What the Comprehensive Addiction and Recovery Act Means for Health Care Providers

Not a week passes that I don’t have a conversation with a client regarding the opioid and heroin addiction epidemic. Not only does this burden impact individuals, it ties up emergency medicine resources and costs providers and payers billions of dollars. As health systems increasingly focus on population health and take on risk, managing behavioral health and substance use disorders is a core initiative.

In an unprecedented bipartisan act, the Comprehensive Addiction and Recovery Act of 2016 (CARA) passed both houses and was signed by President Barack Obama on July 22. CARA builds on earlier initiatives to restrict access to addictive prescription opioids and expand access to treatment and acute intervention. It carves out initiatives to support prevention, treatment and recovery in specific populations affected by the epidemic. While details of the bill are summarized in several different forums, including the National Association of Addiction Treatment Providers website, this post focuses on key elements impacting health care providers and steps that can be taken now, even before funding is secured.

CARA Tackles All Phases of Addiction and Intervention
Acute Intervention
With the death rate from opioid-related overdoses rising significantly over the last few years, expansion of acute overdose intervention is essential. Naloxone (Narcan) is an effective agent for rescue in the case of opioid overdose and has been used to save over 25,000 lives. But, as of 2014, there were only 644 reported community-based overdose education and naloxone distribution (OEND) programs in the US.

CARA calls for expansion of the use of naloxone by first responders, including law enforcement and emergency medical services (EMS). The bill also recommends co-prescribing naloxone with opioids for individuals at high risk for overdose, which will be easier to administer given the FDA’s approval of a nasal spray formulation of naloxone last year.

Treatment and Recovery
There is considerable evidence that medication-assisted treatment (MAT) can have a large impact in promoting recovery in opioid-addicted patients; however, it is largely underutilized. A Stanford research study highlighted the gap between opioid use and MAT. In the Medicare population in 2013, there were over 56 million prescriptions for opioids, but less than 500,000 prescriptions for buprenorphine/naloxone. When considering provider access, for every 40 prescribers of opioids, there was only 1 prescriber of buprenorphine/naloxone.

Recent initiatives from the Obama administration increased the number of patients that an addiction specialist can manage using MAT from 100 to 275. However, the expanded patient pool may not have as large of an impact on access since 67% of the 34,000 MAT-certified providers are only certified for 30-patient panels. Additionally, only an estimated 44% to 66% of certified addiction specialists actually prescribe buprenorphrine.

The CARA law expands the list of providers who can be certified in MAT to include nurse practitioners and physician assistants with addiction training.

If you attended one of Sg2’s Executive Summits this summer, you heard about the impact this epidemic has had on pregnant women and their newborn babies. Between 14% and 22% of pregnant women are prescribed opioid therapy, and every 25 minutes a baby is born addicted (with neonatal abstinence syndrome [NAS]). And, in some markets, the rate of NAS is rising quickly. One organization we work with went from having 2 cases in one year to 200 the following year.

CARA specifically requires monitoring of NAS incidence, tracking of current programs and capacity, and recommendations to improve access under state Medicaid. For the pregnant and postpartum patient population, CARA includes provisions for grant money to develop best practice treatment programs. It also extends access to residential treatment services for prenatal and postpartum patients through 2021.

Opioids have become a first-line therapy for management of acute pain and are frequently prescribed for chronic back pain. With the high use of opioids to treat pain, prevention requires a change in prescribing habits, in addition to education, changing incentives and research on better ways to manage pain.

Earlier in 2016, the CDC published 12 guidelines for prescribing opioids for pain management to help improve provider communication with patients about the risks and benefits of opioid therapy, increase the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy. Click here to access the full guidelines, or you can review them in a special communication from the Journal of the American Medical Association. Given the CDC’s evidence-based approach, we expect payers and pharmacies to leverage these guidelines to create internal checks and balances for prescriber’s practices.

The FDA Advisory Panel also recently recommended that prescription drug training become a requirement for physicians prescribing opioids. Medical schools are increasing training on appropriate use of opioids and their risks. In addition, CMS is seeking ways to promote evidence-based approaches to pain control. For example, in its proposed rules, CMS has recommended removing the pain management–related questions on the HCAHPS survey for hospital quality scoring that defines payment beginning in fiscal year 2018.

CARA addresses the need for more resources and research on prevention of opioid overuse and addiction. First, the law calls for the development of a task force to develop best practices for pain management. It also mandates increased education and public awareness, including a national drug awareness campaign. Because a significant amount of prescribed opioids are used for something other than their original use, CARA also enables expansion of drug take-back and disposal programs.

Take Action Today, Despite CARA Law Implementation Challenges
The CARA law has created a lot of optimism among addiction service advocates, but there are still some significant hurdles to cross. Funding for the roughly $1B in targeted costs has not been secured and will certainly be a sticky point during budgeting later this year. The bill does not address the shortage of psychiatrists and other behavioral health workers, which is limiting access to addiction services. Much of the treatment burden could fall on primary care providers (PCPs). CMS has proposed increasing funding for chronic disease management (which includes addiction services) but doesn’t specifically address the need to enhance resources or skills to enable PCPs to better manage these individuals.

Given these challenges, many providers may take a “wait-and-see” approach. However, we recommend taking some fundamental actions today to positively impact this patient population.

  • Understand the scope of your community’s problem and identify the specific components where the law (and other initiatives) will have a positive impact.
  • Develop educational materials for physicians on opioid prescribing. Embed opioid prescribing guidelines into EHR and prescribing systems to support appropriate use. Enlist pain management specialists active in development of nonopioid chronic pain options to educate primary and specialty care on emerging practices.
  • Work with first responders to begin preparing for adoption of OEND programs. Seek local or grant dollars where available to get these programs started. Leverage the Substance Abuse and Mental Health Services Administration (SAMSHA) toolkit to develop these programs.
  • Review current buprenorphrine practices and identify best avenues to expand access as needed. Support physicians by increasing clinic resources as appropriate.
  • Partner with community mental health centers, Federally Qualified Health centers and other providers in the community to increase access and develop educational initiatives.

Building Leading Practices in Addiction Medicine
SAMSHA and many state organizations have grant funding available for the development of programs that identify individuals with substance use disorders and move them into treatment and recovery. In a recent webinar, we highlighted a case study from Robert Wood Johnson-Barnabas Health System (RWJBarnabas Health) on its use of peer recovery specialists to increase utilization of addiction recovery services. We know the RWJBarnabas Health story is only one of many leading practices around the country. If you have a case study you would like to share with us, let us know. We would be excited to hear your story and share it with the Sg2 membership.

Sources: Centers for Disease Control and Prevention, 2016; Rudd RA et al. MMWR Morb Mortal Wkly Rep. 2016;64:1378–1382; Rothenberg G. Suboxone underused, opioids overused in Medicare. MedPage Today. July 20, 2016; US Department of Health and Human Services. The Opioid Epidemic: By the Numbers. Updated June 2016; Rodriguez T. Supporting community-based naloxone programs to curb opioid overdoses. Clinical Pain Advisor. June 29, 2016; US Department of Health and Human Services. HHS announces new actions to combat opioid epidemic [press release]. July 6, 2016; Jones CM et al. Amer J Public Health. 2015;105:e55–e63; Dowell D et al. JAMA. 2016;315:1624–1645; Chaiyachati K and Hom J. Let’s put opioids for treating addiction on equal footing with prescribing opioids for pain. Health Affairs Blog. May 10, 2016; Punke H. CMS proposes eliminating pain management from HCAHPS payment score. Becker’s Infection Control & Clinical Quality. July 07, 2016; SAMHSA. Medication-Assisted Treatment: Physician and Program Data. Updated December 12, 2015.

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