The nation's top public health officials have joined in a call for expanded availability of medication-assisted treatment (i.e. methadone, buprenorphine, and naltrexone) to address the illegal use of heroin and prescription opiates.
In a commentary published in the New England Journal of Medicine on April 23, 2014 ("Medication-Assisted Therapies — Tackling the Opioid-Overdose Epidemic"), Nora D. Volkow, M.D., of NIDA; Thomas R. Frieden, M.D., M.P.H., of the CDC; Pamela S. Hyde, J.D., SAMHSA; and Stephen S. Cha, M.D., Center for Medicaide and CHIP Services, write:
"When prescribed and monitored properly, MATs have proved effective in helping patients recover. Moreover, they have been shown to be safe and cost-effective and to reduce the risk of overdose. A study of heroin-overdose deaths in Baltimore between 1995 and 2009 found an association between the increasing availability of methadone and buprenorphine and an approximately 50% decrease in the number of fatal overdoses.3 In addition, some MATs increase patients' retention in treatment, and they all improve social functioning as well as reduce the risks of infectious-disease transmission and of engagement in criminal activities. Nevertheless, MATs have been adopted in less than half of private-sector treatment programs, and even in programs that do offer MATs, only 34.4% of patients receive them.4
"A number of barriers contribute to low access to and utilization of MATs, including a paucity of trained prescribers and negative attitudes and misunderstandings about addiction medications held by the public, providers, and patients. For decades, a common concern has been that MATs merely replace one addiction with another. Many treatment-facility managers and staff favor an abstinence model, and provider skepticism may contribute to low adoption of MATs.4 Systematic prescription of inadequate doses further reinforces the lack of faith in MATs, since the resulting return to opioid use perpetuates a belief in their ineffectiveness.
"Policy and regulatory barriers are another concern. A recent report from the American Society of Addiction Medicine describing public and private insurance coverage for MATs highlights several policy-related obstacles that warrant closer scrutiny. These barriers include utilization-management techniques such as limits on dosages prescribed, annual or lifetime medication limits, initial authorization and reauthorization requirements, minimal counseling coverage, and “fail first” criteria requiring that other therapies be attempted first (www.asam.org/docs/advocacy/Implications-for-Opioid-Addiction-Treatment). Although these policies may be intended to ensure that MAT is the best course of treatment, they may hinder access and appropriate care. For example, maintenance MAT has been shown to prevent relapse and death but is strongly discouraged by lifetime limits.5
"In addition, although Medicaid covers buprenorphine and methadone in every state, some Medicaid programs or their managed-care organizations apply the utilization-management policies described above. Most commercial insurance plans also cover some opioid-addiction medications — most commonly buprenorphine — but coverage is generally limited by similar policies, and access to care may be limited to in-network providers. Few private insurance plans provide coverage for the depot injection formulation of naltrexone, and most do not cover methadone provided through opioid treatment programs.
"Implementation of the Affordable Care Act (ACA) will increase access to care for many Americans, including persons with addiction. This expansion builds on the Mental Health Parity and Addiction Equity Act, which requires insurance plans that offer coverage for mental health or substance-use disorders to provide the same level of benefits that they do for general medical treatment. The ACA significantly extends the reach of the parity law's requirements, ensuring that more Americans have coverage for mental health and substance-use disorders and that coverage complies with the federal parity requirements. These reforms present new opportunities for reducing prescription-opioid abuse and its consequences by expanding the number of high-risk people who receive MATs through either public or private insurance. The importance of access to MATs and other treatment services for substance-use disorder is underscored by the recent recognition of increased heroin use; what may be less widely recognized is that the majority of these new heroin users initially abused prescription opioids before shifting to heroin."
The full text of the commentary is available from the New England Journal of Medicine.