP meeting turnout represents a large proportion of the entire discipline. “While we’re getting more attendance, it still feels like a small community of folks getting the opportunity to talk to each other,” Marienfeld said. “This provides a network of support, for people who in some locations are the only addiction specialist.”
Attendees of this month’s annual meeting of the American Academy of Addiction Psychiatry appear focused on maximizing present opportunities in health reform, with many patients still lacking access to evidence-based treatments.