What’s Next? Coming to Grips with America’s Addiction Crisis

While the TV pundits dissect the implications of a split Congress and politicians begin jockeying for 2020 – I wondered what it means for families and communities struggling with the biggest public health crisis of our time? 

The addiction crisis affects 1 in 3 American families and the latest estimates suggest that it cost the American economy almost $1 trillion annually. In addition, the rise of opioids is cited as one of the possible reasons that, despite a booming economy, 500,000 millennial men remain unemployed - creating the distinct possibility of a lost generation. The 72,000 overdose deaths last year – most, but not all of which involved opioids, have drawn so much attention; yet deaths related to alcohol, claiming more than 88,000 Americans last year alone, have gone largely unnoticed. The over-prescribing and over-reliance on medications that drove the opioid epidemic continues with benzodiazepines, stimulants and now marijuana. So, before the politicians lay out their agendas for the coming two years, I call on them – local, state and federal – to make sure the addiction crisis in America remains front and center. While the recently signed SUPPORT Act, a compilation of 70 bipartisan bills that broadly addressed addiction, from prevention to recovery support, will soon take effect – this public health crisis is far from resolved. We need to build on the momentum and bipartisanship the SUPPORT Act generated to address this crisis comprehensively and fund those programs appropriately. 

What Does that Mean? 

Consumer protection

For the past few years, Caron has worked for change in the treatment sector to address the ethical issues that hurt both patients and providers alike, while advocating for standards of care that finally treat substance use disorder as the chronic disease it is. One of the key changes made by the SUPPORT Act extends anti-kickback protections beyond federal health care benefit programs like Medicaid to other health care benefit plans that cover most Americans. This is important to this effort. “Eliminating Kickbacks in Recovery” prohibits kickbacks and bribes in return for referring patients to recovery homes, substance use disorder (SUD) treatment providers, or labs. This closes a loophole that allowed for serious breaches of trust between patients, providers, and payers. Another important bill included in the SUPPORT Act subjects those services that engage in unfair or deceptive practices while purporting to provide SUD treatment, referrals to treatment, or recovery housing to Federal Trade Commission (FTC) enforcement. Caron has been calling for these measures. We’re grateful to see them enacted, but we need to see these provisions enforced.  

IMD Exclusion Issues (Still)

Designed to keep Medicaid recipients from being treated in massive mental health institutions, the IMD exclusion was originally intended to keep states from using Medicaid dollars to pay for care at facilities with more than 16 beds. But because much of America’s capacity to provide inpatient or residential addiction treatment comes from facilities with more than 16 beds, the IMD exclusion had the unintended consequence of keeping many Medicaid recipients from receiving the level of care their disease required. 

While the SUPPORT Act included an IMD exclusion revision, it limits SUD treatment to 30 days within a 12-month period. We know that 30 days is not enough time to effectively treat this complex, chronic disease – and so does the government. The National Institute on Drug Abuse advises, “Generally, for residential or outpatient treatment, participation for less than 90 days is of limited or no effectiveness, and treatments lasting significantly longer often are indicated.” The IMD Exclusion needs to be eliminated entirely to improve access to treatment and to provide the tools necessary to maintain recovery.

Inclusive Best-Practice-Setting

To transform the sector and improve long-term outcomes for patients, SUD treatment providers, including Caron, have called for the standardization of best practices to ensure safe, ethical, and quality addiction treatment and support for recovery maintenance. We urge HHS to ensure that a variety of SUD treatment providers and recovery residence operators are included in the process. As standards of care are developed and implemented, treatment providers need to be included in the discussions. We have valuable, first-hand knowledge about the issues confronting patients and families, substance use patterns and trends, we know what works clinically and what gaps to look for in the continuum of care that can impact recovery. As providers, we have insight into the effects and potential unintended consequences that standards and policies have on patients and treatment. Providers have practical understanding of the evidence-based treatment modalities and best practices in use today. We bring expertise that is absolutely critical to the development of actionable standards.

Prevention Education K-12 and Universal SBIRT

We can make a difference in preventing teenage substance use from developing into a lifelong disorder, but we must collectively stop treating underage drinking and drug use as healthy experimentation or a rite of passage. America must invest in evidence-based prevention education and substance use screenings for at-risk youth. We know from the CDC’s Monitoring the Future Study and our own Student Assistance Program that prevention programs work. Caron also advocates for and incorporates into its prevention programming Screening, Brief Intervention, and Referral to Treatment (SBIRT) with ninth graders. Launched in 2008 by SAHMSHA, SBIRT is a universal evidence-based model that provides early intervention. It has been used to evaluate more than one million at-risk youth for substance use and has the potential to make a significant difference in reducing more serious SUDs. Providing education and intervention programs are more cost-effective than the long-term costs of substance use. We encourage further funding and implementation support in this area of prevention.            

Parity enforcement

Parity, which requires comparable coverage by health insurers to pay for behavioral health and SUD treatment as it does for other diseases, celebrated its 10th Anniversary this year. Yet, there is still a disconnect in coverage for treatment. Parity laws need to be enforced. 

We Need Treatment

Ask any public health official for the challenge most constraining America’s response to the opioid crisis and they’ll give you three words: access to treatment.

Ninety-percent of those who meet the criteria for SUDs don’t get treatment. Reasons for that range from the symptoms of the disease to social stigmas—many are complex and societal in nature. But there are actions government can take to help. As I wrote last year, “We need to make the most successful solutions available to as many people as possible. That means building our approach around improving the availability of proven, outcomes-driven, evidence-based treatments and making it possible for anyone facing addiction to get treatment for it.”  Right now, there are people who want treatment but can’t get it because there aren’t enough providers to treat them at their appropriate level of care or they can’t pay for the treatment they require, or both. If our goal is to save lives, we can’t ration the life preservers. With nearly 200 people dying daily from this preventable and treatable disease, we need to do everything in our power to get more people into treatment – now.

It is a long road ahead to provide the fundamental shift in policy we need to truly address America’s addiction crisis. That shift is going to require funding coupled with comprehensive and cohesive policy changes that target the root of the epidemic and widen the bandwidth for treatment.

Caron will continue advocating for these changes, just as we continue to push from within the treatment sector for widespread adoption of the best practices and standards of care that give patients the best chance in recovery.