Commentary: ASAM Survey to Identify Where Patient Access to Addiction Treatment is at Risk

As a growing number of states have either passed new legislation or are considering legislation limiting payment for opioid treatment, the American Society of Addiction Medicine (ASAM) has launched the patient advocacy task force, which focuses on FDA-approved medications for opioid dependence. ASAM Acting President Dr. Stuart Gitlow explains the group is starting with a survey that will identify locations in which patient access to treatment is at risk.

Over a decade ago, there were but two medications in the addiction specialist’s prescription pad: the relatively little-used, off-patent and inexpensive disulfiram, and the more frequently used but also off-patent and inexpensive methadone. Those accounting for the cost of treating addiction focused on the comparative expenses of various treatment modalities, saving funds for the short-term by preferring treatment at the least intensive level of care. Ambulatory treatment of addiction was not even a blip on the radar because it generally involved no procedures and no medication.

Times have changed. We have many medications now indicated for use in various states of addictive disease. These medications are far more expensive than disulfiram and have been utilized extensively. Physicians across the country are prescribing a variety of medications such that outpatient addiction treatment no longer represents a mere blip on the accountants’ worksheets.

Addiction treatment, and opioid dependence in particular, has risen to the upper part of the chart if we look only at the cost of ongoing medication prescribed to those afflicted. The question from the accounting perspective has always been, “How can we contain costs?” The big picture, of course, sees the cost of treatment as being only one side, with the other side represented by improved function, improved productivity, longer life and reduced costs associated with more rigorous treatment which might be necessitated if the illness is not addressed in an ongoing manner. But these gains take time to establish and are difficult to demonstrate within an election cycle, which unfortunately has become the important unit of time with which we are now concerned.

State legislatures have noticed the impact on the balance sheet, and while it is highly unlikely that they would say, “You may treat hypertension for two years, but then must stop the antihypertensive,” or “I’m sorry about your 10-year-old’s diabetes, but she’s already been on insulin for two years and therefore must discontinue her medication,” they seem to have little difficulty asking our opioid dependent patients to discontinue or limit their dosage of medication.

Utah, Michigan, Maine, Tennessee and Indiana have either passed new legislation or are considering legislation addressing buprenorphine specifically. The potential Tennessee legislation, not yet introduced, even has statements to the effect of requiring buprenorphine treatment to be terminated should there be positive urine drug test results. Imagine that: “Hmmm, your blood pressure is 200/120. I’m required by law to stop your antihypertensive.”

The ASAM has launched the patient advocacy task force specifically focusing on FDA-approved medications for opioid dependence (methadone, buprenorphine, buprenorphine/naloxone and ER injectable naltrexone). We’ve started with a survey to identify examples of access which can serve as models for both public and private sectors, but also to identify locations in which patient access to treatment is at risk. Our first press conference is scheduled for June 20 at the National Press Club in Washington, D.C., but even before that time, we’re focusing on individual states where the risk is most immediate.

An individual can have hypertension but not be hypertensive. An individual can be diabetic yet have a normal blood sugar. An individual can have addictive disease even while in recovery. And just to make matters more complex, an individual with addiction can be in recovery either while entirely abstinent from psychoactive substances or while taking a prescribed medication such as methadone or buprenorphine. Short-term economic considerations, combined with the stigma against treatment of those with addictive disease, should not drive treatment decisions or determinations.

Stuart Gitlow, MD MPH MBA is a member of the American Medical Association’s Council on Science & Public Health, and Acting President of the American Society of Addiction Medicine. 

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    April 14, 2013 at 10:02 AM

    Dr. Gitlow, I applaud your stance. In addition, though I am not a medical Doctor, I have used the same anti-hypertensive analogy. I was tired of comparing to Diabetes. However, I cannot believe how short sighted our policy makers have become. In a rush to stop the misuse of pharmaceuyical medications, they are trying up sources for those so assailed, and driving them right to the underground marketplace, where they can get the medication that they need; unfortunately, that is now Heroin. Not the Heroin produced and controlled by Bayer Pharmaceuticals, but by whoever has the muscle to control the illicit marketplace. Ironic, but I wonder how many policy makers and legislators are themselves addicted? After all, we do know that there is nothing that stops a person from addiction; it is a primary, genetic, treatable, progressive, terminal condition, like many other chronic illness, there are adjustments to medications that have to be made from time to time. However, I sense our society is slowly becoming more cruel. Why does it have to take someone that is famous or powerful to succumb to this illness before our society realizes that our policy, regarding prohibition is as destructive as slavery. I guess if you were a slave owner, slavery was a good thing; I don’t think the slaves were that happy. Additionally, you would take a stance on one side or the other. No one said well, it’s ok to have a few slaves, but not more than? No you were either an abolitionist, or you supported slavery. Today, and for the last 20 years or so, I’ve watched the treatment of addiction become something that is parsed out in days, and then society points how how poorly treatment works. Of course treatment works poorly; we have given it over to the Criminal Justice System to implement. Dr. Gitlow, imagine if that patient with hypertension had to be treated by a beat cop? How well do you think that person would do? So why do we expect that the same people that we train to serve and protect, would be efficient at treating addiction?

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    M. C. Chaffin, M.S.

    April 12, 2013 at 11:56 AM

    Great article and great insights! Reducing access to medications for opioid dependence is short-sighted and not likely to save money. The societal costs of untreated addiction (police, child welfare, and emergency room visits) far outweigh the cost of providing these medications.

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