The fight against opioids requires better payment of doctors and education

WASHINGTON – Despite the many barriers to expanding treatment access for opioid-related disorders, bright spots are emerging, clinicians, government officials and policy experts say at a workshop here .

Efforts are underway to reduce stigma, properly train and reimburse physicians and target special populations. But they do not meet the needs.

"Of the estimated 2.1 million people with opioid-related disorders, only 30% received treatment at a specialty facility or private doctor's office," said Mark McClellan, MD, PhD, director of the Duke Center. Margolis the National Survey on Drug Use and Health, recently published by the Administration of Substance Abuse and Mental Health Services (SAMHSA).

The lack of trained doctors to intervene, reimbursement issues and stigma all contribute to the low treatment rate, said Janet Woodcock, MD, director of the FDA's Center for Evaluation and Drug Research. (The workshop was organized by the Duke-Margolis Center for Health Policy as part of a cooperation agreement with the FDA.)

But "the major problem is that medical treatment is often not even tried," she said.

"Do not try to treat an often fatal disease – it's not something that we see very often in medical care."

Fight stigma

On the one hand, there are not enough providers willing to treat patients with opioid-related disorders. On the other hand, many patients with an opioid-related disorder do not believe they need treatment, suggested experts at the workshop.

Panelists from the one-day workshop debated both sides of the issue: access to voluntary providers and the engagement of reluctant patients – citing a complex set of factors, including external and internal stigma, lack of provider training and patient fears.

Stigma often prevents people seeking help for addiction problems or ongoing treatment, said Sharon Stancliff, MD, associate medical director of the Coalition for Risk Reduction for the AIDS Institute.

When the public calls opioid users "addicts" who are "immoral" and "responsible" for their own diseases, this discourages potential patients.

Finally, the fact that patients who use methadone or buprenorphine "replace one addiction with another" upsets Edwin Salsitz, MD, a clinical professor of psychiatry associated with the Icahn School of Medicine in Mount Sinai, New York.

Physical addiction is not necessarily equal to addiction, he said, and the stigma surrounding evidence-based treatment for opioid-related disorders does not serve patients well. .

One way to reduce stigma is to raise awareness of success stories, through social media and in-person visits, for example by former patients at clinics where they received their first treatment, Stancliff said.

Special Populations

Pregnant women with opioid problems are easy targets for stigma.

Universal screening for disorders related to the use of opioids is recommended by the American College of Obstetricians and Gynecologists and by the American Academy of Pediatrics. But Kaylin Klie, MD, founder of the Addiction Treatment Clinics at the University of Colorado and the University of Colorado, pointed out that such screening should take the form of a conversation and not a request for information. urine sample.

Many women worry that if their use of opioids is detected, they will lose custody of their children, which is not an irrational concern, Klie said.

"Some states have laws that protect women[‘s] Toxicological information during pregnancy is not used in criminal charges, but custody of children takes place in civil and non-criminal courts, "she wrote.

Twenty-three states and the District of Columbia consider drug use during pregnancy as an abuse by children, and 24 states and C. require health care providers to report "presumed prenatal use" . However, according to the Guttmacher Institute, 17 states and developing countries grant pregnant women "priority access" to state-funded drug treatment programs.

Yet, research has shown that although they are a "priority" population, pregnant women in most states do not receive treatment at higher rates than non-pregnant people.

Payment challenges

Sarah Wattenberg, director of quality services and addiction at the National Association for Behavioral Healthcare, said that payment policies are the main obstacle to treating opioid-related disorders.

Some payers do not cover drugs for all forms of opioid-related disorders, some do not pay for the full continuum of providers and others do not pay a sufficient number of counseling sessions for a patient. people stay in treatment. Payers can also limit the duration of drugs, forcing patients to reduce them in a "dangerous" way, she said.

A common problem is that paying for office visits is not enough to support the time needed to diagnose and treat patients, said Shawn Ryan, MD, MBA, president and chief medical officer of BrightView, an outpatient treatment firm. .

The American Society of Addiction Medicine and the American Medical Association have jointly designed an alternative payment model, the treatment of patient-centered opioid dependence, which encourages non-visual services, including appeals. outpatient treatment programs and other health providers.

The outpatient model involves a one-time payment for the initiation of MAT with monthly payments for maintaining the medical and psychosocial aspects of care.

Each physician's practice is measured by factors such as the percentage of patients who comply with their treatment plan and the average risk-adjusted number of opioid emergency visits per patient.

Ryan sees payment innovation as an urgent need, arguing that without proper reimbursement, physicians (many of whom already have many records) will not take the time to evaluate and treat patients with opioid-related disorders .

Education, Supplier Awareness

Raising awareness among physicians and clinicians is one of the last hurdles to reducing stigma.

"We really need to ensure that all health professionals can screen, diagnose and, if not treat, refer" patients with opioid-related disorders, "said Kathryn Cates-Wessel, CEO and Executive Director of OI. American Academy of Addiction Psychiatry. MedPage today after speaking at the workshop.

She highlighted an initiative, the Providers Clinical Support System for Assisted Medical Treatment, which provides training in the identification and treatment of patients using MAT, as well as the prevention of abuse. # 39; opioids. Physicians can receive free buprenorphine waivers and listen to webinars and podcasts.

The group also offers free, individual or group coaching focused on specific clinical cases or other issues, and people seeking advice can also post questions on a discussion board anonymously, under the surveillance of addiction specialists.

A second program, executed through a grant from SAMHSA State Targeted Response – Technical Assistance, provides even more comprehensive technical support, provided by a group of physicians experienced in MAT, recovery and prevention.

2018-09-21T18: 15: 00-0400