WASHINGTON -- States need to do more to get patients with opioid addiction on to medication-assisted treatment (MAT), experts said Monday at an event sponsored by the American Medical Association (AMA).
"MAT [is] the gold standard," said Joel Ario, JD, managing director at , a consulting firm that worked with the AMA to issue a . "It's [a] very important part of treatment in many or most cases.... [We need to] remove barriers to MAT that insurers or Medicaid agencies put up."
Access to MAT could be improved if providers were paid more for prescribing it, said Jocelyn Guyer, also a managing director at Manatt. "Eliminating barriers to MAT is critical. What does that mean? We should not be seeing a lot of prior authorization paperwork requirements."
A key part of increasing the number of providers willing to prescribe MAT "is review of reimbursement rates for providers, to make sure they have compensation for the work they're doing," she added, noting that MAT works best if the patients using it also are being connected to social services to help them with housing, employment, and other issues.
Another barrier to MAT is providers who only prescribe abstinence therapy. "Some states are saying, 'We are unable to reimburse you with Medicaid funds if you're not practicing the gold standard of providing MAT, or at least connecting people with it,'" Guyer said.
Although there are federal limits on the number of patients for which a particular physician can prescribe MAT, those limits haven't really proven to be much of a problem, Guyer told ľֱ. Instead, "state Medicaid agencies typically have the opposite challenge" in which the doctors who are allowed to prescribe MAT are prescribing it to far fewer patients than they legally can do. "I have seen Medicaid agencies become more focused on how [they] support [their] providers going up to that maximum number."
Susan Kansagra, MD, Chronic Disease and Injury Section Chief at the North Carolina Department of Health and Human Services, said her state is trying to increase the number of physicians who have received the 8-hour training required to be allowed to prescribe MAT. "One way is to incorporate that 8-hour training into residency programs, so a physician graduating is already receiving that training." For physicians already in practice who want to receive the training, the state provides a number they can call with their prescribing questions.
AMA President Patrice Harris, MD, an Atlanta psychiatrist, agreed with these approaches, within limits. "We support providers in going up to the number that's appropriate [for them] ... Providers each have their own practice communities and their own patient load," she said. "The key is supports to allow physicians to incorporate this into their practice as they see fit, and as it meets the needs of their patient population."
Increasing access to MAT was only one of the report's six recommendations. Ario highlighted the five others:
- Enforcing mental health parity laws. "They have been out there for a number of years, but many people will tell you [they aren't] particularly well-enforced."
- Enhancing provider networks. "It's one thing to say that the laws require [addiction treatment] to be covered; it's another thing to say there are available providers and available networks."
- Improving pain care. Limiting opioid prescribing "doesn't help a lot for people with pain if there aren't alternatives available.... I hear doctors say, 'Gee, it's easy to find opioids but harder to find alternatives.'"
- Expanding access to the overdose-reversal drug naloxone. "There are standing orders in most states; you can just walk into any pharmacy [for it] ... but in some pharmacies it's still not available."
- Evaluating the treatments. "There is a lot of money flowing to help with this issue, but we've got to look at what works and doesn't work."
Harris cautioned, however, that efforts to address the opioid crisis should not deprive patients who truly need opioids from receiving them. "I am hearing that patients who have chronic pain cannot get access to medications they need; this is a huge issue," she said. "There are also unintended consequences of many who have misinterpreted the CDC's [pain management] guidelines. Our guidance remains that the decision to treat or not treat remains between patients and their physicians."
"We certainly don't want patients who have pain to suffer, and we [also] want to make sure physicians prescribe judiciously, and to make sure patients have equitable access to non-opioid and non-pharmacological alternatives," she continued, noting that "if medication requires a $10 copay and physical therapy requires a $50 copay, that's not equitable."
Sustainable funding is also important for combatting the crisis, said Kansagra, who noted that her state had received $75 million in federal funds -- not a lot of money given the problem's scope. Moreover, "those funds are coming in 1- and 2-year grants, so that's not a way to build in a sustainable structure through the long term," she said.
While North Carolina officials are pleased with the way some of their programs are working -- such as peer support counselors to speak with overdose patients in the emergency department -- "we need a sustainable source [of funding] for many things to come," Kansagra said.