Opioid treatment focus increasingly shifts to outpatient options

The use of outpatient services to treat opioid addiction has grown as health officials and insurers look to treat addiction as a disease and overcome stigma that can keep people from seeking help.

Treating opioid misuse and abuse means recognizing addiction as a disease, which like any other chronic disease, such as diabetes, heart disease and hypertension, can be treated inside the hospital or in an outpatient setting depending on the patient’s condition.

“Because we recognize addiction as a chronic disease, it deserves treatment that is equal to that,” said Gail Nelson, program manager of the Total Care & Cost Improvement program for CareFirst BlueCross BlueShield, the largest private insurer in Maryland.

For insurers, outpatient treatment comes with many benefits over inpatient treatment, just as it would with other diseases.

Just like hospitalizations for any other condition, inpatient treatment is costly, very costly. It also tends to be a relatively short-term stay for what could be a lifelong fight for many patients.

Many inpatient treatment programs run around 28 days. But there is a long-term treatment that needs to take place later to help patients focus on recovery, including understanding what triggers their cravings.

“Whenever people think about (treatment for) addiction … they think about beds, said Dr. Leana Wen, Baltimore City’s health commissioner. We should be thinking, “What is evidence-based medical care?”

Use of medications

In many cases that means using medication-assisted treatment, which uses medicines like buprenorphine to help patients in recovery. The treatment has attracted criticism from some, including former U.S. Department of Health and Human Services Secretary Tom Price, who compared it to replacing one addiction with another.

But the treatment is often considered one of the best evidence-based methods for combating addiction, especially when addiction is recognized as a disease.

For comparable diseases like diabetes, patients may need insulin and have to watch their diets and other risk factor.

Medication-assisted treatment is a significant part of how CareFirst wants to treat patients with the disease of addiction and it is a requirement for any recovery center they partner with.

“This is a disease of the brain,” said Dr. Daniel Winn, CareFirst’s chief medical officer. “The brain chemistry changes as part of the disease and it takes a long time for healing to occur.”

As part of its efforts to address the opioid epidemic, CareFirst has waived out-of-pocket fees for members seeking treatment, including copays and deductibles. It has also partnered with nine outpatient recovery centers that have 23 different locations in the region.

Those centers must meet requirements, including the offering of medication-assisted treatment, and they must offer treatment for at least a year.

While CareFirst prefers outpatient treatment in most cases, it will still pay for inpatient treatment, which can be necessary in some cases.

Stigma concerns

Despite the options available, stigma can still remain a barrier to people seeking treatment, whether it’s inpatient or outpatient.

Only about 1 in 10 people with the disease of addiction get treatment, Wen said.

Many of these people avoid seeking treatment because of the stigma that comes with addiction. Despite health professionals’ attempts to recognize addiction as a disease, the worry that others will see a patient’s addiction as a personal or moral failing affects how or if they seek treatment.

Even those who do seek treatment have their actions affected by perceived stigma. CareFirst says many members choose to seek treatment on their own, paying for it themselves, rather than reaching out to the insurer to see what resources it has to help.

“One of our major efforts is to educate our primary care physicians and our CareFirst care coordinators to identify if there is an issue with addiction,” Nelson said.

That stigma can extend to doctors prescribing medication like buprenorphine.

Gaining the ability to prescribe the drug requires special training for physicians and they can only manage a certain number of patients using the drug.

At the same time, doctors worry about a stigma of changing how they run their practice and who will be coming to their practice if they begin prescribing the drug.

But if CareFirst and other advocates want to improve access to outpatient treatment, they will need doctors to get on board.

“We’re hoping that our efforts will encourage more physicians to prescribe buprenorphine,” Winn said.

This article is part of The Daily Record's special edition examining Maryland's response to the opioid crisis

Read articles in the series:
Attorney addiction | Local government litigation | Outpatient treatment | County programs | A mother's message | For-profit treatment | When to prosecute? | When to prescribe? | Employers' best practices | Rural communities' response | Opioid chief interview

Read commentary:
Maryland's courts | MSBA Lawyer Assistance Program | Using data | The good, the bad and the ugly