Here is a statistic that gave me pause—57% of emergency room (ER) physicians reported that for consumers with opioid use disorder who present in the ER, detoxification or rehabilitation services are rarely or never accessible (see 57% Of Emergency Physicians Report Detoxification Or Rehabilitation Centers Are Rarely Or Never Accessible For Opioid Addicted Patients).
My question is—why would that be the case? Lack of health insurance coverage? No room available in area detoxification or rehabilitation programs? Lack of physician knowledge of available resources? Lack of agreement between the physician and the consumer’s health insurance plan about “clinically appropriate” treatment? My educated guess is that all four of these issues are part of the answer.
This issue is the easiest to address. Work by the Kaiser Family Foundation shows that for at least 20% of consumers with opioid addictions, one out of five were uninsured (see 6 Things to Know About Uninsured Adults with Opioid Addiction). Currently 8.1% of the adult population in expansion states, and 13.3% of the adult population in non-expansion states is uninsured—an interesting contrast (see Key Facts About The Uninsured Population).
Available detoxification or rehabilitation programs capacity
The hard-to-answer question is, do we have enough beds for medication assisted treatment (MAT), detox, and rehab? The answer is, “it depends.” Work done last year by my colleague Athena Mandros, found that opinions from the field varied—with the general consensus being that there are enough beds overall, but the beds are not distributed in the right areas (see How Many Psychiatric Beds Are Enough? Opinions Vary). Additionally, our current system is not operating at current capacity for MAT (see Buprenorphine & Methadone – Do We Actually Need To Increase Treatment Capacity?), and the American Psychological Association reports that despite the ability for more physicians to get waivers to prescribe methadone and/or buprenorphine, most are not willing to increase their ability to prescribe MAT (Why Are Doctors Underusing a Drug to Treat Opioid Addiction?). But we do know that there has been work done at the state level in recent years to expand the number of residential addiction treatment beds available (see How Much Residential Addiction Treatment Capacity Do We Need?).
Lack of physician knowledge of available resources
Do physicians know what community resources are available? Studies indicate that a lack of resources, compounded by the stigma of substance abuse can result in physicians being unprepared to treat consumers with opioid addiction (Training Physicians to Treat Substance Use Disorders). For an “in the field” perspective, I reached out to my colleague and OPEN MINDS Senior Associate, George Braunstein, who noted:
Overall, it is likely that physicians know a few referral sources, regardless of their availability and whether they are appropriate for that specific consumer. But different settings, training, and available resources mean that physician ability to connect consumers with treatment varies widely. In a setting like a busy ER, physicians are under pressure to manage the acute symptom and discharge (a few ER physicians I used to know called it “surf and turf”), rather than focus on addiction treatment.
Lack of agreement about “clinically appropriate” treatment
Determining “clinically appropriate” treatment is often an area of professional interpretation, much like the criteria for medical necessity and equivalence of services-driven by the current evidence base. Additionally, the treatment system is still changing to address the current reality of payments and new models for treatment. Mr. Braunstein explained:
This creates access issues. If resources are better aligned, access would improve. There are three evidence-based levels of care for detox. The most acute requires hospitalization with acute medical oversight (withdrawal for some chemicals can be life-threatening-alcohol being one of the worst). The next level is medication assisted, which can be done in an ambulatory setting where the individual can be seen daily by the prescriber to ensure safety. The third is usually call “social detox”, where individuals are in a safe place, ambulatory, and get emotional/medical support. Very few places have all three levels and that causes access problems. Using an emergency room for the two lower levels of detox is a serious waste of resources. In some places, hospitals are reticent to accept medical detox individuals both because of payment issues and that the withdrawal can be messy and loud.
Some emergent issues such as an opioid overdose and acute medical detox have some evidence-based standards. But treatment and long-term rehab are lacking a sufficient evidence base. It is hard for a behavioral leader to advocate for more resources when the service provision community was arguing among themselves about what is needed.
Like much in health and human services, the strategic question for executive teams remains the same: Are you positioned to take best advantage of changes in the market? Finding solutions to each of these can help provider organizations position themselves to provide the services that consumers may not otherwise have access to.
If your team is tracking the changes in the addiction treatment landscape, be sure to share this resources from the OPEN MINDS Industry Library:
- The Politics Of Addiction
- If MAT For Addictions Is So Good, Why Aren’t More Consumers Using It?
- The Framework For A Marketing Strategy For Addiction Treatment Programs
- Jumping The Addiction Treatment Gap
- The Changing Face Of Opioid Addiction In 2017
- The Ethics Of The Medical Costs Of Opioid Addiction
- Mental Health & Addiction Treatment Parity Is Smart – & Bipartisan
- The Market Impact Of The New Medicaid Addiction Treatment Benefits
- Addiction & Hospital Utilization – The Endless Loop?
- Opioid Addiction – The Crisis, The Impact & The Responses
For more addiction services coverage, check out The 2017 OPEN MINDS Technology & Informatics Institute session, How Technology Is Shaping Addiction Treatment: Remote Monitoring, Mobile Apps, & More.