The urgency of the opioid epidemic is now recognized at a national level, but states have been dealing with the issue for years. Neither of the two most prominent federal responses—prescription drug monitoring programs (PDMPs) to discourage the inappropriate prescribing of opioids, and use of naloxone to reverse overdoses—is treatment. But the third response, as detailed in a March announcement from the U.S. Department of Health and Human Services (HHS) on how to approach the epidemic, is medication-assisted treatment (MAT) with methadone, buprenorphine and naltrexone, a strategy that a small group of states has already embraced.
“States see the urgency of any problem more quickly than the federal government,” either the executive branch or Congress, says Rob Morrison, executive director of the National Association of State Alcohol and Drug Abuse Directors (NASADAD). It just takes more time for the federal government to respond to a problem. The slowness at times is “frustrating, exasperating, and exhausting,” Morrison admits.
“States can’t wait,” he says. “They have to move, they have to act, they have to deal with what they see on the ground.”
At the federal level, there is a proposed $40 million spending cut for the Substance Abuse and Mental Health Services Administration's (SAMHSA's) Center for Substance Abuse Treatment (CSAT) for fiscal year 2016. “That’s tough messaging to absorb during a time when we’re facing such a challenge,” says Morrison.
However, HHS Secretary Sylvia Burwell has made addressing the opioid crisis a priority, with additional funding for treatment. There is an additional proposed $25 million for opioid addiction treatment, and MAT would constitute an allowable use of this money. There also is a proposed increase of $10 million for prescription drug abuse prevention. While this isn’t enough money, says Morrison, no proposed budget has ever been able to address the true demand.
Having Michael Botticelli as director of the Office of National Drug Control Policy (a Cabinet-level official who used to run the treatment system in Massachusetts) also benefits the field greatly, says Morrison. Botticelli has repeatedly championed the use of MAT. “That helps make treatment a priority,” says Morrison.
In January 2013, NASADAD issued a consensus statement, signed by all state directors with authority over the federal Substance Abuse Prevention and Treatment block grant, endorsing MAT. It was an important clinical statement, sending a message to providers across the country that methadone, buprenorphine and naltrexone are the appropriate evidence-based treatments for opioid use disorders. NASADAD earlier this year issued an opioid fact sheet as well.
Addiction Professional spoke this month with two state directors with authority over the block grant who have managed innovative approaches to treatment of opioid use disorders. Mark Stringer, director of the Division of Behavioral Health in Missouri, oversees efforts that focus on oral naltrexone and the injectable formulation Vivitrol, but that also use buprenorphine and, in the opioid treatment programs (OTPs), methadone. We also talked to Barbara Cimaglio, deputy commissioner for the Vermont Division of Alcohol and Drug Abuse Programs, who has overseen an ambitious program to get every Vermonter who needs treatment for opioid use disorders into either an OTP—the only type of facility that can provide methadone—or an office-based treatment program that uses buprenorphine.
Missouri and Vivitrol
“We embraced MAT early on in our public system,” says Missouri's Stringer. “All of our providers are providing at least oral naltrexone and Vivitrol; some are also providing buprenorphine, with methadone provided by our opioid treatment programs.”
Providers are encouraged to choose the treatment that best suits the patient, says Stringer. “In this field, we have a sad track record of everybody getting the same thing—we’ve really tried to avoid that.” Some opioid treatment patients maintain on buprenorphine, while some eventually switch to Vivitrol and then to oral naltrexone.
“We’re training providers to be open,” says Stringer. “We try to get them to think about addiction in modern terms.” Like schizophrenia, addiction is a brain disease, he says. If the first medication tried for a patient with schizophrenia doesn’t work, “You don’t just throw up your hands and say, ‘You fail,’” he says.
Every year Missouri treats about 45,000 people with substance use disorders. But there are still 2,500 people on waiting lists now, says Stringer. “It would be hard to say what we’re doing is working, because we don’t have enough of it.”
Why isn’t more treatment funded? “I wish I knew the answer,” says Stringer. “That is one of the biggest tragedies.” In Missouri, there has been a significant push to educate healthcare providers and others to get engaged in treatment of opioid use disorders. “But what we’ve failed to do is to fund the treatment services to support it,” he says.
Stringer’s advice to fellow state directors in terms of getting money for treatment is to collaborate with other state agencies. “I’ve been able to get funding for medications that we didn’t have before,” he says. “Missouri’s economy is doing OK, but you wouldn’t know it from the alcohol and drug abuse budget.”
Medicaid offers a major source of funding, especially for expensive medications such as Vivitrol. Missouri didn’t expand Medicaid, however.