We would help a lot more people with opioid use disorders and quell a lot of criticism if we stopped using this inaccurate paradigm in addiction treatment

Earlier this year, we read Anne Fletcher’s 2015 Wish List for Substance Use Disorder Treatment and agreed on all counts. We also agreed that, as she says, “each one of these wishes is a tall order.”

Of the six wishes, we appreciated the hat tip as brief intervention experts under #4 (“Address the needs of the far greater number of people with substance use problems that are not severe”) and nodded emphatically as we read the comments under #5 (“Provide integrated treatment for people with co-occurring substance use and mental health disorders.”)

“It’s time to stop making a priori decisions about the need to ‘treat the addiction as primary,’ as I found to be the case at some rehabs as I did the research for my book,” wrote Fletcher. “Institute of Medicine recommendations for implementing quality care for individuals with co-occurring disorders clearly state that all types of disorders should be treated as ‘primary.””

Definitely. That’s a huge, complex issue.

Fletcher’s list also got us thinking about our own hopes and goals this year.

In our work with treatment providers and payers, we’ve seen systemic problems play out as the result of an inaccurate paradigm used in addiction treatment. The move to correct this inaccuracy is one of our wishes for 2015. To add a couple more inches to an already very tall order, we thought we’d tack it onto the list. Here it is:

What does it mean to separate medication from level of care?

Patients who aren’t well-served don’t do much for the reputations of opioid use disorder medications.

There are reasons for the lack of acceptance of medications for opioid dependence. Suboxone doesn’t work, people say. It’s diverted, it’s abused. And plenty of folks question the value of methadone treatment. Doubts prevail even though I can show you the faces and the stories of people for whom medications have worked.

We would help a lot more people with opioid use disorders and quell a lot of criticism if we stopped treating medication like a level of care. Let me explain what that means.

Before you receive treatment for a substance use disorder, you have to undergo an assessment. This is designed to tell you, your insurance company, and your treatment provider what kind of care you need–inpatient, outpatient, that sort of thing. That’s your “level of care.”

The most widely used criteria for determining level of care is the ASAM Criteria, which classifies levels of care on a numerical scale between 0.5 and 4. The 0.5 level of care is the least intensive–it’s an early intervention for at-risk individuals. Four is very intensive–it’s medically managed intensive inpatient services, consisting of 24-hour nursing care, daily physician care, and counseling.

Your placement in a particular level of care depends on a few factors, including how severe your withdrawal process is likely to be, any physical and mental health disorders that might pertain to your addiction treatment, how you’ve done in the past in treatment, and your current living environment. These factors are  known as the six dimensions of multidimensional assessment.


The ASAM Levels of Care. Credit: ASAM

The problem is that we tend to treat medication as its own level of care, rather than a tool that can be used at any level of care. That is to say: if a person would benefit from a medication, the idea of an individualized assessment to determine an appropriate level of care usually goes out the window.

We basically tell patients, “You go to methadone” or “You go to buprenorphine.” Most often, patients receive these medications in outpatient settings, (Level 1 in the ASAM criteria), regardless of their needs.

These are medications. They do not describe the sort of physical and therapeutic environment that someone needs to recover. Patients are not well-served when their needs are fit into the shape of a program. And patients who aren’t well-served don’t do much for the reputations of opioid use disorder medications.

Unbundle the payment

One way for payers to incentivize treatment that incorporates medication at different levels of care is to unbundle the payment.

This means separating reimbursement for medication and its administration from psychotherapy treatments. In Pennsylvania, Medicaid pays for approximately 70 percent of all methadone treatment services. The standard Medicaid payment for methadone is an “all inclusive” daily or weekly payment. Under this bundled system, the provider receives the same payment regardless of the amount of psychotherapy provided.

A Medicaid managed care program in Philadelphia has worked out an exception that permits them to pay for the medication separately from the psychotherapy, or “unbundled.” Under an unbundled payment for methadone services, providers only receive payment when psychotherapy is provided. This allows providers to offer services up to Intensive Outpatient (ASAM’s Level 2.1) and Partial Hospitalization (ASAM’s Level 2.5) in conjunction with medication and receive full reimbursement for their time and effort.

Southwest Behavioral Health Management, Inc. worked with the IRETA, Value Behavioral Health of PA and 11 counties in western PA to develop standards that require methadone providers accepting Medicaid managed care payments for methadone to ensure that the patient receives treatment consistent with the ASAM criteria. In this work, they found that only a handful of residential addiction treatment providers in PA will accept and treat a client on methadone; most require the client to go off of the methadone.

This is an illustration of programmatic rules artificially making what should be individualized decisions on the use of a medication, methadone. The requirement to go off of methadone is not only unsupported by medical research, but:

a) It may be dangerous to the client and

b) It blocks to access to care that the client may badly need

“We need to stop only using medication in minimal outpatient programs,” said IRETA Executive Director Peter Luongo, Ph.D. “It presumes that the medication itself is sufficient for treating addiction, which is usually not true. And it’s not the way Dole and Nyswander [who pioneered methadone treatment in the 1960s] intended for the medication to be used.”

 Recommended Resources

Medicaid Benefits for the Treatment of Opioid Use Disorder Nationwide (an interactive map by ASAM and the Treatment Research Institute)

The ASAM Criteria online

David Mee-Lee, Chief Editor of the ASAM Criteria, on the role of clinical judgment in determining level of care (February 2015)

Organization for Recovery, Inc. (an example of a program that offers methadone in conjunction with different levels of care)