Treatment: Barriers to Access to Care - American Society of Addiction Medicine's Advancing Access to Addiction Medications Initiative

1. Barriers
to
Access
to
Care:
American
Society
of
Addic4on
Medicine’s
Advancing
Access
to
Addic4on
Medica4ons
Ini4a4ve
Na4onal
RxDrug
Abuse
Summit
Atlanta,
GA
April
22,
2014

2. Panelists
–
Commercial
Disclosures
Kelly
J.
Clark,
MD,
MBA,
FASAM
-­‐
Medical
Affairs
Officer,
Behavioral
Health
Group
-­‐
Medical
Director,
CVS
Caremark
Stuart
Gitlow,
MD,
MPH,
MBA,
FAPA
-­‐
Consultant;
Orexo
US
(US
Medical
Director)
-­‐
Consultant;
UNUM,
Metlife,
Pruden4al
Mark
Publicker,
MD,
FASAM
-­‐
none

3. Learning
Objec4ves
1. Explain
the
scien4fic
and
economic
data
suppor4ng
evidence
based
medica4on
treatment
of
opioid
addic4on.
2. Describe
the
current
barriers
for
pa4ents
in
accessing
appropriate
addic4on
treatment.
3. Outline
opportuni4es
for
pa4ents
to
access
treatment.

4. American Society of Addiction Medicine
(ASAM)
Professional society founded in 1954 representing 3,100+
physicians & other associated professionals
Mission:
– Increase access to & improve the quality of addiction
treatment
– Educate physicians, other health care providers & public
– Support research & prevention
– Promote appropriate role of the physician in patient care
– Establish addiction medicine as a recognized specialty

5. ASAM
Defini4on
of
Addic4on
Addiction is a primary, chronic disease of brain reward, motivation, memory and
related circuitry. Dysfunction in these circuits leads to characteristic biological,
psychological, social and spiritual manifestations. This is reflected in an
individual pathologically pursuing reward and/or relief by substance use and
other behaviors.
Addiction is characterized by inability to consistently abstain, impairment in
behavioral control, craving, diminished recognition of significant problems with
one’s behaviors and interpersonal relationships, and a dysfunctional emotional
response. Like other chronic diseases, addiction often involves cycles of
relapse and remission.
Without treatment or engagement in recovery activities, addiction is progressive
and can result in disability or premature death.
Adopted by ASAM Board of Directors April 12, 2011.

6. Project
Approach:
Key
Phases
Mission: Advocate for patient access to
appropriate evidence-based, cost-effective
medication treatment for opioid dependence.
Phase
I
Start-­‐up
and
Data
Collec4on
Phase
II
Data
Synthesis
and
Repor4ng
Phase
III
Collabora4on
and
Outreach

7. Project
Phases,
Cont’d
PHASE ONE
1. Patient Advocacy Task Force appointed by ASAM Board
Members: Drs. Kraus and Soper (Co-chairs); Drs. Clark, Christiansen, Gaskin,
Publicker, Roy, and Shore
2. ASAM secured financial and endorsement support from public and private partners
3. Payer policy and legal research conducted by leading organizations
PHASE TWO
1. Advancing Access to Addiction Medications Report issued June 2013; stakeholder
summit and press conference in Washington, DC
2. Online outreach toolkit developed
3. National Speakers Bureau organized
PHASE III
1. Federal briefing in October 2013; ongoing participation in stakeholder conferences
and briefings
2. Communications strategy approved; outreach continued
3. Targeted policy briefs and payer policy updates under development

8. AAAM
Research
• State
Medicaid
survey
of
coverage
&
access
• Commercial
insurer
survey
of
coverage
&
access
• Literature
reviews
of
clinical
and
cost
effec4veness
of
medica4ons
to
treat
opioid
addic4on
• TRI
and
Avisa
Group
retained
to
do
research
• Available
on
ASAM
website
(www.asam.org)

9. Advancing
Access
to
Addic4on
Medica4ons
(AAAM)
May
2011:
Dr.
Mark
Publicker,
an
ASAM
addic<on
specialist
physician,
alerted
ASAM
to
Maine
legisla<on
that
limits
pa<ent
access
to
addic<on
medica<ons.
April
2012:
ASAM
Board
of
Directors
appointed
a
Pa<ent
Advocacy
Task
Force
(PATF)
to
advocate
for
pa<ent
access
to
evidence-­‐
based,
cost-­‐effec<ve
medica<on
treatment
for
opioid
dependence.
June
20,
2013:
PATF
Stakeholder
Summit
at
The
Na<onal
Press
Club
in
Washington,
DC;
Report
results
are
disseminated.
September
30,
2013:
ASAM
Hill
Briefing
on
pharmacotherapy
for
opioid
addic<on
treatment.
October
23,
2013:
ASAM
Legisla<ve
Day
on
Capitol
Hill;
ASAM
members
bring
awareness
of
the
issue
to
policymakers.

10. What
is
Medica4on
Assisted
Treatment
(MAT)
of
Opioid
Addic4on?
– Use
of
medica4on
with
FDA
approved
primary
indica4on
for
the
maintenance
treatment
of
opioid
dependence:
• Methadone
in
Opioid
Treatment
Programs
(OTPs)
• Buprenorphine
(Suboxone,
Zubsolv
brand
names)
• Extended
release
naltrexone
shots
(Vivitrol
brand
name)
– While
we
don’t
have
special
alcohol
or
methamphetamine
or
cocaine
brain
receptors,
humans
do
have
opioid
receptors
– At
adequate
doses,
these
three
medica4ons
sit
on
the
receptors
and
block
their
availability
for
other
opioids
to
be
used
to
“get
high”

11. Clinical
provision
of
MAT
– Methadone
• Daily
dosing
in
specially
licensed
centers
(OTPs)
• Increasing
privileges
earned
over
4me
• Required
counseling,
call-­‐backs,
drug
tes4ng
– Buprenorphine
• Prescrip4ons
can
be
given
at
a
doctor
office
• Ability
to
refer
to
counseling
is
required
– Extended
release
naltrexone
• Once
monthly
shot
must
be
procured
by
and
given
in
provider’s
office

12. Keep
in
mind:
– Addic4on
is
a
chronic
disease
– These
medica4ons
are
FDA
approved
for
Opioid
Dependence,
and
act
on
the
opioid
receptors
• We
do
not
expect
them
to
have
any
significant
impact
on
use
of
non-­‐opioids,
even
though
they
“treat
addic4on”
• 12
step
mee4ngs,
individual/group/family
counseling
,
and
reward/repercussion
systems
address
other
drug
sue

13. What
do
effec4veness
and
cost
effec4veness
mean
-­‐
Pa4ents
– Health
Effec4veness
Outcomes:
mortality
(
not
dying),
morbidity
(
not
geing
Hep
C,
HIV,
other
skin
and
heart
infec4ons,
liver
disease,
etc)
– Interpersonal:
Regaining
child
custody,
marriage,
func4oning
in
family
system
– Voca4onal:
improved
work/school
func4oning
– Legal:
decreased
legal
involvement
– Financial:
money
to
be
used
produc4vely
rather
than
on
drugs

14. What
do
effec4veness
and
cost
effec4veness
mean
-­‐
Community
– Health
cost-­‐effec4veness:
less
ED
visits,
hospitaliza4ons,
costs
of
trea4ng
addic4on-­‐caused
condi4ons
– Interpersonal:
ability
to
parent
children
(
not
orphan
them;
not
involving
child
services
/
foster
care
system)
– Voca4onal:
improved
workforce
contribu4on
– Criminal
Jus4ce:
decreased
legal
involvement
AND
decreased
engagement
in
illegal
ac4vi4es
– Financial:
money
to
be
used
produc4vely
rather
than
fuel
drug-­‐
based
economy

15. Methadone
and
Buprenorphine:
-­‐ Reduce
opioid
use
more
than:
-­‐ No
treatment
-­‐ Outpa4ent
treatment
without
medica4on
-­‐ Outpa4ent
treatment
with
placebo
medica4on
-­‐ Detoxifica4on
only
-­‐ Reduce
overall
medical
costs:
-­‐
Related
to
Emergency
Department
use
-­‐
Related
in
inpa4ent
hospitaliza4ons

16. TRI
Review
of
Effec4veness
of
MAT
• Hundreds
of
effec4veness
studies
(methadone)
• All
medica4ons
have
demonstrated
modest
or
beker
cost
effec4veness
in
maintenance
• No
evidence
for
effec4veness
in
detoxifica4on
• All
medica4ons
are
under-­‐u4lized

18. Barriers
to
Access
– S4gma?
– Lack
of
understanding
of
the
data?
– Lack
of
providers?
• 30/100
pa4ent
limit
for
bupe?
State
wai4ng
lists
for
methadone?
• Lack
of
geographical
access
to
treatment?
– Cost?
– Health
Plan
coverage?
– U4liza4on
Management
Protocols?
– Legisla4ve
and/or
Regulatory
Restric4ons?

19. AAAM
State
Medicaid
Survey
Results
• Every
state
Medicaid
program
covers
at
least
one
of
the
FDA-­‐
approved
medica4ons
• Many
state
Medicaid
programs
have
a
variety
of
authoriza4on
requirements
which
must
be
met
for
these
medica4ons
to
be
approved
• Requirements
for
approval
range
from
limited
to
severe,
and
may
include
“fail
first”
policies
or
a
history
of
frequent
service
u4liza4on

20. Commercial
Insurer
Findings
• No
commercial
plans
covered
methadone
• Inclusion
in
a
plan’s
formulary
does
not
equate
to
easy
access
• U4liza4on
management
(UM)
can
reduce
access
• Most
common
UM
requirements
are:
– Prior
authoriza4on
– Quan4ty
and
dosage
limits
– Step
therapy
or
“fail
first”
requirements

21. Coverage
of
All
Three
FDA-­‐Approved
Medica4ons
for
the
Treatment
of
Opioid
Dependence

22. Life4me
Limits
on
Prescrip4ons
for
Buprenorphine

23. Types
of
limita4ons:
• Limits
on
dose
• dura4on
of
treatment
• number
of
treatment
episodes
• life4me
limits
• required
tapering
schedules
• required
ancillary
services
(
counseling)
which
may
not
be
covered

24. Direct
Costs
• Methadone
=
$70-­‐$130
per
week
(includes
medica4on,
counseling,
doctor,
urine
screens,
nursing/pharmacist
dispensing
service)
• Buprenorphine
medica4on
=
$7
per
tab/film.
Package
insert
may
be
up
to
5
individual
tab/
films
per
day
(2
“large”
and
3
“small”)
• Extended
release
naltrexone
$700+
injec4on
once
per
month.

25. Buprenorphine
a
“top
cost”
for
Medicaid
pharmacy
plans
Example:
In
the
State
of
Michigan
buprenorphine
products
are
the
#1
cos4ng
medica4ons
in
their
Medicaid
formulary.
However,
note
that
“pain
pills”,
like
hydrocodone
plus
acetaminophen,
have
mul4ple
generics
and
are
typically
inexpensive.
They
are
“low
cost”
medica4ons!

26. Issues
of
Diversion
• Methadone
requires:
• random
call
backs
• urine
screens
• inges4on
in
front
of
nurses
• daily
dosing
un4l
earning
take
home
doses
• take
home
doses
must
be
in
locked
box
• Formula4on
(liquid,
5
mg
and
40
mg)
different
than
methadone
formula4on
for
pain
(10
mg)

27. Issues
of
Diversion
• Buprenorphine:
• Reports
of
pa4ents
receiving
higher
than
necessary
doses
and
selling
or
sharing
“extra”
doses
• Payer
then
is
subsidizing
this
costly
diversion
• Diversion
highest
where
access
is
lowest
• No
counseling,
call
backs,
drug
screens,
inges4on
in
front
of
staff,
specific
formula4ons
are
required
• Extended
Release
Naltrexone:
no
diversion
poten4al
reported

28. How
can
we
help
pa4ent’s
access
treatment?
Educate
and
Advocate!
– For
MAT
to
be
including
in
health
plan
coverage
under
Parity
as
part
of
the
con4nuum
of
care
– Improving
the
coordina4on
of
care
throughout
the
con4nuum
of
care
– Educa4ng
stakeholders
about
the
medical
and
economic
benefits
of
MAT
– Helping
educate
stakeholders
about
what
cons4tutes
appropriate
care
for
opioid
addic4on
guideline
development

29. ASAM’s
Next
Steps
• Partnering
on
the
development
of
ASAM’s
Na<onal
MAT
Guidelines
• Partnering
at
the
chapter
and
na4onal
level
with
a
variety
of
concerned
stakeholders
• Crea4ng
briefs
and
toolkit
from
research
for
use
by
all
for
local
outreach
• Building
and
training
speakers
bureau
• Planning
for
2014
na4onal
outreach
day

30. Thank
you!
Stay
tuned
for
next
steps.
All
reports
are
available
online
at:
hkp://www.asam.org/docs/advocacy/
Implica4ons-­‐for-­‐Opioid-­‐Addic4on-­‐Treatment