For individuals with substance use disorder, access to evidence-based treatment is a major issue. Addiction treatment medications are highly regulated, the workforce is inadequate and unevenly distributed, and treatment programs lack quality standards. The American Society of Addiction Medicine (ASAM) is changing that.
ASAM advocates for legislative and regulatory changes that will increase patient access to the three medications clinicians use to treat opioid use disorder. Two of the medications, buprenorphine and methadone, are themselves opioids. “Because they’re opioids, this has created stigma around them, and they are subject to far more regulation than opioids that are prescribed for pain,” says Penny Mills, executive vice president and CEO of ASAM. “From ASAM’s perspective, we believe that patients and clinicians should have access to all of the available medications because you don’t know what’s going to work with each patient.”
In 2016, ASAM advocated for passage of legislation that granted nurse practitioners and physician assistants the ability to prescribe buprenorphine. Before 2016, it was the sole medication in the United States that only physicians could prescribe, and this new legislation significantly expands treatment options in underserved areas. “The opioid epidemic particularly has hit rural areas,” Mills says. “There are a lot of rural areas where there are no physicians, but there may be a nurse practitioner or a physician assistant who could care for the patient.”
However, physician assistants’ and nurse practitioners’ ability to prescribe is limited, both by the legislation itself, which was written to sunset in five years, and by state regulations around the prescribing of controlled substances. Some state regulations specifically prohibit nurse practitioners and physician assistants from prescribing buprenorphine. Others require them to have a collaborative arrangement with a physician who has a waiver to prescribe the medication, which can be challenging in certain rural areas.
“This is an example of where you get a win at a federal level and then you have to battle it out on the state level,” Mills says. “Sometimes, you take a step forward at the federal level and then you take 50 little steps backward at the state level.”
Even physicians with prescribing privileges were limited in how many patients they could treat. Legislation and regulation specified that a physician could treat no more than one hundred patients with buprenorphine. “There is no other medication in the United States where the number of patients a doctor can treat is limited by law,” Mills says. ASAM fought this rule on both the legislative and regulatory sides, and in 2016, a new regulation was enacted that increased the patient limit from one hundred to two hundred and seventy-five, further increasing patients’ access to the medication.
To increase the number of physicians working in rural areas, ASAM is advocating for a loan forgiveness bill that would offer financial compensation for addiction and mental health professionals who serve in underserved areas for a set amount of time. They are also advocating for legislation that would provide incentives to medical schools to incorporate content related to managing patients with opioid use disorder and pain into their curriculum. Medical students who complete this curriculum content would be eligible for a waiver to prescribe buprenorphine upon graduation.
Currently, physicians who are not addiction specialists have to take at least eight hours of education to apply for a prescription waiver, and for nurse practitioners and physician assistants, the training is three times as long. ASAM was the first organization to provide training for nurse practitioners and physician assistants, in collaboration with the American Association of Nurse Practitioners and the American Academy of Physician Assistants. At time of publication, more than ten thousand nurse practitioners and physician assistants had registered for the training, and around half of them had completed it, allowing them to apply for a waiver. “That’s a pretty phenomenal impact from legislation to practice,” Mills says.
In 2016, ASAM increased its partnerships and amplified its voice through the creation of the Coalition to Stop Opioid Overdose. “We like to say we’re small but mighty. We have five thousand members, and compared to many other professional societies, that’s relatively small,” she says. “And we do this by bringing other voices to the table to advocate for these legislative and regulatory changes.”
Medication is a central part of treatment for opioid use disorder, but there aren’t medications to treat addiction to methamphetamines, cocaine, and other substances. Furthermore, even when medications are an option, psychosocial services are also offered to support the patient’s full recovery. To more accurately match patients with appropriate treatment and levels of care, ASAM created the ASAM Criteria, a set of guidelines for assessment, service planning, placement, continued stay, and transfer or discharge of individuals with addiction and co-occurring conditions.
The criteria are now used by more than thirty states and many private payers to make medically necessary determinations for what level of care a patient needs. “It has been validated and researched that if you send the patient to the right level of care, you get a better outcome,” Mills says. “If you either send someone to too low a level of care or even too high a level of care, you don’t have as good an outcome.”
In 2018, ASAM will launch a certification program, which will certify that programs deliver the stated services for their level of care, as well as advocating that all patients receive a standardized assessment to match them to the appropriate level of care. Currently, a program might state that they are a residential program without clarifying whether they are a level 3.7 residential program, which has onsite physicians and nurses, or a level 3.1 residential program, which does not.
These long-term solutions, from legislative changes to standardizing care, are central to addressing substance use disorder in the United States. “This problem has been in the making for more than twenty years, and you’re not going to turn it around with $4 billion in the 2018 budget,” she says. “It’s going to take long-term changes and long-term investment.”