By Elise Meyer
For the past two weeks, the Northwestern Public Health Review has been posting summaries of the three-point plan that evolved out of an interdisciplinary roundtable meeting of experts on the opioid epidemic response in Chicago. This week marks the last week of the series and, aptly, focuses on recovery.
Recovery is the goal of treatment and key to overcoming the opioid epidemic. The white paper identifies two major areas of focus in recovery: (1) getting to treatment and (2) treatment programs themselves.
Getting to Treatment
Those suffering from substance use disorder (“SUD”) “face a range of obstacles preventing them from entering or gaining access to treatment.” Therefore, it is essential to implement procedures and programs that overcome these barriers and work effectively to connect those suffering from SUD to treatment services. Three important methods of connecting individuals with SUD to treatment discussed in the white paper are screening, pre-arrest diversion, and post-arrest interventions.
Screening refers to a process whereby health care professionals “identify whether an individual has a SUD that needs intervention.” Equally important is screening for co-occurring mental health issues. Primary care providers are well positioned to take up the task of increasing screening efforts because they have extensive access to patients. Additionally, many patients do not come into contact with someone who could provide screening other than a primary care provider. However, at the moment, many primary care providers are not providing such screening as a regular aspect of their work.
In the context of the opioid epidemic, pre-arrest diversion programs such as A Way Out, LEAD, and the Safe Passage Program offer substance users “SUD treatment without fear of arrest, and police provide referral and transportation to treatment facilities.” While police departments are well suited to run such diversion programs – officers are available 24/7 and police regularly interact with those suffering from SUD – diversion programs do not have to be run out of the police department.
Drug courts are “special court dockets” that employ “a multidisciplinary team of professionals” to implement a treatment program for criminal defendants suffering from SUD. Often, “[i]n exchange for successful completion of the treatment program, the court may dismiss the original charge, reduce or set aside a sentence, offer some lesser penalty, or offer a combination of these.” However, judges do not typically have a background in SUD treatment and their background in dealing with criminal defendants can result in strong opinions about how treatment programs should be administered, including misconceptions about SUD and associated behaviors. For these reasons, and because the judge ultimately determines the success of the participant, it is essential that judges presiding over drug courts receive formal training.
Treatment of SUD is at the heart of addressing the opioid epidemic. Misunderstandings about the nature of SUD being a moral or behavioral issue over which people have control, rather than a physiological medical illness, have resulted in treatment programs that are not appropriately tailored to SUD.
For instance, medication-assisted treatment (“MAT”) – a combination of drugs like methadone to relieve symptoms of withdrawal and cravings for opioids with behavioral therapy – has consistently been acknowledged, including by the U.S. Department of Health and Human Services, as “the most effective form of treatment for opioid use disorders.” Despite that MAT is considered “the gold standard” of SUD treatment, strong stigma surrounding MAT, typically arising from misunderstandings about MAT and the misinformed view “that use of medication is simply replacing one drug for another,” has resulted in its underutilization.
Moreover, because co-occurring mental illness is so highly correlated with SUD, it is necessary to have integrated treatment – i.e., “treatment that addresses mental and substance use conditions at the same time.” In addition, treatment programs must include “wrap around” services, particularly in the areas of housing, employment, and child care. Such treatment is extremely successful and is “associated with lower costs and better outcomes” including “reduced substance use, improved psychiatric symptoms and functioning, decreased hospitalization, increased housing stability, fewer arrests, and improved quality of life.”
Despite its success, integrated treatment is not used frequently enough. Two barriers stand in the way. First, reimbursement and coverage by Medicaid and health insurance for mental health treatment is abysmally low. Second, the federal Institutions for Mental Diseases (IMD) exclusion in the Medicaid program “prohibits federal Medicaid funds from reimbursing services provided in an inpatient facility treating ‘mental diseases’ (including SUDs) that have more than 16 beds.” There are, however, ways to overcome these barriers: Federal legislation should be passed to repeal the exclusion altogether and until then, the Department of Health and Human Services Secretary should, as recommended by the President’s Opioid Commission “immediately grant waivers to each state that requests one.”
The lessons from the white paper are clear: we know how to fix the opioid epidemic. Evidence-based solutions such as MAT and integrated treatment exist and can be implemented. The issue is our willingness to act. Policymakers must take steps immediately to address the legal and social barriers to accessing these solutions. The numbers continue to rise; we have yet to crest the arc of the opioid epidemic. There is no time to lose.
Elise Meyer is the Schuette Clinical Fellow in Health and Human Rights at Northwestern Pritzker School of Law where she supports the Access to Health Project.