RECOMMENDATION 14
Enhance Medicaid Support for Evidence-Based Treatment
More than 20 million people in the United States—roughly 7.4% of the population over age 12, or 1 in 14 people—are estimated to have a substance use disorder (SUD). Drug overdose is the leading cause of injury death among Americans; in 2018, 67,367 people died from a drug overdose. Two out of three fatal drug overdoses involve a licit or illicit opioid, but researchers and law enforcement are identifying worrisome trends in other drug fatalities as well. From 2012 to 2018, for example, the rate of overdose deaths involving cocaine tripled, and the rate of death involving psychostimulant drugs such as methamphetamine increased five times over. These statistics do not include the thousands of people who die every year from alcoholism and alcohol-involved incidents.
Figure 2: Overdose Deaths by Drug
The criminal justice system weathers the heaviest impacts of this toll. Some studies have estimated that roughly two-thirds of the U.S. prison population suffers from some form of SUD, and that an additional 20% were under the influence of a substance at the time of their crime. Ensuring justice-involved people have access to evidence-based treatment services in their communities can help break the cycle of substance use and incarceration. Studies of people on parole have shown that relapse rates improve by 10 to 20% when treatment is continued in the community post-release. Medication-Assisted Treatment (MAT) is a particularly effective regimen that uses FDA-approved medications in combination with counseling and behavioral therapies. MAT programs have shown greater retention in treatment, reduction in illicit opiate use, decreased cravings, and improved social function when compared with behavioral treatment alone. But states face obstacles when expanding treatment capacity in communities, both for justice-involved people and general populations. Current policies restrict both the duration of treatment and the location where it can be delivered. Institutions for Mental Disease (IMDs)—defined as residential mental health and substance use treatment facilities with more than 16 beds—are barred from receiving federal Medicaid funds, limiting the number of treatment slots available to the more than 70 million people covered by the public insurance program. In addition, physicians must obtain special training and certification to prescribe buprenorphine, one of the most effective MAT options; as of 2016, only 4% of physicians qualified to write opioid prescriptions had sought such a license. States seeking to introduce innovative treatment practices must request a waiver (known as an 1115 Waiver) from the federal government for these services to be reimbursed by Medicaid, creating a cumbersome delay in expanding evidence-based responses to a deadly crisis. This Task Force recommendation aims to expand access to evidence-based SUD treatment, including MAT programs. Building the capacity of community health care networks will help fill the deficit of MAT providers and meet the needs of the reentering population. Access to residential and community-based treatment services will help justice-involved individuals recover, build resiliency, and successfully reenter their communities.
Recommendation
Congress should support and incentivize increased access to residential and community-based treatment services that are evidence-based, including expanding access to Medication-Assisted Treatment (MAT) in order to strengthen reentry programs, prevent recidivism, and promote better health outcomes.
Implementation Steps
- Congress should make permanent the SUPPORT Act requirement that state Medicaid programs provide MAT, and expand to an additional 10 states the provider capacity demonstration grants established in section 1003 of the SUPPORT Act to increase access to SUD and recovery services. These grants should build capacity in behavioral therapy, counseling services, and the use of appropriate FDA-approved drugs.
- Congress should increase the quantity and quality of clinically appropriate residential treatment through two changes: expanding the availability of Medicaid-financed treatment for Opioid Use Disorder in IMDs by amending the SUPPORT Act to permit residential treatment for 60 days—rather than 30—each calendar year, and requiring that providers use evidence-based practices and deliver services as part of a full continuum of care.
- Congress should require the U.S. Government Accountability Office to review and report on the quality of and access to IMD services financed by Medicaid, including services funded through 1115 Waiver demonstrations, the state plan option authorized in the SUPPORT Act, and in Medicaid managed-care contracts.
- Congress should make the enhanced Medicaid matching rate for SUD health homes established in section 1006 of the SUPPORT Act available indefinitely for all states, in order to expand access to effective, coordinated community services.
Annotated Citations
De Andrade, Dominique, et al. “Substance Use and Recidivism Outcomes for Prison-Based Drug and Alcohol Interventions.” Epidemiologic Reviews, vol. 40, no. 1, 3 May 2018, pp. 121-133. https://academic.oup.com/epirev/article/40/1/121/4992689 The authors of this study conducted a systematic review of substance use interventions. To support their study, the authors used public health, criminology, and psychology databases. All studies analyzed were from Jan. 1, 2000 and June 30, 2017. In total, the authors chose 49 studies that fit their criteria. Their results suggest that therapeutic communities are effective in reducing recidivism and, to a lesser extent, substance use after release. There is also evidence to suggest that opioid maintenance treatment is effective in reducing the risk of drug use after release from prison for opioid users. Furthermore, care after release from prison appears to enhance treatment effects for both types of interventions.
Bart, Gavin. “Maintenance Medication for Opiate Addiction: The Foundation of Recovery.” Journal of Addictive Diseases, vol. 31, no. 3, July 2012, pp. 207-25. https://www.researchgate.net/publication/230636543_Maintenance_Medication_for_Opiate_Addiction_The_Foundation_of_Recovery Illicit use of opiates is the fastest growing substance use problem in the United States and the main reason people seek addiction treatment services for illicit drug use throughout the world. It is associated with significant morbidity and mortality related to HIV, hepatitis C, and overdose. Understanding that behavioral interventions alone have extremely poor outcomes, with more than 80% of patients returning to drug use, this article studies the long-term treatment viability of three FDA-approved medications: methadone, buprenorphine, and naltrexone. The study’s results indicate that maintenance medication provides the best opportunity for patients to achieve recovery. Methadone and buprenorphine are associated with retention in treatment, reduction in illicit opiate use, decreased cravings, and improved social function. By contrast, systemic reviews of oral naltrexone show that it is ineffective in treating opiate addiction. Naltrexone also showed poorer retention outcomes when compared to the other two maintenance drugs studied.
Downey, P. Mitchell, et al. “The Costs and Benefits of Community-Based Substance Abuse Treatment in the District of Columbia.” District of Columbia Crime Policy Institute and Urban Institute. April 2012. https://www.urban.org/sites/default/files/publication/25481/412584-The-Costs-and-Benefits-of-Community-Based-Substance-Abuse-Treatment-in-the-District-of-Columbia.PDF This report forecasts the annual costs and benefits of community-based substance abuse treatment (CBSAT) in Washington, D.C. The study found that, on average, there is a 55% chance that a CBSAT program serving 150 people would yield benefits that exceed its costs. The median benefit of CBSAT is $615 per person higher than its costs. The authors define CBSAT programs as those that provide treatment in the community for offenders with histories of drug abuse and dependence. Building on research that indicates that CBSAT programs have better long-term outcomes than other methods, such as probation, this report places particular emphasis on the cost benefits for municipalities. On average, preventing one arrest in the District of Columbia generates $72,000 in benefits. Of that amount, the overwhelming portion (86 percent) results from preventing victimization. About $8,900 of the benefits are received by federal agencies (of which $2,800 accrues to the Bureau of Prisons and $1,500 to the D.C. Court Services and Offender Supervision Agency).
Ventura Miller, Holly, et al. “Reentry programming for opioid and opiate involved female offenders: Findings from a mixed methods evaluation.” Journal of Criminal Justice, vol. 46, September 2016, pp. 129-136. https://www.sciencedirect.com/science/article/pii/S0047235216300253 “This study examined the effectiveness of the Second Chance Act Grant funded reentry program for dually diagnosed female offenders involved in opioid and opiate use.” It focused on results from the female cohort of the Delaware County, OH, Transition Program, a reentry initiative funded by the Second Chance Act Co-Occurring Offenders Grant Program. Results from the quasi-experimental model show that program participation significantly reduced recidivism. Focus group interviews indicated that participants responded positively to the program. Moreover, interviews with program participants revealed several findings, including the fact that the pathway to heroin addiction typically began with opioid prescription medication (either licit or illicit). While the study concludes that reentry programs primarily designed for male offenders can also reduce recidivism for female offenders, there are several identifiable challenges that surfaced through the qualitative interviews. The program in question failed to clearly define female-specific components such as trauma-informed care, child-care elements, or parenting classes.
Vestal, Christine. “In Fighting An Opioid Epidemic, Medication-Assisted Treatment Is Effective But Underused.” Health Affairs, vol. 35, no. 6, June 2016, pp. 1052-1057. https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2016.0504 Until recently, most people with addictions have had to rely on treatment by specialists outside of mainstream medicine who focus on abstinence, 12-step programs, and long residential stays. This article highlights the effectiveness and underutilization of Medication-Assisted Treatment (MAT) in tackling the opioid crisis. The author highlights that MAT is often safer than traditional “12-step” programs that lack accompanying medication. Opioid users lose their tolerance when abstaining from drugs, thus making small doses potentially fatal if a relapse occurs. However, the main barrier to the widespread use of MAT is the stigma associated with it, given that the maintenance medications buprenorphine and methadone are themselves opioids. As of the writing of the article, only 4% of physicians qualified to write opioid prescriptions had sought a license to prescribe buprenorphine. As a result, the physicians who do prescribe this effective treatment method lack the resources to meet growing demand. Another significant barrier is that commercial insurance and Medicaid coverage have offered only limited reimbursement for addiction treatment. The Affordable Care Act, however, expanded coverage by requiring providers to cover addiction services, and more than half of states have provided additional support by expanding state Medicaid services to include substance abuse.
Yang, Yang, et al. “Treatment Retention Satisfaction, and Therapeutic Progress for Justice-Involved Individuals Referred to Community-Based Medication-Assisted Treatment.” Substance Use & Misuse, vol. 54, no. 9, 29 April 2019, pp. 1461-1474, https://www.tandfonline.com/doi/abs/10.1080/10826084.2019.1586949?src=recsys&journalCode=isum20 This study examined the influence of client- and counselor-level factors on 90-day treatment retention, satisfaction, and progress for justice-involved individuals referred to Medication-Assisted Treatment. The article looked at several factors that could influence treatment retention satisfaction, including depression, social support, and treatment motivation. By studying these client-level factors, the author found that anxiety and depression were risk factors for treatment outcomes. On the other hand, the data showed that treatment motivation and high levels of social support were protective factors and led to higher levels of treatment satisfaction. The findings of the current study also underscore the importance of social support in enhancing treatment satisfaction, which in turn helps to promote treatment progress. The study concludes by highlighting “the importance of integrated treatment services, collaborating with community corrections, and teaching clients strategies for dealing with deviant peers as to facilitating recovery.”