There is a recognizable need for improved treatment for substance use disorder in the United States. Drug overdose deaths are at an all-time high and standardization of the delivery and coverage for addiction treatment can be hard to find. Unfortunately, as it stands, addiction treatment and reimbursement practices can vary greatly from state to state, community to community, and even treatment organization to treatment organization and payer to payer.
To improve standardization among substance use disorder treatment programs and their reimbursement, some states have adopted The ASAM Criteria to varying degrees. The ASAM Criteria is an assessment, treatment planning and treatment assignment decision support tool that assists clinicians in managing treatment for individuals with substance use disorders.
The American Society of Addiction Medicine (ASAM) released the Speaking the Same Language Toolkit at the end of 2021. The goal of the toolkit is to help strengthen patient-centered addiction care across the United States by elevating the need for adopting a common framework for addiction care, such as The ASAM Criteria; educate stakeholders about the diverse strategies and tools available to support more effective and comprehensive implementation of The ASAM Criteria; and empower those seeking to build sustainable, quality and integrated addiction treatment and coverage systems. By “speaking the same language”, these systems will be able to connect patients with substance use disorder and co-occuring conditions with the right care.
IRETA spoke to Dr. Margaret Jarvis, a member of ASAM’s Board of Directors and the Chief of the Addiction Medicine Division of the Department of Psychiatry at Geisinger, about the importance of the Speaking the Same Language Toolkit and her thoughts on the future of addiction treatment in the United States.
What prompted the creation of the Speaking the Same Language Toolkit?
Over the last five or six years, ASAM has been aware that different states have introduced The ASAM Criteria into regulation or law for their addiction treatment and coverage systems. This has been increasing over time, and we knew that there was a lot of variation in how those regulations and laws were being implemented. As we have made a concerted effort to ensure that the use of The ASAM Criteria is more uniform and consistent with what is written, we realized we needed to do something to help educate interested states on how the Criteria is going to work best. It’s one thing to write into law that you must use The ASAM Criteria, but if the people who are interpreting it have very different ideas about what following the Criteria means, you end up with so much variation it becomes difficult to know to what extent it’s being helpful.
Who would you describe as being the audience for this toolkit?
Policymakers, treatment providers, payers, and other stakeholders interested in ways for improving addiction prevention and treatment services should find the toolkit particularly educational. The toolkit offers high-level strategies for integrating The ASAM Criteria into a state’s approach to addiction services, as well as potential pathways that states can pursue, implementation vehicles, and state examples.
Can you elaborate on the importance of the need for states to “speak the same language” when it comes to addiction care? What does the field currently look like where states are not speaking the same language for addiction care?
Imagine you live in a state where there is wide variation among addiction treatment programs and among payers when it comes to the appropriate treatment of addiction. Now, imagine a state where addiction treatment programs provide a consistent way to assess a person’s biopsychosocial circumstances, identify an appropriate level of care based on individual needs, and define the services that should be provided at each level of care based on generally accepted standards of care recognized by experts in addiction medicine and where payers reimburse those programs for appropriate services. Steps taken by the latter states are how we are going to finally reach addiction parity in this country; how we are going to collect better data to improve patient outcomes, and how we are going to better ensure that more people with addiction have affordable access to good and effective treatment in every state and in every community.
On another level, the expectations of what can be classified as an addiction treatment program can vary from state to state. If an addiction treatment program is run in one state, the requirements for what treatment looks like might be completely different at an addiction treatment program of the same purported capacity and level of care in another state. That inconsistency sometimes means that addiction treatment programs and payers get extremely confused. Fair enough; they should be confused. And this confusion can reduce the likelihood that people are going to want to work in the field of addiction medicine. There are companies both small and large that are going to be affected by that. Where it becomes really sad is when addiction treatment organizations that have traditionally received Medicaid funding or state-level funding throw up their hands and say they don’t do this work anymore on account of their confusion.
How do you hope this toolkit will help improve quality of care in addiction treatment?
The person with addiction who says they need help will receive medical care that meets generally accepted standards of addiction care, no matter their zip code. Now, there are always going to be organizations that excel at delivering good addiction care. But a person should be able to say confidently that they want help and know that as they walk in the door of a licensed addiction treatment program that they will receive treatment that is effective and helpful to them. Increasing standardization in addiction treatment and coverage decisions and educating the lay public about what good treatment is will be important. I don’t think you can do one without the other.
Can you talk a little bit more about the gap between the efficacy of treatment in clinical trials and effectiveness in real-world settings? What is getting missed in this gap? How are people with substance use disorders falling through the cracks?
While highly effective treatments for addiction are available, outcomes achieved in community settings rarely approach those that can be achieved in the best-designed treatment systems. Historically, there has been significant heterogeneity across states and communities in the organization and oversight of addiction treatment systems. This has contributed to high variability in the quality of care and resulting patient outcomes.
The place it’s most visible is around the use of medications for opioid use disorder. (While there are delivery and coverage gaps in psychotherapy treatments as well, it’s less easy to get data for that.) It is abundantly obvious from the science that treating OUD with FDA-approved medications for OUD is efficacious in reducing drug use and keeping people from overdosing, but those medications are not universally available to the people who need them. There are many treatment organizations/facilities/individuals who do not even support offering those medications. As a result, patients get mixed messages as far as the use of medications for OUD and the efficacy of them. They struggle to make sense of what would be useful to them and know where they can find these medications. Misunderstanding about these medications and therapies – even among some in the medical community – make it difficult for patients to access effective treatment and is likely resulting in unnecessary death.
The good news is that I am seeing shifts in different parts of the industry. I’ve seen providers – who ten years ago would have said twelve-step programs without the use of medications are the only way for someone to enter remission and recovery – now saying that they are open to using addiction medications. Criminal justice organizations are also increasingly embracing the idea that we need to get people with OUD onto these addiction medications, including methadone and buprenorphine. However, there are some voices in the treatment community who still believe that these medications do not have a place. Change takes time, but are there ways we can facilitate that change? Yes. This is where the Speaking the Same Language Toolkit can help some of that.
In addition, over the last number of years, we have seen instances of fraud and really unethical business practices by some addiction treatment programs. Part of the reason those things have been able to occur is because we don’t consistently insist on fidelity to nationally recognized standards about what treatment should look like. That’s another reason why this toolkit becomes so important so that interested states have pathways and tools for saying, “If your treatment program does not have the ability to deliver services meeting nationally recognized criteria, we aren’t going to license you and Medicaid is not going to pay for programs offering treatment that fails to address the individualized needs of patients.”
What does the implementation of The ASAM Criteria currently look like in the United States and what is the goal for the future?
What ASAM would really like to see is acceptance of baseline national standards across the country. Whether that’s The ASAM Criteria or something better, we need to insist on fidelity to standards that people could look at and say that’s what good care is. Having that universal understanding of what is needed is going to improve addiction treatment throughout the nation and help address practices that are killing people with addiction.
The pandemic has made everything harder. We’re seeing more patients that are more ill. Care delivery has been a problem. This is multi-leveled. But I’m grateful that there is a noticeable shift in how addiction and its treatment are being approached. The fact that we are even talking about this is a positive.