January 09, 2020
Addiction treatment is often associated with inpatient rehabilitation services, where patients are committed for a period of time. But there are several pathways to addressing addiction. In fact, most treatment is in relatively inexpensive community and outpatient facilities that are often supplemented with self-help groups. But inpatient rehabilitation likely gets more attention because of the increased costs.15 There is no “right way” to treat addiction. The brain is complex and what works for one patient might not be effective for another.2,16
For many people with SUD, medication-assisted therapy (MAT), provided concurrently with behavioral health interventions, can be an effective treatment. For opioid addiction, extended-release naltrexone, buprenorphine, and methadone are effective treatments that help individuals in acute detox situations wean themselves off of prescription opioids or heroin. MAT is also used for active ongoing treatment to help patients with SUD live a functional life.17 Methadone is most effective when used for at least 12 months.18
For alcohol use disorder, naltrexone and acamprosate are effective for many people at preventing a return to drinking. For every 12 patients who take acamprosate, one is prevented from returning to drinking.19 For naltrexone, it is 20 patients. That might seem low, but it compares favorably to many commonly-used, evidence-based treatments (e.g., the number of patients needed to take statins to prevent just one adverse heart event is 25 to 100.)20 Some health care providers do not provide MAT in part because of the stigma against using medication to treat SUD.
The Role of Primary Care
Primary care providers (PCPs) play a key role in helping patients manage their pain and anxiety. They are partners with their patients in working to prevent psychological or physical dependence, as well as in identifying and responding when the use of addictive meds is getting out of control. PCPs and/ or their staff regularly conduct Screening, Brief Intervention, and Referral to Treatment (SBIRT). PCPs form the front line in identifying patients in need, those who may feel stigmatized for seeking treatment from a specialist, or individuals who might not be aware that their substance use is a problem. While only 10% of people with SUD receive treatment for it, over 50% of people see a PCP each year.21 However, less than 20% of PCPs feel “very prepared” to identify alcoholism or illegal drug use. Innovative health systems integrate behavioral health services into multiple settings, including primary care, which often involves educating PCPs to appropriately identify and refer SUD patients.
Community and Home Care
The American Society of Addiction Medicine recommends treatment in the least restrictive environment that is clinically appropriate.22 Providing treatment in the community or the home in which an individual resides can be beneficial because it gives patients and providers the ability to address some of the environmental risk factors that facilitate substance use, like peers or family who also abuse addictive substances. Inpatient treatment is necessary for some people, but removing people from the normal context of their lives to recover followed by putting them right back in that situation after discharge can lead to high risk of relapse. Care in the home should be coordinated with a patient’s behavioral health and primary care providers.
Individual and group counseling is the most common treatment for SUD. It can be delivered in community settings, in the home, or in outpatient treatment facilities. Counseling focuses on skill-building to reinforce positive behaviors, cognitive behavioral therapy (CBT), and motivational enhancement.23 Many 12-step recovery programs are common and effective for some, but success rates may be under 10%, and drug abstinence-only programs that exclude MAT are not evidence-based.16 These self-help groups should be integrated with outpatient and other treatment settings.
Outpatient rehabilitation centers (ORCs) provide many of the same treatments as those listed above, but are often used for intensive care at the beginning of a patient’s SUD treatment. This may involve several treatment sessions a week before a patient is prepared to move toward community and home care.23
Telebehavioral Health Extending
According to the Business Group's 2020 Large Employers’ Health Care Strategy (LINK ON NEW WEBSITE) and Plan Design Survey, 82% of large employers will offer mental/behavioral health virtual services in 2020; another 13% are considering doing so in 2021 or 2022. Offering mental health services virtually can help maintain continuity of care between visits with providers and extend access to people in locations with few or no providers, particularly those treating substance use disorders.
Treatment in an inpatient rehabilitation center (IRC) is generally reserved for patients with the greatest risk for serious adverse events (e.g., overdose) related to SUD, and who need 24-hour safe supervision. Patients may voluntarily commit themselves to several days of treatment during which they are monitored, receive intensive therapy, and are often helped through withdrawal symptoms that can be intense and dangerous.
Residential treatment centers (RTCs) also admit SUD patients for an extended period of time, though they may focus on less acute patients. RTCs may be located in a patient’s community, though some out-of-state RTCs advertise spa-like treatment facilities to encourage patients—and their families—to travel for this type of treatment. Some employers have identified potentially-fraudulent providers that offer to waive a patient’s cost sharing, while charging the plan significant sums of money for treatment not coordinated with the patient’s health care providers in their home community. Other facilities that own their own labs have been flagged for running unnecessary urine and blood tests on their SUD patients; health plan pre-certification should catch unnecessary or excessive testing, but implementation is inconsistent.
Relapse rates after an inpatient stay are high: One study found that 91% of patients admitted for opioid dependence relapsed, including 59% within the week after discharge.24 Coordination with home providers is paramount for successful IRC and RTC treatment resulting in long-term SUD management. Return to work carries significant challenges for employees, but there are benefits. People in recovery with jobs are more successful in integrating back to normal life. Employers may want to consider flexible workplace policies to aid in return to work, and should make sure to follow relevant nondiscrimination laws.
Why is it so Hard to Measure Quality
The brain’s complexity, evolving standards of care, and decades of stigma against both seeking and providing treatment for SUD might explain why the field of addiction care is behind others in quality measurement development. The lack of good quality metrics combined with provider shortages has meant that insurance networks are thin for patients in many geographies and patients often seek treatment in unaccredited out-of-network facilities. Some health plans have begun requiring CARF or Joint Commission accreditation for inclusion in networks or out-of-network coverage. But this should be considered a quality “floor” rather than an expectation of excellence. At least one health plan is working on creating centers of excellence for SUD for 2018.
It is possible to look at outcomes, such as whether a patient completed treatment before leaving inpatient care (only 42.1% of patients in 2008), or remission rates after treatment.2 Risk adjustment for these metrics is complex, and a patient’s ability to readjust to normal life after inpatient care is largely dependent on community supports upon return home. Patients should look for facilities that conduct follow-up care and coordinate with their other providers.
Network Approaches Inpatient SUD Treatment
Some IRCs have taken advantage of employer out-of-network (OON) benefit structures by offering to waive the patient out-of-pocket expenses for treatment and charging high prices. Out-of-state IRCs may advertise spa-like experiences, offer to pay for a patient’s travel expenses, and charge the plan exorbitant amounts. Several sober homes, ORCs, and IRCs have been prosecuted for filing fraudulent claims. Employers have taken varied approaches to addressing OON treatment facilities, including the aggressive step of eliminating OON coverage across their entire medical plan.
- Coordinate with employee assistance programs (EAPs), health plans and other partners to conduct anti-stigma campaigns in the workplace.
Employers report that stigma is the number one barrier to connecting people to addiction treatment.4
EAP providers, health plans and several other organizations like Stamp Out Stigma, Action Alliance for Suicide Prevention, #IWillListen and Stigmafree conduct trainings to help people better understand addiction and other behavioral health conditions, and learn about empowering language that encourages people to seek help when they need it. These trainings can be done in concert with company campaigns to create awareness about mental health issues and the resources needed to help people maintain positive emotional well-being, as well as address conditions like addiction.
- Consider conducting peer-support training programs to encourage constructive conversations and the use of behavioral health resources.
Many employee orientation and training programs teach health benefits leaders, company managers, and employees strategies for having empowering and constructive conversations with peers who may be struggling with addiction. These trainings teach people how to avoid allowing privacy concerns to get in the way of seeking help, while offering support and resources (e.g., EAP services, health plan care coordinators) that could help them in a variety of ways. Examples include Mental Health First Aid, Mental Health Mediate, the Partnership for Workplace Mental Health ICU program and EY’s “r u ok?” program.
- Consider first-offense forgiveness policies that, in the case of an addiction-related workplace incident, trigger treatment interventions rather than immediate termination.
One reason only 10% of people with addiction seek treatment is a concern that they may lose their job. Employees with security clearances or those who operate heavy machinery, such as airline pilots, may be particularly worried about termination. Some employers have instituted policies that forgive an employee’s poor performance or safety-event if it is related to a substance use disorder, so long as they sign a contract to receive treatment, adhere to EAP recommendations, and avoid a second offense; one employer reported a 90% engagement rate with such a policy for eligible employees. This policy may create an environment that is supportive of struggling employees, and may encourage people with addiction who have not experienced an adverse event to seek treatment before one occurs.
Mental Health Parity Concerns
Consult with legal counsel to ensure that your network strategies comply with mental health parity requirements. Plans cannot impose any non-quantitative treatment limitations (NQTLs) for mental health/substance use disorder that are more restrictive than those for medical/surgical benefits in the same category (inpatient, outpatient, out-of-network). For example, employers that eliminate OON coverage for nonaccredited inpatient facilities for SUD must have a comparable restriction in place for a medical/surgical treatment.
Consider requiring out-of-network (OON) inpatient rehabilitation centers (IRCs) to be accredited by CARF or the Joint Commission, and consider excluding facilities from coverage that are not accredited.
Facilities accredited by CARF or the Joint Commission must follow evidence-based treatment protocols and provide a comprehensive set of inpatient and follow-up care services for patients. Given evolving evidence for addiction treatment, regular accreditation can be an effective strategy for ensuring that patient care is evidence-based. Accreditation should be considered a quality “floor” rather than proof that a facility is high-performing. For example, accreditation generally doesn’t require a facility to provide medication-assisted therapies (MAT), even when they are clinically appropriate.
One large health plan began eliminating OON coverage for nonaccredited IRCs on January 1, 2017. Some employers have entirely eliminated OON coverage for all medical services, in part to discourage people from using OON IRCs that take advantage of vulnerable populations with inappropriate, sometimes fraudulent treatment.
This is a major benefit design change with many ramifications outside of addiction treatment. A note of caution: as of 2013, 56.9% of substance abuse treatment facilities were not accredited by CARF or the Joint Commission; before making this change, an employer should talk to their health plan about the potential disruption due to eliminating OON coverage of nonaccredited facilities.25 An exception process should be used based on patient circumstance. Any restriction on OON coverage for addiction treatment, which can be hard to access in the first place, should be well-communicated to patients and accompanied by navigation services to help them identify available accredited facilities.
- Cover medication-assisted treatment (MAT), such as methadone and naloxone for opioid and alcohol use disorders.
Drug treatments such as naltrexone, buprenorphine, methadone, acamprosate and others should be covered. With patients for whom they are medically-appropriate, these treatments have a strong effectiveness evidence base and coverage should not be a barrier.17 MAT therapies have often carried a stigma because they use drugs to treat drug addiction. But evidence gained over the past 20 years makes it clear that MAT is effective and appropriate for many patients.26
- Work with health plans to promote, or directly contract with, health systems that have integrated behavioral and mental health treatment into primary care, acute care and surgical support programs.
As many health systems take on financial risk for the total cost of care for attributed patients, they must implement comprehensive strategies for increasing access to evidence-based addiction treatment. The Business Group’s Executive Committee on Value Purchasing (NEED NEW LINK) has identified integrated behavioral health services as a key indicator of a high-performing accountable care organization. When considering whether to provide some form of steerage to an ACO or to a high-performance network, employers should ask about behavioral health integration into primary care, primary care provider training to treat and triage SUD patients, EAP training of providers, and overall timely access to behavioral health services.
About 50% of UCLA Health System’s reimbursements are through value-based contracts, which have driven efforts to integrate behavioral health into primary care, educate providers on health plan and employer EAP resources, and expand access to intensive care for addiction. Patients with addiction who have interacted with the system’s behavioral health associates have experience a 13% reduction in emergency room use.
- Ensure that care managers, navigator services, decision-support programs and EAP managers are acquainted with resources that plan members can access to receive high-quality care.
All partners that have medical interactions with plan members with SUD should be trained on resources that are available to these patients. Vendor partners should refer to one another, when appropriate, to drive the use of effective resources. EAP resources are chronically under-used by employees who could benefit from them. This is especially important for employers that provide limited access to OON care.
- Reduce exposure to potentially addictive pain medications (e.g., opioids) by implementing utilization management strategies, such as limiting “first fills,” and covering pain management alternatives.
There are several strategies available to employers through their medical and pharmacy benefit plans to reduce the likelihood that a patient becomes addicted to prescription opioids:
- Covering evidence-based alternative pain management techniques under the plan, including massage therapy, physical therapy and acupuncture (see the Business Group’s Non-Invasive Treatments for Low Back Pain benefit manager guide);
- Educating employees about alternative pain management techniques;
- Encouraging health plans and PBMs to reach out to top opioid painkiller prescribers to educate them about appropriate use of these drugs;
- Implementing utilization management strategies to limit coverage for first fills of opioid painkillers to a week or less of pills to discourage stockpiling;
- Asking for reports from the PBM and health plans to track the percentage of the population that is prescribed opioids, and benchmarking across industries;
- “Locking in” patients who use prescription opioids for chronic pain to one pharmacy to reduce “doctor shopping;” and
- Encouraging employees to safely dispose of unused pills.
Successful treatment of addiction is difficult. People with SUD are often viewed as weak, of poor character or hedonistic. This stigma has reduced both the demand and supply of addiction treatment; people with SUD are scared that seeking treatment might ostracize them, and young clinicians find addiction medicine less attractive, leading to treatment shortages.2 Employers, along with their vendor partners, can lead the way in addressing stigma and facilitating pathways for patients to receive evidence-based care in their communities.
- U.S. Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: results from the 2015 national survey on drug use and health. September 2016. https:// www.samhsa.gov/data/sites/default/files/NSDUH-FFR1-2015/NSDUH-FFR1-2015/NSDUH-FFR1-2015.pdf. Accessed May 19, 2017.
- The National Center on Addiction and Substance Abuse. Addiction medicine: closing the gap between science and practice. Columbia University. June 2012. http://www.centeronaddiction.org/addiction-research/reports/addictionmedicine-closing-gap-between-science-and-practice
- National Council on Alcoholism and Drug Dependence, Inc. Drugs and alcohol in the workplace. April 2015. https://www.ncadd.org/about-addiction/addiction-update/drugs-and-alcohol-in-the-workplace. Accessed July 25, 2017.
- National Business Group on Health. Employers’ forum on mental health and emotional well-being: key insights & learnings. February 2017. https://www.businessgrouphealth.org/pub/74c577dd-782b-cb6e-2763-1e234175e033
- American Society of Addiction Medicine. Definition of addiction. December 2011. http://www.asam.org/qualitypractice/definition-of-addiction. Accessed March 15, 2017.
- U.S. Substance Abuse and Mental Health Services Administration. 2014-2015 National survey on drug use and health national maps of prevalence estimates, by state. https://www.samhsa.gov/data/sites/default/files/ NSDUHsaeMaps2015/NSDUHsaeMaps2015.pdf. Accessed March 15, 2017.
- National Institute on Drug Abuse. What are the short- and long-term effects of inhalant use? https://www. drugabuse.gov/publications/research-reports/inhalants/what-are-short-long-term-effects-inhalant-use. Accessed March 15, 2017.
- National Institute on Drug Abuse. What are the short-term effects of cocaine use? https://www.drugabuse.gov/ publications/research-reports/cocaine/what-are-short-term-effects-cocaine-use. Accessed March 15, 2017.
- National Institute on Drug Abuse. Overdose death rates. https://www.drugabuse.gov/related-topics/trends-statistics/ overdose-death-rates. Accessed March 15, 2017.
- National Institute on Drug Abuse. Comorbidity: addiction and other mental illnesses. Research Report Series. https://www.drugabuse.gov/sites/default/files/rrcomorbidity.pdf. Accessed March 15, 2017.
- Owens P, et al. Emergency department visits related to suicidal ideation, 2006-2013. HCUP Statistical Brief #220. January 2017. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/ statbriefs/sb220-Suicidal-Ideation-ED-Visits.pdf. Accessed March 15, 2017.
- Dragisic T, et al. Drug addiction as risk for suicide attempts. Mater Sociomed. June 2015; 27(3): 188-191. https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC4499285/
- Employee Benefit News. Top 10 causes of disability. http://www.benefitnews.com/slideshow/top-10-causes-ofdisability?slide=4. Accessed March 15, 2017.
- National Council on Alcoholism and Drug Dependence, Inc. Drugs and alcohol in the workplace. April 2015. https://www.ncadd.org/about-addiction/addiction-update/drugs-and-alcohol-in-the-workplace. Accessed March 15, 2017.
- The Pew Charitable Trusts. Substance use disorders and the role of the states. March 2015. http://www.pewtrusts. org/~/media/assets/2015/03/substanceusedisordersandtheroleofthestates.pdf. Accessed March 15, 2017.
- Glaser G. The irrationality of alcoholics anonymous. The Atlantic. April 2015. https://www.theatlantic.com/ magazine/archive/2015/04/the-irrationality-of-alcoholics-anonymous/386255/. Accessed March 15, 2017.
- Substance Abuse and Mental Health Services Administration. TIP 43: Medication-assisted treatment for opioid addiction in opioid treatment programs. November 2012. https://store.samhsa.gov/shin/content//SMA12-4214/ SMA12-4214.pdf. Accessed March 15, 2017.
- National Institute on Drug Abuse. Principles of drug addiction treatment: a research-based guide (third edition.) December 2012. https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-basedguide-third-edition/preface. Accessed March 15, 2017.
- Jonas D, Amick H, Feltner C. Pharmacotherapy for adults with alcohol use disorders in outpatient settings, a systematic review and meta-analysis. JAMA. 2014; 311(18): 1889-1900.
- Partnership for Drug-Free Kids. Medications to help people stop drinking rarely prescribed. May 2014. http://www. drugfree.org/news-service/medications-to-help-people-stop-drinking-rarely-prescribed/. Accessed March 15, 2017.
- Centers for Disease Control and Prevention. Ambulatory care and office visits. National Center for Health Statistics. January 2017. https://www.cdc.gov/nchs/fastats/physician-visits.htm. Accessed March 15, 2017.
- American Society of Addiction Medicine. Public policy statement on office-based opioid agonist treatment. 2010. http://www.asam.org/docs/default-source/public-policy-statements/1obot-treatment-7-04.pdf?sfvrsn=0. Accessed May 22, 2017.
- Substance Abuse and Mental Health Services Administration. Treatments for substance use disorders. August 2016. https://www.samhsa.gov/treatment/substance-use-disorders. Accessed March 15, 2017.
- Smyth B, et al. Lapse and relapse following inpatient treatment of opiate dependence. Ir Med J. 2010 Jun;103(6):176-9. https://www.ncbi.nlm.nih.gov/pubmed/20669601
- U.S. Substance Abuse and Mental Health Services Administration. National survey of substance abuse treatment services (N-SSATS): 2013. https://www.samhsa.gov/data/sites/default/files/2013_N-SSATS/2013_N-SSATS_ National_Survey_of_Substance_Abuse_Treatment_Services.pdf. Accessed May 22, 2017.
- Substance Abuse and Mental Health Services Administration. What is methadone? September 2015. https://www. samhsa.gov/medication-assisted-treatment/treatment/methadone. Accessed March 15, 2017.