By Joshua Sharfstein, MD, and Zachary F. Meisel, MD, MPH, MSHP
One of the unfortunate realities of the opioid epidemic is that some of the most heavily advertised services offering addiction treatment actually provide little in the way of evidence-based care and may actually increase the risk of fatal overdose. These are residential programs that fail to provide access to opioid agonist medications, shown to reduce the risk of fatal overdose by 50% or more. Instead—perhaps because of misunderstanding, incapacity, or stigma—these facilities force participants to withdraw from opioids, which leads to the loss of tolerance and a higher risk of death in case of relapse.
Desperate individuals and their families may perceive these risky programs as the gold standard of care. That’s what Elise Schiller, a Pennsylvania woman and author of a memoir about her daughter’s fatal overdose, recalled she thought when her major insurance carrier referred her daughter, Giana, into care. The young woman had to stop taking buprenorphine to get admitted to the residential facility and tragically died of an overdose shortly after discharge.
In addition to such profound and tragic consequences, there are significant economic costs of low-value (or no-value) care. The many millions of dollars paid by families, employers, and private and public insurers to these facilities represent resources that could have been spent on treatment based on evidence and other support services. A recent workshop at the Leonard Davis Institute of Health Economics at the University of Pennsylvania, sponsored by the Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV (CHERISH), explored a variety of paths to recouping this investment by reducing the use of ineffective care.
Educating the Public
One foundational approach is to educate the public about what works and what does not for treatment of opioid use disorder. That’s a key goal of investigative journalism, government websites, and books (including one coauthored by one of us). Exposés of outright fraud have led to probes by state attorneys general, federal investigations, and new state laws, as well as to changes in Google and Facebook advertising policies. But many programs that fail to follow the standard of care remain in the market, with warnings by health authorities alone unlikely to reach and persuade many families at the moment they are desperate for assistance.
An additional strategy is for accrediting and certifying agencies to refuse to endorse programs that do not offer medications and other essential services. Low-value programs now show “seals of approval” to hesitant patients and families; removing these endorsements might cut into their marketing success.
Such a step, however, is easier said than done. There are multiple sets of standards offered by different accrediting and certifying agencies, including the Commission on Accreditation for Rehabilitation Facilities and the Joint Commission; treatment programs can choose from among them. These agencies, which receive regular fees from programs they accredit or certify, are unlikely to lead in establishing strong standards. Indeed, accredited and certified programs commonly offer well-known but unproven types of care for opioid use disorder, such as “detox.” Moreover, some accrediting agencies have been quite open to promoting nontraditional modalities of care—even “dolphin-assisted psychotherapy” for opioid use disorder.
Recently, the American Society of Addiction Medicine (ASAM) has begun taking steps to encourage residential treatment facilities to offer medications for opioid use disorder. The standards for ASAM’s level of care certification program, which will be rolled out later this year by the Commission on Accreditation for Rehabilitation Facilities, will require treatment facilities to offer at least 2 forms of medication for opioid use disorder to achieve certification. Since certification through this standard will be voluntary, it is likely that residential facilities that do not offer medications will still be able to find some other type of credential claim.
A third strategy is to use the power of the purse. Public and private payers have a strong economic incentive to invest in treatment shown to be cost effective. Still, it has been challenging to cut off reimbursement for low-value or no-value care. A key reason may relate to the local treatment environment. A residential facility that does not provide evidence-based treatment may be the only provider in a region. The facility may feature “testimonials” from individuals who oppose the use of proven medications and other forms of evidence-based treatment (a phenomenon also commonly seen with suspect medical products). Another promising effort is ongoing work led by the organization Shatterproof to develop a consensus set of quality standards (including access to medications and other evidence-based care) that could be adopted by payers as standards for reimbursement.
A fourth approach is the most aggressive: states can move to revoke the licenses of programs that do not offer medications or other vital services for opioid addiction. Many such programs are licensed today. Without standing as a treatment program in the state, however, many residential facilities would find their accreditation and certification, as well as reimbursement, very much at risk. The threat of loss of licensure could lead many to reconsider their opposition to medications or close down altogether.
However, even more intensely than payers, states face political obstacles to change. For example, legislators with strong ties to residential facilities opposed to medications for treatment may threaten state agencies with budget cuts or worse. In one state, the ties between residential facilities and state officials were so close that it was alleged that the director of the addiction agency relied on a lobbyist to vet key hires.
Signs of Change
Despite these challenges, there are signs of change. In 2015, the Obama administration required that drug courts receiving federal funds not send patients to programs that refuse to accept patients who were taking medication for opioid use disorder. California recently passed a law specifying that residential treatment programs cannot be licensed if they refuse to admit someone “solely based on the individual having a valid prescription for [treatment] medication.” Massachusetts has adopted a standard that requires programs receiving state funding to facilitate “access to medication assisted treatment whether in conjunction with existing treatment, or as a transition from one level of care to another.” As another example, Missouri health officials have instituted a policy to stop contracting with treatment providers that do not “offer or arrange for” the appropriate use of medications for opioid use disorder.
The urgency of reducing low-value or no-value care for opioid disorder is matched by the complexity of the US treatment system. No single organization or agency can solve the problem by itself. The solution is for health agencies, private insurers, accrediting agencies, patient advocates, and others committed to progress on the opioid epidemic to each do what they can to accomplish this goal.
Bolstered by the emerging ASAM standard, accreditors and certifying agencies should pledge to phase out seals of approval for programs that do not meet core requirements. Public and private payers should announce the goal of ending support for residential facilities that do not offer opioid agonist medications, such as buprenorphine or methadone. More states should use the regulatory process to codify these improvements in licensing. The guiding principle in such efforts should be to save lives, not to punish long-standing programs that have yet to catch up with the evidence. As a result, states should offer technical assistance and resources to existing programs to help them transition quickly to more effective approaches to care.
Transforming a treatment system is not easy. There are substantial practical and political obstacles. But success will be measured in dollars well spent—and lives saved.
About the authors:
Joshua M. Sharfstein, MD, is Vice Dean for Public Health Practice and Community Engagement at the Johns Hopkins Bloomberg School of Public Health. He previously served as Secretary of the Maryland Department of Health and Mental Hygiene, as the Principal Deputy Commissioner of the US Food and Drug Administration, and as Commissioner of Health for Baltimore. He is also a consultant to Audacious Inquiry and to Sachs Policy Group. A pediatrician, he lives with his family in Baltimore. (Image: Chris Hartlove)
Zachary F. Meisel, MD, MPH, is associate professor of Emergency Medicine at the University of Pennsylvania, where he directs the Center for Emergency Care Policy and Research and codirects the Penn Injury Science Center. He also leads Policy and Dissemination for the Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV (CHERISH). He has written regularly for Slate and Time.com. He lives with his family in Philadelphia. Image: Hoag Levins/University of Pennsylvania
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