Despite millions in federal funding to combat the opioid crisis and task forces developed to study it at both the state and city level here, not much has changed. The crisis continues unabated here, and overdose deaths soar. Why?
Some of the expanded services incorporate treatment philosophies that create barriers to long-term medication assisted treatment, when evidence shows that restricting access to maintenance medication increases overdose deaths.
Additionally, current Medicaid rules for reimbursement are inadequate to support the costs of a robust medication assisted treatment (MAT) program. Funding is not based on clinical disease treatment models, and there is no compensation for nurses — the backbone of opioid clinics.
Also, enrollment in Medicaid overall remains an issue. The majority of the most marginalized citizens — the homeless and those re-entering society after incarceration — are not enrolled in Medicaid despite a bill passed last session that assures in theory, but not in practice, presumptive eligibility for Medicaid.
The treatment van operated by the Behavioral Health Leadership Institute provides buprenorphine treatment to people leaving jail, and the majority have no Medicaid when released. We need better outreach linking people to Medicaid. Yet, last year, the state failed to increase funding for case management to assist with Medicaid enrollment.
Perhaps, the problem is that the issues are so overwhelming, it is difficult to know where to start. A path forward must be based on guiding principles for action, such as:
- Addiction is a disease and not a moral disorder or a crime.
- Evidence and best practices are essential. The gold standard is long-term medication treatment on demand using flexible and individualized treatment plans.
- Education about prevention, treatment and the complexity of this devastating disorder is a necessary component of developing and implementing an effective treatment system.
- Access to treatment must be broad and barrier-free. Systems must include a multitude of entry points available for entering and maintaining treatment. We must also eliminate barriers to Medicaid enrollment.
- There must be a plethora of flexible services and programs to meet individualized and changing needs of clients.
- Funding should be made available to maximize the sustainability of effective treatment models rather than modifying services to maximize funding. Funding should support evidence- based models by rewarding outcomes, innovation and quality care.
Consistent with these guiding principles, funding should be made available to develop a comprehensive system of services.
- “Safe spaces” for people who continue to use drugs but who also want to reduce their risk. They need a place to go that can be accessed by self-referral or through a case manager, a health provider or the police.
- Needle exchange programs in several locations.
- A multitude of first tier, low-threshold, on-demand treatment programs.
- A second tier of low-threshold substance use treatment programs that offer, but do not mandate, a variety of counseling options and peer support groups tailored to patient needs and preferences.
- A third tier of primary care providers/clinics that provide comprehensive treatment, including medication maintenance.
- A package of financing reforms to including presumptive Medicaid enrollment, increases in case management funding and incentives for housing programs to support in-house medication treatment.
- Services for people who are incarcerated, recently released, living on the street or homeless shelters. Services should be provided by using mobile or other innovative low-threshold interventions.
- Prevention interventions including a curriculum to provide education about the nature of the disease, the medication and the brain. Mental health clinics in the schools should be included in trainings on these issues and given toolkits to work with students of all ages.
- Improved data collection and data-sharing systems where data is related to improving programs and evaluating outcomes. Also needed are protocols for sharing across the relevant agencies to allow coordination of care and support surveillance efforts.
We have the means to create a new model that offers hope for recovery. We must do it. Now.
Deborah Agus (firstname.lastname@example.org) is executive director of the Behavioral Health Leadership Institute. Also contributing to this op-ed are BHLI board members: Lenny Feldman, Jay Unick, Richard Boldt, Charon Burda, Michael Fingerhood, Tom Marshall and Haneefa Saleem.