State Strategies for Integrating Substance Use Disorder Treatment and Primary Care

twitterSubstance use disorder affects an estimated 20.8 million people in the United States,[i] however, national survey data show that fewer than 10 percent of individuals with an alcohol use disorder and 20 percent of individuals with an opioid use disorder receive treatment for the condition.[ii],[iii] Individuals battling substance use disorder may not perceive a need for treatment, which poses a barrier to states trying to connect individuals with care. Primary care physicians are well positioned to identify and engage those individuals who may benefit from treatment services.

Substance use disorder treatment has a possible 12:1 return on investment when accounting for both medical and societal benefits.[iv] As the largest payer of substance use disorder treatment services in the United States, Medicaid agencies and policymakers have significant incentive to increase access to and the coordination of primary care and substance use disorder treatment.

Primary care providers already play a significant role in ensuring individuals with complex health needs receive appropriate care across the healthcare continuum by acting as the primary touch point to the healthcare system. Primary care providers administer Screening, Brief Intervention, and Referral to Treatment to identify individuals with substance use disorders and, with some additional training, can provide medication-assisted treatment services to individuals with alcohol and opioid use disorders. The provision of these services in the primary care setting is not meant to supplant specialty care, but is intended to promote an integrated approach to substance use disorder treatment.

States have promoted collaborative and team-based care through strengthened partnerships between federally qualified health centers and community health centers, enhanced telemedicine and teleconsultation programs to overcome geographic barriers and workforce shortages, as well as increased provider training and education opportunities to combat critical provider capacity issues.

Beyond these initiatives, states have enacted major Medicaid delivery and payment system reform to build primary care capacity for the purpose of treating substance use disorders and strengthening connections with specialty providers. Much of this work has been accomplished through leveraging the flexibility of federal authorities such as section 1115 waivers and section 1945 Medicaid Health Home State Plan Options.

For example, New Hampshire’s section 1115 demonstration waiver uses the Delivery System Reform Incentive Payment program to create regional integrated delivery networks that are required to partner with a substantial percentage of primary care and substance use disorder providers in their region, as well as peer-based supports, community health workers, and community-based organizations that provide social and support services. Each of the integrated delivery networks work to promote integration of physical and behavioral health, improve care transitions, and increase treatment capacity.

Vermont’s statewide Blueprint for Health program, which connects recognized patient-centered medical homes with multidisciplinary community health teams, provided a foundation for the establishment of the , which built a comprehensive regional, “hub-and-spoke” system of treatment designed to provide more accessible and better coordinated care for individuals with an opioid use disorder. Under this model, funded in part by the state under the health home state plan option, accredited Opioid Treatment Programs offering methadone treatment serve as hubs. Buprenorphine-waivered providers, offering office-based opioid treatment, serve as the spokes. The Care Alliance significantly augmented services for individuals seeking substance use disorder treatment by expanding buprenorphine treatment, connecting individuals receiving care at Opioid Treatment Programs to primary care, and embedding registered nurses and masters-level clinicians trained in addiction medicine into primary care practices.

The role of primary care providers is especially critical in combatting the growing national opioid epidemic. Primary care providers, including nurse practitioners and physician assistants collectively write about half of all opioid prescriptions in the United States, which makes these providers well-positioned to ensure appropriate opioid use.[v] State prescription drug monitoring programs, utilization management policies such as prior authorization, and expanded access to Naloxone are important state levers to support the ability for primary care providers to prevent opioid misuse and overdose. Additionally, a recent study found the majority of states have passed Naloxone Access and/or Good Samaritan Laws and these policies have been shown to significantly reduce opioid related deaths with no evidence of increased recreational use.[vi]

A new issue brief written by the National Academy for State Health Policy (NASHP) further discusses the evidence-based interventions that can be implemented in primary care settings, current state payment and delivery system reforms, and key policy considerations to support primary care providers in combatting the nation’s growing opioid epidemic highlighted in this blog.

This work was made possible by The Commonwealth Fund.

[i] National Institutes of Health, “10 Percent of US Adults Have Drug Use Disorder at Some Point in Their Lives,” news release, November 18, 2015, https://addiction.surgeongeneral.gov/executive-summary.pdf.

[ii] Substance Abuse and Mental Health Services Administration. Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings (Washington, DC: U.S. Department of Health and Human Services, 2014), http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf.

[iii] Brendan Saloner and Shankar Karthikeyan, “Changes in Substance Abuse Treatment Use Among Individuals with Opioid Use Disorders in the United States, 2004-2013,” JAMA 314, no. 14 (October 13, 2015): 1515–17.

[iv] National Institute on Drug Abuse, Principles of Drug Addiction Treatment: A Research-Based Guide (Rockville, MD: National Institutes of Health, 2012), https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/frequently-asked-questions/drug-addiction-treatment-worth-its-cost

[v] “Prescribing Data.” Centers for Disease Control and Prevention, last modified December 20, 2016, Accessed February 6, 2017, https://www.cdc.gov/drugoverdose/data/prescribing.html.

[vi] Daniel I. Rees, et al., With a Little Help from My Friends: The Effects of Naloxone Access and Good Samaritan Laws on Opioid-Related Deaths (Cambridge, MA: National Bureau of Economic Research, 2017), http://www.nber.org/papers/w23171.