Best Practices to Address Opioid Use Disorder for Medicaid Directors

The overdose death rate from prescription opioids rose by 12 percent from 2016 to 2017, urging states to address opioid use disorders. As the opioid epidemic shows no signs of slowing, healthcare workers are scrambling looking for effective solutions.

Non-profit organizations, health systems, public health agencies, and community programs are all using different strategies to combat the opioid epidemic. So states struggling with their response to the epidemic are left wondering which strategies are the most effective.

To help state Medicaid programs understand best practices, strategies, and resources available to them to address the crisis, Manatt Health developed a toolkit titled “Using Medicaid to Advance Evidence-Based Treatment of Substance Use Disorders.”

Patricia Boozang, MPH, senior managing director at Manatt Health and lead author of the toolkit, spoke with HealthPayerIntelligence.com about the strategies outlined in the toolkit and how states can leverage limited resources to address the opioid epidemic.

“We try to optimize and maximize the benefit of their Medicaid programs in everything from coverage to addressing public health crises like the opioid epidemic,” Boozang said. “A lot of states are grappling with the opioid epidemic. We are interested in helping states identify and implement strategies to address those public health issues, but we are really interested in trying to give states very tactical, practical tools to do it.”

The toolkit highlights Medicaid programs in particular because they are the bedrock of the state’s ability to respond, Boozang argued.

“Medicaid is already covering a lot of people with opioid use disorder and that coverage can be comprehensive,” she pointed out. “People have co-occurring problems. They have mental health diagnoses that go along with substance use. Both of those things either create or coexist with other physical health issues. Medicaid is important because it can address all of it.”

The first recommendation by the toolkit is to increase access to medication-assisted treatment (MAT).

“MAT has the best evidence base of any therapy for opioid use disorder. It is the gold standard,” Boozang said.

The evidence of MAT’s effectiveness is overwhelming. This treatment method uses agonist drugs such as methadone and buprenorphine to activate opioid receptors in the brain and prevent withdrawal symptoms. Using MAT has been shown to reduce opioid use in patients.

“It’s not so much making the case that MAT has an evidence base, but it’s helping states understand what levers they can pull to expand that mode of treatment,” Boozang explained.

“There’s a lot of thought leadership that’s written about MAT and what you should do. But we really wanted to pull out some real examples both in terms of which states are the ones to look at and the state’s policy,” Boozang furthered. “Here’s another state’s Medicaid managed care contract language. Here’s how a particular state thought about provider communication. We were trying to make it very tactical.”

Focusing on MAT should be a state's number one priority, Boozang argued.

“If you have really limited resources, MAT expansion should be a state’s highest priority. We hope the toolkit gives states the ability to look at strategies they think they can leverage and implement in their states,” she continued.

The second strategy outlined by the toolkit is coordinated, team-based care.

Treating the physical, mental, and psychosocial factors of opioid use disorder requires the work of many individuals across the healthcare system.

A team-based approach delivers more coordinated care to patients rather than the disjointed and delayed care of multiple specialists. 

“It really does makes sense to pay providers to put together these types of care teams that really can be effective. Pay them for the additional care management that goes along with putting together those teams,” Boozang noted.

The final strategy outlined in the toolkit is monitoring and evaluating opioid use disorder interventions on an ongoing basis.

“Sometimes in Medicaid, in healthcare generally, we don’t put enough of a premium on monitoring and evaluation or really shifting resources to those strategies and tactics we know work,” Boozang emphasized.

The opioid epidemic is growing quickly, so states do not have time to implement one strategy at a time. But some interventions might be more effective than others. Deciphering which program has the greatest impact can help decision-makers more appropriately allocate funds to the most effective efforts.

To fully understand this, data is needed on engagement in treatment, retention in treatment, transitioning from treatment to recovery, emergency room utilization, number of overdoses, and mortality data, Boozang said.

Access to all of this data can be challenging, so Boozang recommended partnering with a local university to leverage resources.

“That’s another resource that states can look to for help on an ongoing basis to evaluate the strategies they’re implementing,” she said.

It is critical that this final strategy is not overlooked. In an environment where budgets are frequently limited and resources can be sparse, identifying what is and is not working can help manage budgets and promote the most successful programs.

“It’s so important for states to be checking on what they’re doing. If it’s not working, end it and put those dollars into things that are working,” Boozang noted.

Ultimately, she hopes the toolkit will help state Medicaid programs identify strategies that can work for them.

“Find a state that mirrors your state environment or is consistent with the strategies you’re thinking about,” Boozang concluded. “State Medicaid programs are all really different, so it won’t be true that every strategy works for every state. We’re really hoping it’s a roadmap for states to look at and compare or borrow other state’s approach.”