Are we making progress or stuck in neutral with the opioid crisis?
Today’s opioid crisis requires no introduction. The deaths, costs and subsequent lawsuits have become front-page articles for many publications and news outlets. As awareness of the problem has increased, Congress has attempted to positively intervene by reducing legislative barriers and improving funding.
Within the past few years, this funding has come through several important pieces of legislation, including the 21st Century Cures Act (Cures Act), the Comprehensive Addiction and Recovery Act (CARA Act) and the SUPPORT for Patients and Communities Act (SUPPORT Act). These laws have authorized funding through appropriations and grants that exceed $10 billion. While significant money has been spent, many have asked whether we have gone far enough, spent money in the proper areas, and been effective in bending the addiction curve.
Defining what success looks like is critical to understanding whether these investments and legislative efforts have been effective. Providers in the addiction field have described opioid addiction as a “chronic, relapsing disease,” tempering expectations of high success rates. Indeed, publicly and privately reported “success” — defined as freedom from abused substances for at least 12 months after completion of a program — has been in the 10 percent range. To date, no major improvements have been noted in traditional treatment methods and no major breakthroughs have been demonstrated.
Despite the lack of treatment breakthroughs, some encouraging statistics have emerged. Recent provisional data from the Centers for Disease Control and Prevention (CDC) have indicated that overdose deaths likely will drop for the first time since 1990. In addition, prescriptions for opioids in the United States have steadily declined over the past few years.
Although we cannot, and should not, ignore the mounting numbers of Americans who have died from overdoses, it is important to understand that those who died represent just the tip of the iceberg. Patients who fall in the spectrum of dependence and misuse of opioids cost the health care system significant amounts of money. Employers in areas hardest hit by the opioid crisis can have difficulty finding employees and frequently suffer because of high rates of absenteeism, reduced productivity at work, and increased health care costs.
When looking at the magnitude of these issues, previous federal government agency reports have indicated that for every one person who dies of opioid use, there are 825 people who misuse opioids.
Through a variety of actions by Congress and the Department of Health and Human Services over the past 20 years, providers have gained the ability to treat patients in their offices with medications designed to help reduce the impact of the opioid epidemic. The focus of most of these actions has been on the use of buprenorphine, which has broad support, from addiction physicians to the Surgeon General.
These changes are in contrast to traditional treatment in facilities known as Opioid Treatment Programs (OTPs). OTPs have significant regulatory burden and primarily have provided treatment through methadone clinics, although many now offer other treatments including buprenorphine. Moving towards office-based opioid treatment (OBOT) has allowed patients seeking treatment to obtain care in their doctor’s office, expanding access.
Recently, the SUPPORT Act required the Centers for Medicare and Medicaid Services (CMS) to expand coverage to include OTPs. Prior to this legislation, patients who received methadone treatment prior to becoming eligible for Medicare would lose coverage for their needed methadone services because Medicare did not have appropriate coverage of methadone in the OTP setting. CMS responded to the requirement from Congress by creating bundled payments for not only methadone treatment but also buprenorphine treatment. This recognized the growing number of patients moving to office-based opioid treatments.
Unfortunately, the SUPPORT Act came short of allowing for truly innovative changes. CMS noted in its final rule for 2020 that it does not have regulatory authority to remove copays and deductibles for patients receiving office-based opioid treatment, but does have regulatory authority to do so under the SUPPORT Act for opiate treatment programs — which in many cases are methadone clinics. This created a hierarchy of treatment modalities by removing financial disincentives for patients if they chose to seek methadone treatment at an opiate treatment program, as opposed to buprenorphine (or other) treatments at an office-based treatment program.
It is important to note that medical literature does not support methadone as a superior treatment over buprenorphine or other office-based treatment.
We are making progress with curbing the U.S. opioid crisis, but there is still significant work to be done. Future efforts must ensure that the most effective treatments are being supported and that providers and patients are free to choose the best individualized treatment plans without undue outside influence, whether financial or legislative.
Finally, Congress needs to evaluate the effectiveness of money spent to date on the problem, identifying areas where success was achieved as well as areas of needed improvement.
Dr. Adam Bruggeman is a spine surgeon in Texas, board certified in both orthopaedic surgery and addiction medicine. He is president of the Texas Orthopaedic Association. He founded NuHope in 2018, an outpatient opioid and pain treatment center. Follow him on Twitter @DrBruggeman.