DISCUSSION PAPER

Guide for Future Directions for the Addiction and OUD Treatment Ecosystem

R. Corey Waller, MD, MS, HMA Institute on Addiction; Kelly J. Clark, MD, MBA, American Society of Addiction Medicine; Alex Woodruff , MPH, Partnered Evidence-based Policy Resource Center; Jean Glossa, MD, MBA, Health Management Associates; Andrey Ostrovsky, MD, Social Innovation Ventures; and the Prevention, Treatment, and Recovery Working Group of the Action Collaborative on Countering the U.S. Opioid Epidemic

April 5, 2021

DISCLAIMER: The views expressed in this paper are those of the authors and not necessarily of the authors’ organizations, the National Academy of Medicine (NAM), or the National Academies of Sciences, Engineer- ing, and Medicine (the National Academies). The paper is intended to help inform and stimulate discussion. It is not a report of the NAM or the National Academies.

Introduction and overdose continue to devastate people across the United States—particularly Black, Latinx, Native Ameri- The United States is in the midst of a multifactorial drug can, LGBTQ+, and other traditionally marginalized overdose and death epidemic. In 2020, over 80,000 communities. Models observing the course of the drug deaths [15] in the U.S. were attributed to drug over- overdose epidemic predict that without treatment ex- dose, more than 50,000 of which were opioid-related. pansion, another 400,000 people will die from over- This is an increase of roughly 10 percent from 2018, dose by 2025 [17]. The COVID-19 pandemic has further when nearly twice the number of people died from a exacerbated the opioid epidemic [52]. Many counties drug overdose than died from HIV/AIDS at the peak of across the U.S. have reported disruptions in public that epidemic in 1995 [51]. According to recent esti- health programs essential to people who use drugs, mates, with nicotine included, over 35 million people disruptions to transportation to treatment providers, have a substance use disorder (SUD) (14 percent of the and ongoing challenges in accessing evidence-based U.S. population), and roughly 10.1 million people re- care because of inadequate access to quality treat- ported opioid misuse or any heroin use in the previous ment providers [52]. Moreover, the SUD treatment sys- year [14]. tem should be adapted to better engage and educate The epidemic of drug, and especially opioid-related, patient family members and support networks about overdose deaths has been declared a national public their loved ones’ treatment plans. There is a clear need health emergency since 2017. What is needed to turn for future-oriented strategies to build a robust addic- the tide of this epidemic is a long-term, sustainable tion treatment system that ensures widespread access approach to preventing and managing addiction as to treatment. a chronic disease that will replace America’s current Overcoming the drug overdose epidemic will require approach of lurching from one crisis to the next. Co- identifying and addressing critical gaps across the SUD ordinated, compassionate, and science-based care is treatment system. The majority of U.S. states, coun- necessary. Despite research on the individual, soci- ties, and municipalities do not strategically distribute etal, carceral, and economic factors that created the funding across the SUD treatment landscape. To ap- epidemic, public policy and treatment resources have propriately align funding to needs across the treat- been unable to keep up with its trajectory [26]. The ef- ment system and invest in training adequate numbers fects of drug use, ill-informed drug policies, addiction, of new providers of multiple disciplines, the following

Perspectives | Expert Voices in Health & Health Care DISCUSSION PAPER

are needed: a technical assessment of the local SUD ment of opioid use disorder (OUD)—the major driver treatment system and administrative time to contract of overdose related deaths. with state vendors; development of data-release pro- cesses; and organization of the reporting structures The 4 Cs: Capacity, Competency, Consistency, associated with state, county, and municipality regu- and Compensation lations. These burdens delay funding to organizations To best describe the needs of and solutions for the ad- that would otherwise be poised to develop and exe- diction treatment ecosystem, the authors of this man- cute programs for people with SUDs. uscript propose the guidance of the “4 Cs”: Capacity, Individuals who encounter the justice system have Competency, Consistency, and Compensation. signifi cantly higher rates of opioid use than the gen- Capacity refers to whether the system is correctly eral population and are at signifi cantly higher risk of sized and nuanced enough to fi ll the needs of the com- overdose upon leaving jail or prison than their peers munity it is serving. The American Society of Addiction who have not encountered the justice system [53]. This Medicine (ASAM) levels of care (LOCs) provide a use- connection is obvious—people who experience SUDs ful framework to understand types of treatment called may perform illegal activities to acquire their desired upon to treat SUD in a community [5]. Competency re- substance, and many of these substances are currently fers to the education, training, and evaluation of those illegal [53]. This reality spotlights the failed history of who work within the treatment system, including but America’s “war on drugs” and how the American crimi- not limited to physicians, psychotherapists, administra- nal justice system currently operates. Any attempt to tors, and peer recovery specialists. Consistency refers improve addiction care in the U.S. must include an to whether the system is delivering high quality care. expansion of assessment, treatment, and support for The quality of a system’s care is often assessed based justice-involved populations based upon scientifi c data on fi delity to best treatment practices and appropriate about best practices while considering the historic and use of the system’s infrastructure. Compensation re- systemic racism that has led to mass incarceration of fers to whether the treatment system fi nancially aligns Black individuals, particularly Black men [39,53]. reimbursement with best practices. Payment can be Policymakers and health leaders have an opportuni- viewed through the lens of the payment amount, pay- ty to make targeted investments dedicated to repairing ment type, including whether payment is being made the damage done by the drug overdose epidemic and for evidence-based practice versus legacy treatment preventing further harm. To create a more robust and practices, and inclusion of carved-out versus carved-in equitable medical system that recognizes and treats behavioral health. While one could rightfully argue that addiction, evidence-based interventions and programs a fi fth “C” could be added for Community, that consid- need to be adequately funded and resourced. There eration is outside of the scope of this publication. The also needs to be an eff ort to construct and enact the sections below explore each of these 4 Cs in detail. missing pieces of the currently fragmented system for treating addiction in the U.S. These investments Capacity and this new system all need to be developed and The disease of addiction, in all its forms, can aff ect and deployed while considering the pervasive impact of is aff ected by issues such as: structural racism on how those with addiction are both • early life trauma viewed and treated (socially and medically). As such, it • behavioral health needs is incumbent upon those building this new system to • biomedical needs evaluate and repair any laws, regulations, or payment • psychiatric needs structures that perpetuate this reality. • chronic pain To ensure that funding is directed to aspects of the • withdrawal management needs system that would most benefi t from additional sup- • housing port, the authors of this paper propose the following • food security architecture and guidance. The authors of this manu- • transportation script hope that this proposed guidance will help direct • communication access funding and action toward a robust, well-functioning • cognitive capability SUD treatment system, but also recognize that much of • cultural context the proposed guidance is most applicable to the treat- • criminogenic history and behavior

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• structural racism patients will require adequate management of their • a myriad of details for each named issue pain to facilitate improvement to their function and quality of life [69]. This manuscript acknowledges the complexity of the In many counties across the U.S., there are no ad- disease of addiction and attempts to discuss this dis- diction treatment facilities [22] even for those most ease in totality, but all of the interventions proposed severely affl icted with SUD—let alone those with mild in this paper will need to be rolled out with the whole to moderate SUD. In some counties, there may be an patient, and all considerations outlined above, in mind. adequate number of addiction specialists, but health The current state of the addiction treatment ecosys- plans do not provide equitable or accessible care, de- tem is unable to manage and appropriately treat the spite the existence of the Mental Health Parity and Ad- millions of people with substance misuse, SUD, and diction Equity Act (MHPAEA) [16]. This Act and other addiction in the U.S. today. Because of the systemic parity-related legislation, such as the Aff ordable Care barriers that make access to this care diffi cult, only a Act, have yet to be fully implemented and enforced. minority of patients receive evidence-based care [26], Developing eff ective monitoring and enforcement of including medications for opioid use disorder (MOUD) mental health and SUD laws is a national imperative. and interventions for the social determinants of health- Despite multiple clear guidelines, the vast majority related issues listed above. Suffi cient consideration of of Americans with addiction do not receive treatment patients with chronic pain who develop a physical de- inclusive of best practices, including MOUD. Many pro- pendence to opioids or suff er from a SUD is also lack- grams rely on abstinence-based treatment, which re- ing. In addition to behavioral health treatment, these quires patients to forgo evidence-based medications

FIGURE 1 | The ASAM Criteria SOURCE: American Society of Addiction Medicine. n.d. What is The ASAM Criteria? Available at: https://www. asam.org/asam-criteria/about (reprinted with permission)

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that save lives [32]. This is particularly unfortunate ASAM Criteria, fi ts into the continuum of treatment given the medical and policy understanding that using (see Figure 2). these medications is consistent with both abstinence Basic concepts should be employed while following and recovery [54]. Given the need to focus on cost-ef- the ASAM LOCs: fective and rapid solutions, it is imperative that fund- ing is allocated to the types and LOCs that are aligned 1. U.S. Food and Drug Administration (FDA)-ap- with the needs of patients in individual communities. proved maintenance medications for addiction For instance, the services unhoused patients need are treatment should be made available at every diff erent from those of people with stable housing, LOC. and the system should be responsive to those diff ering 2. Access to all needs associated with addiction needs. This section will discuss capacity as it relates to treatment should be available either at the loca- the ASAM Continuum of Care, MOUD, workforce, tele- tion (if specifi ed by LOC) or by referral. health, naloxone, and harm reduction services. 3. These services (if not specifi ed by otherwise) can be delivered telemetrically, via group practice or Capacity: ASAM Continuum of Care and the hub, and spoke methodology, via mobile units Treatment Ecosystem or even electronic applications. The single most important concept in the treatment of 4. Currently the ASAM Criteria is in the process of patients with an OUD is the rapid and immediate initia- its fourth revision. The descriptions below are tion of MOUD followed by patient-centered and stig- forward looking to this edition. ma-free services at the appropriate LOC. This means that while the medication is critical to rapidly stabilize Level 0.5 a patient, it must be matched with the correct inten- Level 0.5 is the most basic of interventions and con- sity of interventions that address all components of sists of modalities such as screening, brief assessment, care listed above, including the relevant social deter- brief intervention, and referral to treatment (SBIRT) minants of health, to truly stabilize a patient in their or societal interventions, such as an impaired driving recovery. For instance, consideration of patients’ ac- program for people who do not meet the diagnostic cess to secure housing and reliable transportation as criteria for an SUD or addiction, but have high-risk driv- well as their ability to aff ord care is critical in assessing ing behavior secondary to intoxication. This series of the practical capacity of the treatment system. Without care tasks can, and should, occur in all areas of general consistent access to care, availability of even the best medical care, including hospitals. treatment options will be inadequate. The ASAM Criteria, formerly known as the ASAM Level 1 Patient Placement Criteria, “is the most widely used Level 1 is designed to deliver services in a variety of and comprehensive set of guidelines for [service set- locations and to a diverse subset of individuals. This ting], continued stay, transfer, [and] discharge of pa- LOC can be delivered at school-based clinics, mental tients with addiction and co-occurring conditions” [5]. health clinics, or primary care offi ces, and can be used When used correctly, the criteria guide the treatment for patients who are experiencing mild or moderate provider through a six-dimensional biopsychosocial levels of addiction and are ready for a change or need assessment (see Figure 1) that informs a comprehen- ongoing addiction treatment. This could be an initial sive treatment plan. Once the needs of the patient are LOC or a step-down LOC for someone who is invested identifi ed, an appropriate LOC can be chosen [4]. By in recovery but is leaving residential treatment, or step- identifying the areas where a patient’s support system down treatment for someone who had intensive out- is lacking or underdeveloped, addiction specialists can patient treatment. It can, and should, include referral tailor interventions and service settings that would give for medications for addiction such as buprenorphine, the patient the best chance for stabilization. naltrexone, or acamprosate, among many other choic- After the multidimensional assessment, patients are es. While the prescribing of medication for addiction then recommended an ASAM Criteria LOC based on treatment is of utmost importance, it is only part of the the assessment outcome and the needs identifi ed in treatment and should not be delivered without some the treatment plan. Below, the authors of this manu- ability to address all needs in some fashion. There are script briefl y describe how each LOC, defi ned by the fewer than nine hours of structured clinical services

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FIGURE 2 | ASAM Criteria Within the Continuum of Care SOURCE: Figure created by authors using data from American Society of Addiction Medicine. n.d. What is The ASAM Criteria? Available at: https://www.asam.org/asam-criteria/about.

delivered by peers or addiction counselors provided at use all forms of MOUD. OBOTs are outpatient offi ces this LOC. that use only buprenorphine and naltrexone for OUD. Example: A patient who meets criteria for level 1 However, buprenorphine is a controlled substance, services for OUD could have their medication written highly regulated by the Drug Enforcement Administra- by a primary care physician who, if needed, refers the tion (DEA). At the time of this publication, prescribers patient to an SUD counseling location. must have a DEA waiver to prescribe buprenorphine and meet the state’s requirements for prescribing this Comprehensive Level 1 medication [20]. They need to either deliver on-site This LOC encompasses opioid treatment programs behavioral therapy or have the ability to refer out to (OTPs/methadone clinics) and comprehensive offi ce- behavioral therapy. There should also be access to pri- based opioid treatment providers (OBOT). OTPs are mary care services, either in-house or by referral, at heavily regulated and provide both medication and this LOC. behavioral health services on site or in close coor- Example: A patient who is being treated at a com- dination. They can provide varying levels of intensity prehensive level 1 will need more substantial medica- for clinical services on-site and have some grouping of tion monitoring (daily dosing or short-term prescrip- counselors and licensed staff available for both indi- tions) and closer coordination with case management vidual and group therapies. OTPs can and generally do and behavior services. The addition of peer support

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and more comprehensive toxicological evaluations Level 3.5 Clinically Managed High-Intensity Residen- should be the norm. tial Services This LOC is designed for patients with relationships Level 2.1 and 2.5 that are abusive, chaotic, or non-supportive; who have not developed adequate coping skills for recovery; and Level 2.1 Intensive Outpatient who are in imminent danger, needing 24-hour stabili- This LOC must support medical, psychiatric, psycho- zation and treatment. This LOC is staff ed with licensed logical, laboratory, and toxicology services through clinical staff , including social workers, licensed profes- direct care, through telemedicine, or by referral. They sional counselors, and addiction counselors. There are should have emergency services available 24 hours per daily programmed services that should include cogni- day and have direct access to the other LOCs. This LOC tive behavioral therapies, motivational enhancement provides nine hours or more of programed clinical in- therapies, and psychotherapies. This LOC should have tervention per week. A patient would continue services access to medications for addiction treatment and toxi- here until they are ready to step down to a less inten- cological studies for monitoring purposes. They do not sive LOC or are moved to a more intensive LOC be- have to be on-site. There should be ongoing interdisci- cause of increasing severity of illness. The nine or more plinary assessments and treatment directed at inhibi- hours of programming should be tailored to the indi- tors of recovery and linking to ongoing addiction treat- vidual and not be the same for every patient. This LOC ment. should also have access to medications for addiction and psychiatric illness via telemedicine or direct care. Level 3.7 Medically Monitored Intensive Inpatient Ser- vices Level 2.5 Partial Hospitalization Level 3.7 includes physician monitoring and around- This LOC can be done in the same setting as a level the-clock nursing care. This LOC includes access to psy- 2.1 but will need to provide at least 20 hours of pro- chiatric, toxicological, and lab services on-site, via refer- grammed clinical intervention per week. This should ral or through telemedicine. This LOC is designed for be a mixture of individual, group, or self-help therapy. patients with concerns in dimensions 1–3 (withdrawal, A patient should be living in a sober-living facility, at medical, and psychological) and the need for medical home, or in a shelter to receive this care effi ciently. monitoring for these. There is direct delivery of clinical Both levels 2.1 and 2.5 can be “co-occurring enhanced,” services as in Level 3.5. which means that they will handle all outpatient psychi- While all of the levels described so far are considered atric needs in-house. “residential”, they vary based on the level of clinician Example: A patient with OUD, who meets the in- oversite (the managing clinician may be an LCSW or a tensive outpatient or partial hospitalization LOC, will psychologist, etc.). Level 3.1 has the lowest need for need highly structured behavioral interventions de- clinical intervention and is generally not staff ed with livered by qualifi ed personnel. Someone could simul- licensed clinicians and thus does not deliver psycho- taneously qualify for comprehensive level 1 care (an therapy. Level 3.5 provides the safety of a therapeutic opioid treatment program) and still need level 2.1 or environment and delivers behavioral therapies from li- 2.5. The reason for this is that they would need both censed clinicians. The need for a patient to enter treat- enhanced medical and medication monitoring as well ment in a specifi c level of care in a residential environ- as increased behavioral services. ment to go to residential can vary based on the stability Levels 3.1, 3.5, and 3.7 (Residential) of their living environment, their readiness to change, and their risk of relapse. For those with medical condi- Level 3.1 Clinically Managed Low-Intensity Residential tion that need medical monitoring, level 3.7 provides Services for 24 hour nursing care and access to an on-call physi- Level 3.1 is the fi rst residential LOC and is designed for cian. people who have little or no community connection, a high-risk living environment, or very low recovery Level 4.0 Medically Managed Intensive Inpatient skills. It is generally staff ed by allied health profession- Services (Hospital-Based Services) als, peers, and group living workers. This is the least Level 4.0 is a hospital LOC that includes addiction treat- intensive level of residential treatment when it comes ment. The care is managed by a physician who is re- to direct services delivered. sponsible for diagnosis, treatment planning, and treat-

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ment. This care generally focuses on the withdrawal pain and their expectations of living with pain, which syndrome, stabilization of medical issues, or acute psy- may require supplementary psychosocial supports. chosis, but does not include direct addiction treatment by addiction counselors or clinicians. Capacity: Where Most Patients Fall on the A critical component to successful management of Continuum of Care the chronic disease of addiction is that the LOCs should Because addiction is a chronic relapsing and remitting not live in isolated silos. Patients should be able to fl ow disease, the needs of patients may fl uctuate, mean- from one LOC to the other as their condition improves ing they may need higher and lower LOCs over time. or worsens. This focus on patient response to treat- Therefore, the entire continuum of care must be con- ment can be accomplished by community coordination sidered for a patient’s course of treatment. It should of services through a central assessment and coordi- be anticipated that patients could require higher LOCs nation location, contracted step-down pathways, and as their disease worsens. A process that is more re- knowledge of the array of services delivered at each sponsive to the needs of patients could consider the location. While this integrated system may seem like case of patients who begin care according to Table 1. the idealized state, addiction medicine physicians and For example, patients who suff er from mild OUD may allied professionals have understood this need for over begin and stay at level 1 outpatient, while others may 30 years—now is the time to build the right compo- need initial placement in level 4 treatment. Once stable nents to deliver the right service at the right time. Im- in level 4, they will progress down the intensity cascade portantly, patients with chronic pain may require spe- until in recovery. However, most patients do not prog- cial consideration throughout this continuum of care. ress in a linear fashion and will need restabilization In addition to treating SUDs, clinicians will need to work after relapse. Experts and data from the ASAM Con- with these patients to adequately manage their chronic tinuum evaluation tool estimate that 40-50 percent of

ASAM Levels of Care % of patients 0.5 1 2.1 - 2.5 3.1 - 3.7 4 Dependent and Early 50% misuse intervention/ prevention (secondary and tertiary) 40% of OUD and Early Outpatient 50% misuse intervention/ prevention (secondary and tertiary) 20% of OUD Early Outpatient Intensive intervention/ outpatient prevention (secondary and tertiary) 20% of OUD Early Outpatient Intensive Residential intervention/ outpatient prevention (secondary and tertiary) 20% of OUD Early Outpatient Intensive Residential Hospital intervention/ outpatient prevention (secondary and tertiary)

TABLE 1 | ASAM Levels of Care and Patient Care Trajectories SOURCE: Created by authors.

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OUD patients will start in level 1, while approximately However, for some patients who do not need this over- 20 percent will need level 4 treatment. sight, it is burdensome, expensive, and unnecessary. The SUD treatment system in the U.S. does not In contrast, oral buprenorphine has the ability to be conform to this ideal state, and treatment availability dispensed frequently and fl exibly at a pharmacy; how- across the care continuum varies across the country. ever, currently, only practitioners who obtain a special- Data from internal ASAM surveys reveal that some ex- ized DEA waiver can prescribe this medication [20], and perts feel that capacity is lacking in certain LOCs (e.g., they can only prescribe to a limited number of patients. intensive inpatient and outpatient) and have excess Only 4 percent of doctors nationwide are waivered to capacity for others (e.g., inpatient rehabilitation pro- prescribe buprenorphine and only half of those are ac- grams in level 3.5). However, this perception may be tive prescribers [21]. Given the limited availability and due to diff ering access to insurance, the array of servic- increased fl exibility of oral buprenorphine treatment es available, and the heterogeneity of quality through- options in comparison to those of methadone, it is par- out the continuum. Accessibility to all LOCs throughout ticularly concerning that Black patients are less likely the continuum is required for both clinical and cost- than white patients to be prescribed buprenorphine. eff ective care to occur. This disparity persists across income level, with wealth- It is important for the ASAM Criteria to be used re- ier individuals being more likely than lower-income gardless of the actual substance(s) a person has been individuals to have access to buprenorphine, and ur- misusing. If a community or health plan does not have gently needs to be addressed [70]. a full continuum of care available to treat people ad- Naltrexone injections (extended-release Naltrexone) dicted to opioids, they most likely do not have the ap- are administered monthly at a doctor’s offi ce or clinic. propriate resources to treat people addicted to alcohol As the least-regulated medication, extended-release or methamphetamine. This leads to mismatched care Naltrexone requires abstinence (i.e., free from short- and patients who feel lack trust in their care and pro- or long-acting opioids for 6 or 7–10 days, respectively, viders and the system as a whole. based on ASAM’s National Practice Guideline [6]) upon injection. The current rigid and asynchronous regula- Capacity: Medication for Opioid Use Disorder tions for MOUD are not conducive to a well-functioning (MOUD) treatment system and frustrate an already complex The use of MOUD is a core component of the man- problem. Having these medications fragmented across agement of OUD. Medical science shows that ongo- providers is antithetical to confronting OUD with per- ing medication management saves lives, and the use sonalized treatment options. of MOUD treatment is the gold standard of care [32]. Another barrier to receiving MOUD is the administra- Short-term medication use for withdrawal manage- tive restrictions often faced by patients and physicians, ment is applied extensively in medically managed or including restrictive formularies, prior authorization, medically supervised withdrawal management pro- and step therapy or “fail fi rst” protocols. If a patient is grams (ASAM levels 4 and 3.7). MOUD as a long-term stable on a specifi c medication or formulation of the maintenance treatment is most often associated with MOUD, but the medication is not on a health plan, level 1 outpatient care. In an ideal state, MOUD with all Medicaid, or pharmacy benefi t management company three FDA-approved medications for OUD (methadone, formulary, the patient may be forced to discontinue or buprenorphine, and extended-release naltrexone) delay therapy until a prior authorization can be com- would be a core treatment component throughout the pleted. Sometimes, the prior authorization may be entire residential and outpatient continuum of care [4]. further delayed or denied altogether, forcing the pa- If applied properly, the use of MOUD negates the need tient into withdrawal or subjecting the patient to un- for inpatient withdrawal management. aff ordable costs for out-of-pocket payments to remain The regulations surrounding each of these medica- in compliance. According to a 2018 Substance Abuse tions create diff erent barriers for people seeking treat- and Mental Health Services (SAMHSA) report, only 42 ment. Methadone, the longest standing MOUD, is ini- state Medicaid programs reimburse for methadone tially dispensed daily at an independent OTP. This daily for the treatment of OUD [45]. Patients may also face dosing can be helpful for those needing a stabilizing these hurdles if they switch insurance plans—in that pattern of enhanced medication monitoring while mini- one company might cover a particular formulation, but mizing disruptions to the responsibilities of daily life. if that is not the formulation being used by the patient,

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the only way to obtain coverage may be for the patient all geographic areas, and rarely in rural areas. to fail on the covered medication fi rst. These policies • Despite having the best outcomes for some pa- are not evidence-based and can have deadly conse- tients, methadone still possesses the highest quences. These issues are complicated even further by level of stigma of the MOUD treatment medica- the fact that these policies diff er from state to state, tions. making education surrounding prescribing complex at • Lack of insurance coverage contributes to ac- best and near impossible at worst. cess barriers for this treatment. For patients and providers who are able to navigate the fragmented medication system and a myriad of Capacity: Workforce Needed administrative barriers, patient outcomes have consis- The implementation of MOUD has not kept up with the tently proven that MOUD saves lives, prevents infec- growth of the opioid overdose epidemic in the U.S. The tious disease, and provides economic benefi ts to pa- number of OTP clinics increased by only 36 percent tients and their communities. Methadone treatment from 2003 to 2016, and those off ering buprenorphine is the most studied of the three of the FDA-approved treatment increased from 11 percent to 58 percent medications and shows consistent retention in treat- [3]. In the same timeframe, opioid-related overdose ment—from 60 percent to as high as 80 percent over increased by approximately 230 percent [33]. In 2018, six months [23]. It is diffi cult to diff erentiate whether 20 percent of people with OUD received specialty ad- this is specifi cally a medication eff ect or the eff ect of diction treatment [27]. To close this treatment gap, being in a highly observed and consistent environment clinics need to be properly funded and administrated. with daily interaction with treatment staff . However, the most beautiful building and the best ad- Studies show limited public support for the use of ministration cannot treat addiction without the appro- federal dollars for any form of addiction treatment priate workforce. The compensation structures that [10], and only 19 percent of Americans endorse the make this investment overly complicated are explored use of methadone [31]—one of the most commonly in detail below. The staffi ng numbers listed below take used forms of MOUD [28]. As a result, many people do into account current limitations placed on providers by not seek treatment out of fear of being marginalized, state and federal licensing. They are not endorsed by especially by their coworkers and neighbors. Further- these authors, as they lack nuance and have little to no more, one in seven rural providers will not prescribe data to support them. However, they do represent the buprenorphine because of issues with DEA intrusion current state of the addiction medicine workforce. into their practice [8]. Multiple barriers restrict the availability of top-of-the- While the results are very positive for a certain seg- line OUD treatment, including stigmatizing attitudes ment of patients, methadone maintenance can have toward MOUD, cost of treatment for the individual, and limitations: restrictive regulations for prescribing [46]. One factor • The administration of methadone medication is blocking access to appropriate treatment is the severe highly regulated, limiting the number of treat- shortage of trained professionals available to meet the ment centers qualifi ed to administer this form dramatically expanded treatment need dictated by the of treatment (special licenses and intense over- opioid overdose epidemic. sight required). The schematics on the following page are examples • Methadone treatment is typically delivered in of provider staffi ng needs at each ASAM LOC. The num- an OTP daily, with each dose delivered to the bers in the schematic are derived from limits set forth patient under observed conditions, thus limit- by a combination of the DEA, state licensing boards, ing this form of treatment for patients for which and current payment support mechanisms. Advanced daily treatment is not a viable option. Only after practice clinicians, such as physician assistants and a patient has been stable for six weeks will some nurse practitioners, can only prescribe buprenorphine states even allow patients to have take-home to 100 patients. Physicians can likewise only prescribe doses. For some, achieving “stability” can take for 100 patients, increasing to 275 only if they are spe- years. cialists or working within specifi c qualifi ed practice • Methadone treatment is associated with signifi - settings. The numbers attributed to a therapist and cant stigma. case manager (CM) are restricted by scheduling ca- • Methadone treatment clinics are not available in pacity and, in some states, licensing limits. Peer limits

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are practical limitations as described by multiple peer- • 3 addiction specialists (covering an OTP, level 3.7 based interventions and presumes that peer support and level 4) specialists are supportive of maintenance medications. • 10 prescribers seeing 100 patients, or 50 pre- It is possible to extrapolate the appropriately sized scribers seeing 20 patients workforce needed for a town of 100,000 residents • 100 therapists using the numbers outlined above. This scenario will • 70 case managers build on the assumption that 10 percent of the popula- • 100 peers tion either has an SUD or suff ers from misuse and re- quires an intervention. This estimation is much higher For comparison, the current national average of psy- in communities that are hit hardest by the opioid crisis. chiatrists per 100,000 is 12.9; the average number of This extrapolation yields approximately 10,000 peo- addiction psychiatrists and addiction medicine phy- ple needing care. To make this value more realistic, for sician specialists is 0.3 per 100,000 [56]. While this the sake of this thought exercise, assume only 70 per- thought exercise is oversimplifi ed, this example illus- cent of those want help. This results in 7,000 people trates we only have a fraction of the staffi ng needs needing care, including diff ering levels of need and required for quality care. . This thought exercise also medications for OUD and SUD. Using the numbers in does not include those tasked with community sup- the schematic, this town of 100,000 would need ap- ports for the myriad of social determinants of health or proximately: reentry needs. Given the need for multiple LOCs in the

Level 1: Outpatient ASAM Level of # Patients per # Patients per # Patients per # Patients per Care Prescriber Therapist RN-CM Peer Coach Level 1 Primary 100 100 300 N/A Care Comprehensive 275 [44] 90 200 50 Level 1 or Addiction Specialist OTP 300 65 150 50

Level 2: Intensive Outpatient ASAM Level of # Patients per # Patients per # Patients per # Patients per Care Prescriber Therapist RN-CM Peer Coach Level 2.1 100 - 275* 50 100 50 Level 2.5: Partial 100 - 275* 45 100 50 Hospitalization *If the prescriber is a qualifi ed addiction specialist or working in a qualifi ed practice setting, the higher numbers apply [55].

Level 3: Residential ASAM Level of # Patients per # Patients per # Patients per # Patients per Care Prescriber Therapist RN-CM Peer Coach Level 3.7 30 30 30 N/A

Level 4: Intensive Inpatient ASAM Level of # Patients per # Patients per # Patients per # Patients per Care Prescriber Therapist RN-CM Peer Coach Level 4 20 20 20 N/A

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setting of a limited number of specialists, the addiction and transformative to health care. The lessons learned specialists we do have, are often stretched relatively from the EHR transition are applicable to help build the thin compared to their specialty provider counterparts. capacity to treat complex conditions like addiction in a Remember, in this example we are only talking about a virtual setting. For most providers, virtual care was not city the size of San Angelo, TX—imagine the workforce a choice but a necessity as COVID-19 spread across the needed in a city with over one million people. There is country. Similar to the experience during the rapid ex- clearly a massive national eff ort needed to build an ap- pansion of EHRs, health teams are working to optimize propriately sized workforce, while leveraging the use of telehealth as they are being forced to use it, and there available technology to make the relatively small size of are no clear best practices for virtual care in many set- the current workforce operate more effi ciently. tings. Making the transition to telehealth for addiction care as eff ective as possible will require a focus on: Capacity: Telehealth Telehealth has been shown to be an eff ective modal- • clinician skill building and competency, ity to provide care for many medical and behavioral • development of accepted criteria on when to use health conditions [2]. Despite the evidence for the virtual versus in-person modalities, and appropriate and eff ective use of telehealth in certain • payment parity for virtual and in-person care. conditions, telehealth uptake has generally been slow, largely because of the limitations in payment models Many providers and health systems have undergone and other regulatory barriers. With the onset of the meaningful practice transformation to a model of ro- COVID-19 pandemic and subsequent rollout of stay-at- bust team-based care leading to improved engage- home orders, telehealth rapidly emerged as the solu- ment across the care team and optimization of each tion to provide care while avoiding potential COVID-19 staff member’s unique role. As care teams move into transmission. Most notable has been the rapid expan- the virtual clinical model, practices need to continue sion of telehealth by Medicare members. For example, focusing on the role of each team member and their in a six-week period, there was an 11,617 percent in- interaction with the patient. This can be challenging crease in Medicare member visits alone [36]. This in- in a virtual environment when care is asynchronous crease was the result of a massive expansion of tele- and spread across locations. Practices need to resist health fl exibilities at the federal level. Concurrently, returning to the provider/prescriber-centric model, a one by one, states adopted their own fl exibilities and common occurrence when practices transitioned from updated regulations for the use of virtual platforms to paper to EHR. This is another opportunity to learn from deliver care. Along with the new payment allowances, past experiences as practices move through this para- additional fl exibilities were announced that allowed the digm shift. prescription of controlled substances via telehealth for Using telehealth to treat addiction and behavioral both new and established patients, as well as the abil- health conditions has several distinctly diff erent ap- ity to use a broader array of technology platforms to proaches compared to addressing other physical or communicate with patients. Finally, the DEA and SAM- medical conditions. Most of these diff erences are relat- HSA put in place numerous fl exibilities specifi cally for ed to the need to build an empathetic and responsive patients being treated with MOUD, including the abil- connection with the patient. Building such a connec- ity to prescribe buprenorphine based on an audio-only tion is already diffi cult in the offi ce setting, and physi- telephone visit with a patient [74]. cal separation only makes this more diffi cult. Although The change from in-person to virtual care is a para- there may be less reliance on the “hands-on” physical digm shift in health care on the scale of the transition examination (PE), there is a greater need to connect from paper charts to electronic health records (EHRs). on a personal level that may be challenging in a virtual In the case of EHRs, when federal funding was allocat- world. The clinician must be cognizant of addressing ed to support this transition, there was rapid uptake issues like unanticipated interruptions in connectivity by health systems. However, providers received little and having distracting sounds in the background. Hav- to no training to prepare and develop best practices. ing standard tools and protocols to support this activity As a result of this lack of preparation and despite the is a must. A broad set of skills are needed to treat a potential benefi ts of EHRs, providers and patients alike patient with addiction that requires mastery in a virtual have expressed widespread dissatisfaction with the environment including but not limited to: system. Transitioning to virtual care is equally rapid

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• assessing the medical and behavioral condition Rapid and substantial expansion of naloxone distri- of the patient and associated comorbidities; bution programs, including standing orders in pharma- • assessing other patient needs such as living situ- cies, has proven to save lives and reduce hospitaliza- ation, housing, family dynamics, and relation- tions related to opioid overdose. The FDA has issued ships; and guidance to accelerate the development of over-the- • assessing patient safety in real time. counter naloxone, which could substantially expand access to this life-saving medication [41]. In response to physical distancing guidelines imple- Naloxone distribution is most eff ective when strate- mented during the COVID-19 pandemic, the DEA gically and equitably distributed to at-risk groups. This waived the requirement for an in-person visit prior to equates with free and low barrier availability at many beginning buprenorphine treatment [37]. Many payers locations. There are key distribution points that must expanded their telehealth reimbursement to include be included in a naloxone allocation system for maxi- additional services and increased payment to equal in- mum harm reduction. These locations include: person visits. Each state has its own telehealth statutes • syringe exchange programs and regulations that add to the variability in capacity • correctional departments, prisons, and jails for treatment. • housing shelters One aspect of addiction treatment that is often • hospitals overlooked are disparities associated with socioeco- • emergency departments nomic status. This equates to some patients having • community-based pharmacies decreased broadband access, no data plans for their • community-based naloxone distribution pro- smartphone, and unreliable Wi-Fi connections. There grams is also a digital literacy divide that will need to be ad- • health departments dressed for this population. While data is still being de- • mobile health clinics veloped in how to eff ectively address these issues, the • safety net providers digital and literacy divide will continue to persist and • fi rst responders, including law enforcement cause gaps in care and treatment if not addressed in an expedited manner. However, some of these issues The workforce capacity to distribute naloxone is often may be partially off set by the deceased need for travel, inadequate at the local level and often based on the childcare, and absence from work that an in-person opioid overdose rate in a community. Typically, full- visit requires. time employees are required to run a publicly funded overdose education and naloxone distribution pro- Capacity: Naloxone Education and Distribution gram, with support from other state agencies including Naloxone is a medication that will reverse an opioid the department of public health. overdose. Naloxone is made available in the commu- nity for use in emergencies by multiple distribution Capacity: Other Harm Reduction Services methods, including co-prescription with opioids, stand- Another key capacity-based strategy for addressing the ing state orders by public health physicians, and distri- opioid overdose epidemic is harm reduction programs bution through treatment programs and harm reduc- like syringe services programs (SSPs). Harm reduction tion programs such as syringe service locations (needle refers to any program that provides services to protect exchanges). Naloxone is also available in many areas people who use drugs from disease or harm without as part of emergency medical kits and carried by fi rst demanding people to stop using substances. SSPs are responders. These prescriptions can be provided for community-based programs that provide access to patients with a known OUD or those who take opioids free sterile needles and syringes and safely destroy for pain. Some states have expanded access to nalox- used needles and syringes. These locations can also one by allowing pharmacies to have a standing order act as entry points for treatment, education, and care for the medication, permitting anyone to receive the coordination. High-risk injection behaviors are strongly medication over the counter [57]. Forms of naloxone associated with several communicable diseases such include intramuscular injection, nasal spray, and in- as HIV and Hepatitis C. These and similar programs travenous administration. Naloxone has saved tens of reduce the spread of disease while teaching safe in- thousands of individuals from death due to an opioid- jection practices and training individuals on overdose related overdose. rescue [9]. Harm reduction strategies are highly stig-

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matized and often mischaracterized as enabling drug lationship between a patient and a provider. Without use. There is no proven association between the use of clear practice guidelines, various forms of traditional SSPs and increased drug use. and experimental treatments have been able to thrive Besides the humanitarian argument to protect peo- without scientifi c evidence on their safety or effi ciency. ple in all stages of use and recovery from devastating Without a baseline quality metric, the addiction treat- infection, SSPs are economically advantageous. Pre- ment system does not have adequate means to stan- venting the contraction and spread of communicable dardize and improve its quality. Some medical provid- diseases costs signifi cantly less than the downstream ers are working to integrate addiction treatment into costs of infection and death [53]. Return on investment established primary care and psychiatric practices and (ROI) for these eff orts is as high as $7 for every dollar publish guidelines based on this work. Addiction medi- spent [19], demonstrating very effi cient use of funding cine has recently become a recognized fi eld within the to protect health. This ROI, specifi cally, accounts for National Board of Medical Specialties, which will not only the cost of avoiding having to pay for HIV treat- only provide a scalable specialized clinical and research ment alone—the addition of other avoided costs in- workforce, but also build emphasis on addictive dis- cluding hepatitis C and other related issues will further eases into the medical school curriculum, into hospital increase the ROI of these programs. staff training, and throughout the medical care system. Such programs often use counselors and peer sup- While these eff orts are critical to opening new av- port staff who help patients navigate their way into a enues for care, the deeper issue lies with how health treatment program. Research consistently demon- practitioners and the broader public understand ad- strates the eff ectiveness of unused syringe access in diction as an illness. In the U.S., two ends of a spec- preventing infectious disease transmission and soft trum often emerge as to how addiction develops and tissue infections while also supporting the overall is maintained: as a chronic relapsing and remitting dis- “health and well-being of drug users through linkages ease as understood by the medical and scientifi c com- to drug treatment, medical care, housing, [overdose munities, or as a hedonistic failure of people who just prevention, insurance coverage,] and other vital social “can’t say no.” services.” [75] SSPs also “respect, value, and prioritize Too often, addiction has been treated as a behav- the human rights and dignity of people who use drugs” ioral and moral failure rather than a medical condition [75] while challenging drug-related stigma. with behavioral symptoms [34]. For decades, the U.S. has relied on behavioral interventions such as detoxi- Competency fi cation, incarceration, and other legal penalties—all The Institute of Medicine (now the National Academy of of which fail to address the underlying causes of ad- Medicine) defi ned the core competencies of medicine diction. While these interventions may make sense in 2002, which include patient-centered care, inter- if addiction were an issue of poor choices and moral disciplinary practice, evidence-based practice, quality failings, the lack of eff ectiveness of these methods is improvement, and informatics [24]. These competen- consistent with what is now known about the brain cies have not fully penetrated into addiction medicine science of addiction as a chronic disease. As with any at scale. Integrating research and providing evidence- disease, health providers need to address the needs based care has proven challenging in the addiction of each patient for biological, psychological, and social treatment and recovery system, as many (if not most) interventions. addiction treatment centers do not off er evidence- Framing addiction as a behavioral problem has al- based medical treatment [71]. It is also evident that the lowed for the expansion of short-term treatment mod- core competencies in all of medicine are lacking an un- els such as withdrawal management and residential derstanding of how structural racism and discrimina- treatment. These facilities provide a space to “break” tion impact every level of treatment. physical dependence on opioids and introduce behav- The main reason for the lack of evidence-based care ioral changes but are not eff ective for long-term recov- is that addiction treatment has historically been siloed ery [43]. After one year, the failure rate of withdrawal from traditional offi ce-based medical and psychiatric management alone is 80 percent, and withdrawal practice. When this separation is coupled with stigma, management alone may actually increase the risk of structural racism, and discrimination, it becomes a po- future overdose [43]. While residential treatment is tent mix that permeates the very core of a trusting re- part of the care continuum, diff erent facilities off er a

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huge variation in the treatment, and therefore results from traditional medicine, and that health care provid- are variable [38]. For example, some residential treat- ers are not immune to the deep stigma of addictive ment programs may or may not off er individual coun- disease, those who do not work explicitly in addiction seling or MOUD. Some even require patients who are have increasingly felt that the extent of their ability to stable on MOUD to discontinue use, putting the patient help is to order a referral for the patient to speak to a at even further risk of overdose and death. Therefore, psychologist or social worker [59]. Now that overdose every residential treatment facility must be analyzed is the number one cause of injury-related death in the individually, and persons in crisis do not often have U.S. and the number one cause of death for people un- the time or the mental capacity to do so. Recovery resi- der 50 [18], the medical system must reorient toward dences also face their own stigma from neighborhood appropriate and adequate care for those with addic- and community organizations, often as a result of the tion. perception that people with OUD will attract poverty The latest estimates show that very few primary care and crime to the community [25]. and OB/GYN offi ces in the U.S. actively screen for ad- Because of structural racism, incarceration aff ects diction on a regular basis [47]. To address this gap, racial minorities at signifi cantly higher rates than their medical practices need to add the education and EHR white peers and has been used as a tool to control cer- capability to consistently and predictably apply validat- tain types of substance use for decades [40]. The “war ed verbal screening and early intervention, in order to on drugs” created a pervasive mindset that aligned meet new United States Preventive Services Task Force certain types of drug use and criminality [35]. Although recommendations [60]. One method to reach this goal many people with OUD interact with the criminal jus- would be for the top fi ve EHR systems to build out ap- tice system, few receive any form of evidence-based propriate screening tools, toolkits, and order-sets for treatment while incarcerated or otherwise justice- primary care develop online learning modules to pro- involved [13]. This method of controlling certain sub- mote a high degree of fi delity and precision. stances and the people who use them does not work The provision of addiction medicine via telehealth and is both catastrophic and costly to those within the has become the reality for many providers since the criminal justice system as well as their families and so- COVID-19 outbreak. As previously discussed, this meth- cial groups. The mass incarceration of people with SUD od of health care delivery was not carefully contem- has devastating eff ects on family structures, most no- plated or optimized before its widespread use became tably children [53]. a necessity. Technological competency, in the various Overdose is the most common cause of death among modalities of telehealth, is going to be its own require- the formerly incarcerated, with the month after release ment in the future of addiction medicine. By defi nition, being the most dangerous [11]. Initiating and continu- telehealth encompasses several modalities including ing MOUD in jails and prisons is a common-sense way live or asynchronous video visits, audio phone only, e- to reduce mortality but is rarely done. Removing a consult (peer-to-peer interprofessional consultations), patient’s medication for a chronic illness as they en- e-visits, and virtual check ins. Depending on the needs counter the justice system is cruel and unbefi tting of of the individual patient, the treatment plan could in- their right to health care [12]. Providing methadone or clude care provided over any of these platforms—a buprenorphine treatment, per a patient-centered de- decision the provider should base on the individual. cision-making model, has been shown to signifi cantly The provider, rather than regulatory agencies, should lower overdose deaths in the months post-incarcera- decide on whether it’s possible, appropriate, or in the tion [58]. patient’s best interest to provide care in these ways. Addiction medicine has traditionally been viewed As the use of telehealth becomes more universally as being outside of mainstream medicine and rarely accepted, the provider needs to develop the compe- taught in medical school or residency, as well as in all tency of understanding the appropriate use of these health professions. Due in part to the criminalization virtual care platforms. Whether to off er telehealth or and stigma of addiction, this separation has even been to require an in-person visit should be at the discre- codifi ed in the Code of Federal Regulations (42CFR Part tion of the treating provider, who remains ultimately 2) by segregating the addiction-related medical records responsible for the quality and appropriateness of of those in treatment from the rest of their medical care. Whether to engage in telehealth care remains the records. Given that addiction medicine is so separate choice of the patient, and the totality of the treatment

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plan should be done through a patient-centered and primary care providers and their practices develop the shared decision-making process. skills and confi dence to manage more conditions in the Achieving telehealth competency for addiction treat- medical or behavioral health home. Both e-consult and ment includes the ability to weigh the need for infor- Project ECHO support the competencies of providers mation that can only be collected in person against to screen, diagnose, and treat patients with addiction. the ability to provide care over a virtual platform that Because of the current state of heterogeneous otherwise would not be available to the patient. This approaches to care, diff erent levels of knowledge would be described as “better than nothing.” Does throughout addiction treatment, and a lack of the ap- the telehealth visit meet that standard? It should be plication of evidence-based medicine, the competency the responsibility of the telehealth provider to decide within every LOC that treats patients with addiction whether it is in the best interest of the patient. The pro- must be analyzed, addressed, and grown. Whether vider needs to consider factors of privacy and security, a physician or other prescriber, social worker, nurse, health care literacy and language skills, and the need peer, or administrator, those treating patients with ad- for a PE or lab tests to complete the evaluation [61]. diction should possess a baseline set of competencies Deciding whether the need to treat or prescribe via that allows for a streamlined and evidence-based ap- telehealth outweighs the need for a PE and lab tests proach to care for every person entering treatment. requires telehealth competency—and practicing with- Each of the individuals mentioned above must have out this competency puts the patient, the provider, and suffi cient education covering an array of topics. The the virtual model of care each at their own varying risk. depth of knowledge for each of these topics is depen- Under the umbrella of telehealth or virtual care, e- dent on the location of service delivery, their profes- consult can be an eff ective way to provide the support sion, and the specialty of the provider delivering the of an addiction specialist to a patient’s care team. The service as well as their state’s delineation of their legal value of e-consult is multidimensional: supporting the scope of practice. The following list of suggested com- care provided by the primary provider, keeping more petencies for those treating addiction in any setting is care in the medical home, developing the learning by no means exhaustive but aligns with published ad- curve of primary providers, and avoiding gaps in care diction medicine and addiction psychiatry competen- or drop off s as patients are lost in the referral system. cies. Competency in the use of e-consult for addiction treat- ment is required for both the referring (primary pro- Structure of Addiction Interventions vider) and the receiving or consultant provider. Similar • use of the ASAM Criteria to the traditional referral process, providers need to • outpatient approaches to care understand how to request appropriate referrals and • telehealth approaches to care how to ask for and give clinical recommendations in a • residential approaches to care virtual setting. • hospital-based approaches to care Another technology-based platform to increase com- Team-based Care petency and capacity is Project ECHO [49]. Although • components of high functioning teams [62] not technically telehealth, Project ECHO uses a virtual • care implementation grand rounds-style model to “move knowledge, not pa- • payment structures tients.” The model, which started for support of prima- ry care physicians caring for hepatitis patients across Array of Services New Mexico, has grown to hundreds of Project ECHO • biomedical services (MOUD, infectious disease, virtual clinics across the U.S. and abroad, addressing etc.) a multitude of medical and behavioral health condi- • co-occurring enhanced services tions, including SUD and addiction. Project ECHO is an • pain evaluation and treatment excellent model to support primary care physicians as • withdrawal management it meets many of the same goals of the e-consult, but • housing in a virtual learning community setting, also allowing • case management, including consideration of for virtual collaboration in a multidisciplinary learning the social determinants of health community. The model includes education mixed with • behavioral therapy services case-based presentations and discussions. Over time,

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Competencies for prescribers and healthcare pro- Competencies for care coordinators [65] fessional staff supporting them (RNs, MAs, etc.) [63] • prevalence and demography of addiction • prevalence and demography of addiction • screening and brief assessment of SUDs and • neuroscience and pathophysiology of SUDs other addictions • motivational interviewing • motivational interviewing • toxicological evaluation of SUDs • documentation and utilization management • assessment, PE, and diagnosis of SUDs and oth- • eff ect of stigma and structural racism in treat- er addictions ment • medications used for the treatment of SUDs • recognition and treatment of withdrawal from Competencies for peer support [66] substances • building caring and collaborative relationships • eff ect of stigma and structural racism in treat- • how to share lived experience ment • how to provide support • approaches to special populations with addic- • how to support recovery planning tion (patients with chronic pain, pregnancy, etc.) • motivational interviewing • the addiction treatment system • crisis mitigation • how to communicate with empathy Competencies for therapists (psychologists, LCSWs, etc.) [64] Reaching the competency of care that patients with ad- • prevalence and demography of addiction diction desire and deserve is a necessary and urgent • the six dimensions of the ASAM assessment task. Special consideration should be given to patients • psychiatric screening and assessment tools who require chronic pain management in addition to • motivational interviewing SUD treatment, which will require systematic incorpo- • evidence-based behavioral treatments for SUDs ration of additional competencies related to pain man- and other addictions agement [69]. • adverse childhood experiences (ACEs) and their correlation with behavior Consistency • eff ect of stigma and structural racism in treat- The ideal treatment system sets up providers to pro- ment vide high-quality care and ensures that standards • benefi ts of medications for addiction treatment are being met across the systems for patients with all • social determinants of health and how they re- types of medical conditions, including addiction. This late to addiction treatment consistent LOC also sets up a patient with addiction for success. Consistency is the predictable execution Competencies for counselors and behavioral of knowledge and the correct application of evidence- health support staff (alcohol and other drug counsel- based care in addiction treatment. While the ASAM Cri- ors, BSWs, etc.) [64] teria help provide a tailored treatment plan and loca- • prevalence and demography of addiction tion of care for the patient, the medical care provided • screening and brief assessment of SUDs and must adhere to best treatment practices. Consistency other addictions is measurable and can be observed in clinical decisions • psychiatric screening and assessment tools and patient outcomes across diff erent domains. Cur- • motivational interviewing rently, the Commission on Accreditation of Rehabilita- • evidence-based behavioral treatments for SUDs tion Facilities (CARF) and the Joint Commission accredit and other addictions programs for a range of LOCs, but these do not cur- • ACEs and their correlation with behavior rently confi rm essential elements of consistent quality • eff ect of stigma and structural racism in treat- of care. ASAM and CARF have launched a joint volun- ment tary certifi cation program where level 3 programs for • benefi ts of medications for addiction treatment adults can receive external certifi cation if their poli- • social determinants of health and how they re- cies and procedures have the minimal core elements late to addiction treatment of ASAM levels 3.1, 3.5, and 3.7. The Joint Commission is also including ASAM LOC elements into some of its

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accreditation programs, and ASAM and the National more transparent treatment system to exist. Quality Forum (NQF) provide guidance on ways to A productive element of a measurement paradigm measure quality consistently with their standards and would be to voluntarily submit data which can then be performance measures [7]. While it is outside of this centrally analyzed with benchmarking feedback given paper’s scope to present a detailed list and explana- to the programs. In addition, initiatives for quality im- tion of current performance and outcome measures, provement in treatment settings should be data-driven examples of some of these measures include: in design against process metrics initially, growing into outcome metrics after core treatment quality process- • percent of patients prescribed medication for es are ensured. One measurement framework that alcohol use disorder, encompasses these elements includes the nonprofi t • percent of patients prescribed MOUD, Shatterproof’s ATLAS (Addiction Treatment Locator, • all-cause inpatient residential readmission rate, Analysis, and Standards Tool) framework [42]. Despite • presence of screening for a psychiatric disorder, the promise of ASAM, NQF, and Shatterproof’s work, and barriers to measuring quality may still persist. Even- • percent of patients followed up within seven tually, all providers will need to provide transparent days after withdrawal management episode. reporting on performance, quality, and outcome mea- sures. Starting with benchmarking and incentives will To make these measures and measure concepts oper- go a long way to building a high reliability system of ational, it is important to aggregate and present them care. in a way that is consumable by key stakeholders. Mea- surement approaches also need to be able to capture Compensation variation in quality across the system. Adequate funding is necessary for the delivery of While professional designations and certifi cations go services for people with addiction. As previously dis- a long way in upholding a standard of care, these ap- cussed, addiction services are often siloed from the proaches will not, on their own, advance the consisten- payment and delivery of traditional medical services cy of high-quality practice across the addiction treat- and mental health services. Addiction treatment and ment fi eld. Too often these certifi cations are limited to recovery services are often developed through a so- specifi c LOCs, service types, and audiences and require cial service model outside of medical care—a model opting in. To address this gap, the measurement para- for payment and service delivery at odds with helping digm needs to encourage and be transparent about people manage what is recognized as a chronic brain the use of best practices by all addiction treatment fa- disease. The current system of payment for addiction cilities and include strategies to care for patients with services in the U.S. marginalizes people with addiction, the added need of chronic pain management. Such a is unpredictable, and does not follow the mechanisms paradigm needs to measure the use of best practices and evidence-based requirements in place for other through a combination of validated data sources and medical treatment. Moreover, a streamlined process is public reporting. The measurement paradigm could needed to ensure adequate compensation of services triangulate quality measures by examining the struc- for patients in need of both addiction care and chronic tures, processes, and outcomes of a facility using a pain management. voluntary treatment facility survey, a crowd-sourced It is important to recognize that while all health care approach to patient experience feedback, and mea- issues are intimately tied with social determinants sures calculated using health insurance claims. An ac- of health, it is inappropriate to focus on those issues cessible website can be built to empower patients and without also ensuring a robust treatment system and their loved ones to navigate to the most appropriate, recovery resources. Combating stigma and discrimina- high-quality care. A website would also be accessible tion requires that compensation systems be put into not just to people with OUD and their families while al- place to allow care for people with addictive disease at lowing state agencies, health insurers, and employers the same level as for those with other conditions. to align policies and payment decisions with the use of expert-agreed upon best practices. Although this is not Compensation: Parity a total solution, given lack of predictable access to in- The federal MHPAEA of 2008 required that some health ternet and devices, it is a start and will allow for a much insurance plans for mental health and addiction ser-

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vices have no less restrictive qualitative or quantitative tual treatment elements in place. This lack of consis- limits than their coverage of other medical conditions tency and transparency must be addressed for value- [16]. This was a landmark law that applied to many based payment structures to progress. Currently, CARF health plans but still left many insured people without has an ASAM LOC certifi cation program through which this protection. A range of other federal and state laws it certifi es programs that meet the specifi c criteria of have added to these protections, often simply called the LOCs described above. This type of certifi cation, “parity.” But these protections are only as good as their coupled with recent lawsuits that health plans must enforcement—and there is no robust enforcement of use national placement payment criteria for parity these parity requirements. compliance [48], has the potential to set the ground- The concept of parity brings into stark relief the de- work for improving quality and decreasing cost. fi ciencies of the current addiction treatment system. The ability to gather data on each patient’s journey Typically, health plans would not pay for health care through the health care system can be achieved by em- services that do not adhere to basic quality standards, bedding a standardized high level of addiction-related such as the ability to prescribe medications to manage data capture into EHRs. Doing this will not only allow their condition. Yet the majority of addiction treatment for the EHRs to collect and report data that can be tied programs in the country fail this basic test, while si- to payment but can also allow for measurement of the multaneously receiving payment often from federal or consistency in services provided. Pay-for-performance state grants. “Parity” does not apply to those funding programs are predicated on incentivizing providers sources. to get better outcomes for less cost without avoid- ing quality standards. The initial Health Maintenance Compensation: Value-Based Payments and Fee Organizations of the 1980s often failed because they Structures skimped on providing needed services to save money Many health care organizations have been working in the short term while setting patients up for harm to develop and implement alternative payment mod- and increased costs at a later date. Holding providers els that link payment to the ongoing management of receiving payment to baseline quality standards, which chronic conditions or episodes of care as well as im- is done currently throughout medicine, is noticeably provements in patient health outcomes instead of absent in addiction treatment. fragmented payments for each face-to-face encounter. Payment dictates capacity over time. Whether fee- Patient-centered medical homes and behavioral health for-service or a value-based payment structure, if the integration are models that may be applicable to ad- payment for services is inadequate, an inadequate ca- diction treatment, but there are also some models pacity will develop. If payment is provided for legacy that are specifi cally designed to improve patient health care, which is not evidence-based or consistent with outcomes in addiction medicine. Examples include the the standard of medical practice, such substandard Vermont Hub and Spoke model [72], the Virginia Med- care will proliferate in defi ance of the underlying spirit icaid Addiction and Recovery and Treatment Services of parity or stated wish to eliminate stigma and dis- (ARTS) model (see case example in Box 1), and the Pa- crimination. Payment structures must be suffi cient to tient-Centered Opioid Addiction Treatment model [73]. support the delivery of medically appropriate care. The In addition, Medicare began paying for offi ce-based argument from payers that “there is no capacity for OUD treatment with monthly bundled payments and good care, so we have to pay for whatever is out there” for OTP services with weekly bundled payments in would be challenged if the disease in question were 2020. cancer or diabetes rather than addiction. A promising Fundamental to value-based payment adoption is case example is that of Virginia Addiction and Recovery the requirement for consistency and clarity around the Treatment Services (ARTS), which expanded addiction services being provided. Each state licenses programs treatment coverage in line with Medicaid expansion, and facilities with diff ering requirements, making it im- focused on alignment with the ASAM Levels of Care possible for payers who manage benefi ts to truly com- [50]. pare the value of programs across state lines. Further, because there is currently no standardized external Compensation: Grant Funding evaluation of the clinical care capacity of programs, Much of the addiction care system is funded by federal payers and patients have no way to determine the ac- and state grants, rather than traditional health plans

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such as Medicaid and Medicaid Managed Care Orga- ensure the treatment available is appropriate—can be nizations. This process puts funding into an unsustain- expected to deliver the same impacts in the near term. able process dependent upon annual appropriations and places it outside the usual medical quality assur- Compensation: Telehealth ance requirements and processes that are in place for The biggest hurdle of large-scale uptake of telehealth other medical conditions. For example, Medicaid and services for addiction treatment has been compensa- Managed Medicaid provide data based on services tion because of reimbursement barriers. During the received with claims on each individual, but a Decem- COVID-19 public health emergency, CMS announced ber 2020 U.S. Government Accountability Offi ce (GAO) signifi cant Medicare fl exibilities for providing virtual analysis of SAMHSA Substance Abuse Prevention and care to lessen the regulatory burden, keep patients at Treatment Block Grant Programs stated that the data home, and decrease transmission of COVID-19. In do- on individuals served by these programs are unreliable ing so, the practice of medicine was not only permit- [67]. ted under Medicare, but encouraged, to be off ered via The U.S. has attempted to impact the overdose crisis telehealth. For many providers, virtual visits were one by allocating billions of new dollars to treat addiction of the few sources of revenue to replace the drastic de- and, in particular, for opioid addiction systems through crease in revenue from the loss of in-person care. the State Targeted Response to the Opioid Crisis Grants Now that some of these compensation barriers have and State Opioid Response grants. The GAO revealed become more fl exible in light of the COVID-19 pan- that states had signifi cant diffi culty in spending the demic, it is critically important to meet the standard grant funds that were available to them [67]. Multiple of care and avoid situations of potential fraud, waste, states had not accessed half of the funding available or abuse of the newly allowed fl exibilities. Particular to to them within one month of the end of the 24-month the treatment of addiction has been the need to pre- grant period, and most states faced challenges in fully scribe MOUD using telehealth. Previous to COVID-19, spending the monies made available. this practice was restricted and limited due to DEA Issues identifi ed as barriers to spending existing regulations for prescribing controlled substances via grants included lengthy contracting processes because telehealth—most notably the Ryan Haight Act’s in- of state rules, implementation delays, and surpris- person exam requirement. The SUPPORT ACT (Public ingly, provider reluctance to participate. Offi cials from Law No: 115-271) mandated the DEA to make the over- multiple states indicated that some providers and lo- due clarifi cations and process for a special registration cal jurisdictions were reluctant to accept grant fund- to engage in the practice of telemedicine. This issue ing because they could not ensure the funding would remained unresolved at the time of the onset of CO- continue after two years of hiring additional personnel, VID-19 and the new telehealth fl exibilities by the DEA as well as reluctance to provide maintenance medica- overrode the Ryan Haight Act. In doing so, several key tion treatment such as buprenorphine [32]. Insuffi - changes emerged, including the ability to prescribe cient treatment capacity was ubiquitously identifi ed controlled medications via telemedicine for a new pa- as a main barrier to spending hundreds of millions of tient not already in established care and via audio-only dollars of grant funds, particularly in rural areas, and initiation with respect to buprenorphine for the treat- the shortage of treatment professionals such as physi- ment of OUD. These unprecedented circumstances cians and licensed social workers trained in addiction could be built on to avoid gaps in care and gaps in pre- was noted as especially lacking. scription coverage during a time of particularly high Given that the grant programs noted above repre- risk of overdose. sent some of the most signifi cant recent federal fund- Compensation: State Medicaid Coverage ing approaches to address the opioid crisis, it is critical One of the most important considerations to ensuring to understand the lessons learned from those eff orts appropriate compensation is the availability of Med- to date. Simply allocating additional funding via grant icaid in individual states or other supporting health programs into the current educational and legacy treat- insurance to cover people with addiction. As the U.S. ment programs has not led to a decrease in overdose entered into the opioid overdose epidemic, the states deaths. Further attempts to fund care—before funding that had expanded Medicaid under the provisions of universities and other training programs for providers the Aff ordable Care Act had a head start over non-ex- and before funding quality oversight mechanisms to pansion states on covering medication for MOUD and

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addiction treatment services. Without this expansion across the U.S., where behavioral health conditions to cover the cost of treatment, patient outcomes are remain a signifi cant source of absenteeism, workers signifi cantly worse. As the opioid overdose epidemic is compensation, and disability issues. Access to behav- changing to one driven by illicit fentanyl, methamphet- ioral health services, including addiction treatment, is amine, and cocaine, it will be essential to ensure that often challenging because of a series of factors includ- all SUDs can be addressed, which will undeniably put ing in-network provider availability (and specialization further strain on the system to provide adequate care. in the case of SUD), insurance coverage, and stigma. Simple supply and demand can be applied to this Payment change must precede (or at least coincide problem—if there is an inadequate supply of evidence- with) quality and capacity improvement to adequately based care, one way to alleviate the problem is to in- fund sustainable improvements. While payment rates crease the compensation for that care. In the case of from commercial plans are typically higher than Medic- Medicaid and Medicare payments, there are other aid, low rates by these payers contribute to inadequate structural impediments, including: access to quality care. The following list highlights spe- cifi c commercial plan coverage challenges that must be 1. use of fee schedules that do not reimburse for addressed. needed services (physicians and providers can- not be reimbursed if there is a primary care pro- 1. High payments: Extremely high payments are vider visit and an addiction specialist visit on the processed for out-of-network and out-of-state same day); low-quality providers. Continuing to pay provid- 2. low reimbursement rates that require volume- ers who provide care that is not only unhelpful driven care; but actively harmful diverts resources from en- 3. low rates, which lead to very thin margins, limit- suring the availability of quality care and leads ing expansion and quality improvement by pro- to increased attitudes that “treatment doesn’t viders; work.” 4. access barriers such as prior authorizations for 2. Human resources departments: Those en- medications to treat addiction; gaged in benefi t systems to employee assistance 5. grants versus sustainable funding development plans and interfacing with direct supervisors for SUD treatment programs; should be approach addiction in the same man- 6. lack of technical assistance support to assist ner as other medical conditions [68]. grant-funded legacy providers in the evolution 3. Network adequacy: These issues include the to evidence-based care with billable services and availability of a suffi cient number of qualifi ed fi nancial stability; and in-network providers who are accepting new pa- 7. lack of requirements to provide standard of care tients, the wait time for appointments, the dis- in order to receive payments. tance and travel time (geographic access cover- age) to these providers’ offi ces, and telemedicine It is often noted that, particularly in behavioral health, service access for the individuals covered by the “health care coverage does not equal health care ac- plan. cess.” While that can hold true, adequate payment is a 4. Total cost of care: Payers should be held ac- critical step to increase access to evidence-based treat- countable to gather and maintain a total cost of ment for addiction. care and total quality of care for individual em- ployees. Siloed data between behavioral health, Compensation: Commercial Plans medical, lab, and imaging claims for patients is The need to ensure value in health care services has problematic to understanding the true cost of led to the management of health care benefi ts by most medical care. An overemphasis on decreasing a employer-sponsored plans, Medicaid, and many feder- behavioral health cost to the business purchas- al health care purchasers. Lack of enforcement of the ing the health plan may lead to underestima- range of parity laws and regulations has allowed con- tion of the additional related medical costs (e.g., tinued discrimination in the coverage of mental health when a person who is not receiving appropriate and addiction conditions. The ramifi cation of this is addiction treatment has a motor vehicle acci- well known within human resources departments dent with resultant major medical expenses).

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Accurate data for patients and dependents can will not pay for treatment of OUD. All hands drive greater access to and use of more valuable must be on deck to treat addiction comprehen- addiction care. sively. (capacity, competency, and compensa- 5. Parity laws: Working with state departments tion) of insurance, the US Department of Labor, and 3. Shift funding incentives to programs that meet other responsible agencies’ state attorneys gen- baseline quality standards and demonstrate eral to conduct and meaningfully enforce state positive outcomes. Increasing payment for qual- and federal mental health and SUD parity laws. ity treatment that meets baseline care standards This includes requiring health insurance compa- will be necessary for those programs to develop nies and behavioral health management organi- and grow. (consistency and compensation) zations to demonstrate compliance at the time 4. Eliminate the barriers of information exchange. of rate and form fi ling. Because parity laws are Incentivize EHR data capture. Incentivize payers comparative by design, comparative analyses to integrate claims data for individuals across the should be provided before plans are approved range of carve-outs including behavioral health, to be marketed and sold to consumers. medical, pharmacy, and laboratory. (competen- 6. Expansion: People across the U.S. continue to cy, consistency, and compensation) be devastated by the eff ects of drug use, ill-in- 5. Standardize care delivery levels and ensure com- formed drug policies, addiction, and overdose— pliance with requirements. Standardize LOCs by particularly Black, Latinx, Native American, and licensing and contracting treatment programs other traditionally marginalized communities. by national criteria such as the ASAM Criteria. New payment structures need to take into ac- Require oversight of programs via an indepen- count these issues and create culturally in- dent evaluation of clinical care quality including formed approaches. state on-site inspections, CARF’s ASAM LOC certi- fi cation, or other means. (consistency) Priorities for Ensuring Accountability and 6. Enforce current parity laws and regulations. Cur- Transparency in Addiction Treatment rently, parity or MHPAEA, is without signifi cant The resources available to support addiction care will enforcement action. While the specifi c nature of always be fi nite, but signifi cant improvements can be proposed enforcement legislation is beyond the made. The U.S. addiction care delivery system was not scope of this report, all federal and state parity built upon the understanding of addiction as a chronic rules require attention and active enforcement. medical condition and can hardly be described as a (compensation) “system” at all. It has largely been funded outside the 7. Find and eliminate instances of fraud and preda- medical system, and therefore lacks the quality require- tory practices that have arisen as a result of poor ments in place for other types of medicine. The time enforcement of quality standards—for example, for transparency and accountability has come. Build- “phantom networks” where health plans identify ing capacity, competency, and consistency requires that they have suffi cient addiction providers, but leadership in the compensation quarter. The following when a patient calls them, these alleged provid- priorities, while not exhaustive, list fundamental areas ers will not see them. Secret-shopper programs to be addressed to move the U.S. into an eff ective and should be used to identify the extent of plan effi cient system of care. phantom networks, with substantial penalties for the plans that contain them. (compensation) 1. Identify and ensure availability of the entire con- tinuum of care as defi ned by state and national Prioritizing these areas and considering the full range guidelines and the capacity priorities outlined in of the addiction treatment system will help to move this manuscript. (capacity) the U.S. into a paradigm where we treat addiction as 2. Ensure qualifi ed providers can bill for treatment the chronic relapsing disease that it is and ensure that of addiction by eliminating the coverage chasm those with addiction have access to comprehensive, in which a behavioral health plan will only reim- durable, high-quality, and evidence-based treatment. burse psychiatrists or board-certifi ed addiction specialists to treat OUD, and the medical plan

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NAM.edu/Perspectives Page 25 DISCUSSION PAPER

acteristics and current clinical practices of opioid Corey Waller, Kelly Clark, and Andrey Ostrovsky treatment programs in the United States. Drug are members of the Prevention, Treatment, and and Alcohol Dependency 205:107616. https://doi. Recovery Working Group of the Action Collaborative on org/10.1016/j.drugalcdep.2019.107616 Countering the U.S. Opioid Epidemic, along with Mitra 72. Brooklyn, J. R., and S. C. Sigmon. 2017. Vermont Ahadpour of the U.S. Food and Drug Administration; Hub-and-Spoke Model of Care for Opioid Use Dis- Jennifer Atkins of Blue Cross Blue Shield Association; order: Development, Implementation, and Impact. Robin Begley of the American Hospital Association; Journal of Addiction Medicine 11(4):286-292. https:// David Beier of Bay City Capital; Kate Berry of doi.org/10.1097/ADM.0000000000000310 American’s Health Insurance Plans; Carlos Blanco of 73. American Society of Addiction Medicine. n.d. Patient- the National Institute on Drug Abuse; Jay Bhatt of the Centered Opioid Addiction Treatment (P-COAT): Alter- University of Illinois at Chicago School of Public Health; native Payment Model (APM). Available at: https:// Richard Bonnie of the University of Virginia; Elizabeth www.asam.org/docs/default-source/advocacy/ Connolly of The Pew Charitable Trusts; Allan Coukell asam-ama-p-coat-final.pdf?sfvrsn=447041c2_2 of CivicaRx; Anna Legreid Dopp of the American (accessed January 27, 2021). Society of HealthSystem Pharmacists; Ed Greissing of 74. U.S. Department of Health and Human Services. the Milken Institute; Helena Hansen of the University 2020. Telehealth: Delivering Care Safely During CO- of California, Los Angeles; Christopher M. Jones of the VID-19. Available at: https://www.hhs.gov/corona- U.S. Centers for Disease Control and Prevention; Kelly virus/telehealth/index.html (accessed March 19, King of the American Institutes for Research; Roneet 2021). Lev of the Offi ce of National Drug Control Policy; 75. National Harm Reduction Coalition. 2020. Guide to Bertha Madras of McLean Hospital and Harvard Developing and Managing Syringe Access Programs. Medical School; Richard Migliori of UnitedHealth Available at: https://harmreduction.org/issues/ Group; Bobby Mukkamala of the American Medical syringe-access/guide-to-managing-programs/ (ac- Association; Alonzo Plough of the Robert Wood cessed March 19, 2021). Johnson Foundation; Carter Roeber of the Substance Abuse and Mental Health Services Administration; DOI Elizabeth Salisbury-Afshar of University of Wisconsin School of Medicine and Public Health; Joshua https://doi.org/10.3147/202104b Sharfstein of Johns Hopkins University; Matthew Stefanko of Shatterproof; Edna Boone Temaner, a Suggested Citation Health Information Technology Subject Matter Expert; Waller, R. C., K. J. Clark, A. Woodruff , J. Glossa, and Brooke Trainum of the American Nurses Association; A. Ostrovsky. 2021. Guide for Future Directions and Sarah Wattenberg of the National Association for for the Addiction and OUD Treatment Ecosystem. Behavioral Healthcare. NAM Perspectives. Discussion Paper, National Acknowledgments Academy of Medicine, Washington, DC. https://doi. org/10.31478/202104b The authors would like to thank Ashley Jansen, Blue Cross Blue Shield Association; Ayana Jordan, Yale Author Information School of Medicine; Patricia A. King, University of R. Corey Waller, MD, MS, is Managing Director, Vermont Medical Center and Past Chair, Federation of Institute on Addiction, Health Management Associates. State Medical Boards; Regina LaBelle, LaBelle Strat- Kelly J. Clark, MD, MBA, DFAPA, DFASAM is President egies; Penney Cowan, American Chronic Pain Asso- of Addiction Crisis Solutions and the Immediate ciation; and Penny S. Mills, MBA, the Doug Brown Past President of the American Society of Addiction Executive-in-Residence at Cornell University for their Medicine. Alex Woodruff , MPH, is a policy analyst at thoughtful contributions to this paper. the Partnered Evidence-based Policy Resource Center, VA Boston Healthcare System. Jean Glossa, MD, This paper also benefi ted from the input of Rodrigo MBA, is Managing Director, Delivery System, Health Garcia, Parkdale Center; Cortney Lovell, Our Well- Management Associates. Andrey Ostrovsky, MD, is ness Collective and Families Together in New York Managing Partner, Social Innovation Ventures. State; Joy Rucker, Texas Harm Reduction Alliance;

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Daniel Sledge, Williamson County Mobile Outreach Team; and Joycelyn Woods, NAMA Recovery.

Aisha Salman, Jenna Ogilvie, and Elizabeth Finkel- man of the National Academy of Medicine also pro- vided valuable support.

Confl ict-of-Interest Disclosures None to disclose.

Correspondence Questions or comments about this paper should be sent to R. Corey Waller at cwaller@healthmanagement. com.

Disclaimer The views expressed in this paper are those of the au- thor and not necessarily of the author’s organizations, the National Academy of Medicine (NAM), or the Na- tional Academies of Sciences, Engineering, and Medi- cine (the National Academies). The paper is intended to help inform and stimulate discussion. It is not a report of the NAM or the National Academies. Copyright by the National Academy of Sciences. All rights reserved.

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