Expand Access to Medicated Assisted Treatment/Recovery (MAT/MAR)

Introductory Paragraph

Medication-assisted treatment (MAT), including opioid treatment programs (OTPs), combines behavioral therapy and medications to treat substance use disorders. Information on medications used in MAT can be found further down on this page. The President's Commission on Combating Drug Addiction and the Opioid Crisis has recommended that the federal government "immediately establish and fund a federal incentive to enhance access to Medication-Assisted Treatment (MAT)."

The above report documents that MAT has been proven to:

• Reduce overdose deaths
• Retain persons in treatment
• Decrease use of heroin
• Prevent spread of infectious disease

Key Information

The Value of MAT (or Opioid-Agonist Treatment)

• International addiction experts consider initial opioid-agonist treatment, or OAT, with no duration restrictions, the evidence-based standard of care for opioid-use disorder, the authors write online November 20, 2018, in Annals of Internal Medicine.
• In California, where more people have been diagnosed with opioid disorder than in any other U.S. state, publicly funded treatment programs require patients to “fail” - twice - at a three-week course of medically supervised withdrawal before they become eligible for OAT. Policymakers likely maintained this medically managed withdrawal requirement under the belief it was saving money. The study demonstrates, however, that the policy creates significantly greater long-term costs for criminal justice and healthcare systems.
  • The study concludes OAT would have saved as much as $850 million over five years, not including savings to the criminal justice system, and more than $2 billion, including the cost of arrests and prosecutions. Over 10 years, the total savings would rise to $2.87 billion.
  • “In order to see overdose deaths come down, we need to make sure people who have opioid addiction are able to access effective treatment more easily than they can access heroin, fentanyl or pain pills."
  • "We need a model whereby patients can get immediate access to opioid-agonist treatment, a lifesaving intervention, without obstacles."
  • “Among experts in the field of addiction, we already know that detox doesn’t work, that they’re going to relapse and when they relapse, they’re going to be at great risk for an overdose, that they’ll be at great risk for hepatitis,” Kolodny said. “Opioid addiction is a life-threatening illness."

Access the study here:

This article talks of how the use of Buprenorphine reduces the cost of opioid addiction

 

Relevant Research

An article in the August 2017 issue of the American Journal of Psychiatry, by Roger D. Weiss, MD, the Chief of the Division of Alcohol and Drug Abuse at McLean Hospital (Belmont, MA) and Professor of Psychiatry at Harvard Medical School and Kathleen Carroll, Ph.D. concluded: "Finally, with 6-month retention rates seldom exceeding 50% and poor outcomes following dropout, we must explore innovative strategies for enhancing retention in buprenorphine treatment."

 

This report reveals the need for significantly more studies that can yield additional insights to inform MAT practices. Current literature focuses mainly on the outcome of treatment retention and negative urine drug screens. Enhanced research would look at broader outcomes of social functioning and well-being including employment, stable housing and other measures of well-being. Also, research would ideally have information on many other factors such as information on co-occurring disorders and different types of behavioral treatments that would be appropriate for different individuals. While not mentioned specifically in that article, a person's history of trauma or adverse childhood experiences (ACEs), length of time with an SUD, their current level of supports, and genetic factors such as the rates at which they metabolize different drugs would all impact what type of treatment would be most appropriate. All of these unique factors and the wide range of potential interventions are reasons that more research is needed, and conclusions from studies that look at a limited number of inputs and outcomes and lack visibility into all the unique factors that influence what might impact successful outcomes should be seen as early insights in a journey of finding the optimal forms of treatment for each person's situation.

 

Weiss and Carroll highlight some key findings from their report in a webinar done through the American Journal of Psychiatry learning center. Key points include:

• Buprenorphine is an excellent medication, but there is still much room for improvement in how MAT is done.
• Research designs, such as the intensity of Medication Management, the dose of buprenorphine, and the characteristics of the group participants, influence outcomes.
• Different sub-groups respond differently to different elements of treatment plans.
• Early treatment response has a major impact on long-term success, and a better understanding of that insight may help decision-making.
  • Patients who abstain from opioids in the first two weeks of treatment have a good chance of a good 12-week outcome.
  • Patients who use opioids during the first two weeks of treatment have very little chance of abstaining by week 12.
• There is evidence that the use of Contingency Management (CM), including the use of computer-based therapies, seems to increase success rates.
• Patients' dependent on prescription opioids seemed to respond more positively to Cognitive Behavioral Therapy (CBT) than those who were primarily heroin users.
• Different treatment approaches appeal to different patients, and using approaches that appeal to the patients helps to increase their retention rates.
• More data is needed to better understand what treatment options are best for different individuals.

Ways to Improve and Optimize MAT

The effectiveness of MAT is enhanced when there is an emphasis on a broad range of treatment and recovery supports, not just providing the medication part of the MAT.  MAT is optimized when those providing and funding the treatment keep striving to improve all aspects of the treatment plan, optimized for each individual as much as practical. 

Some of the ways that MAT can be optimized are listed below:

• Precision medication (Expand DNA Testing to Improve Precision MAT)
• A coordinated, proactive, whole-person care plan (Integrate MAT into whole-person care model)
• Community engagement (Expand community engagement to improve MAT)
• Use of innovative technologies (Use innovative technologies to enhance MAT)

Current Status of MAT Practices

• Only 10% of conventional drug treatment facilities in the United States provide MAT for opioid use disorders (need source and date)
• According to SAMHSA data collected in early 2017, 40 percent of the physicians who have a waiver do not prescribe buprenorphine at all. This may be due to physicians' reluctance to have patients with addictive disorders frequenting their offices or due to concerns about DEA audits, among other reasons.
• Avalere’s analysis finds that 11 states (IA, IL, MD, MI, MO, NC, NH, OH, VA, WI, WV) located in the Midwest and Mid-Atlantic and DC have significantly lower-than-average rates of providers who prescribe buprenorphine compared to opioid overdose deaths.

Co-occurring Disorders

Co-occurring disorders, or dual diagnosis, refers to having a simultaneous mental health disorder and substance use disorder. It is common for people with addictions to also suffer from depression, anxiety, or more severe mental illnesses such as schizophrenia or bipolar disorder. Research shows that people who use alcohol or other drugs early in life are more likely to have mental or emotional problems. It’s also true that many people with mental illnesses “self-medicate” with alcohol or other drugs to numb emotional pain, relieve anxiety, or quiet their thoughts. In the past, the medical profession treated one disorder first, typically the substance use disorder, before addressing the other. It is now understood that treating both simultaneously leads to better outcomes. Any successful addiction treatment program will include a mental health assessment and treat co-occurring disorders at the same time.

 

Different Medications Used in MAT:

Agonists & Antagonists

An opioid agonist activates opioid receptors in the brain. An antagonist blocks opioids by attaching to the opioid receptors without activating them.[Detoxification vs. Stabilization]

 

Buprenorphine

• Buprenorphine is used in MAT to help people reduce or quit their use of heroin or other opiates, such as pain relievers like morphine. One study showed that 50% of the people in treatment who were also on Buprenorphine stayed on treatment compared with 7% who only had treatment.
• Buprenorphine is a partial agonist that suppresses opioid withdrawal symptoms. It can produce opioid agonist effects, such as euphoria, it is milder than full agonists such as methadone.
• Buprenorphine can be prescribed by physicians in an outpatient setting who have completed a training course and received a DEA DATA 2000 waiver. It is taken as a pill or sublingual film. Buprenorphine was also approved in a 6-month implant form in May 2016
• Training for Buprenorphine providers is an 8-hour course (24 for Nurse Practitioners and Physician Assistants) and allow for the following patient loads and responsibilities:

1. 30 Addiction Treatment Patients per provider for the first year
2. 100 patients each year thereafter
3. An additional 175 (totaling 275) patients can be allotted if the Physician is board certified in addiction or if a facility:

• Has 24 Call Coverage for patients
• Uses an EMR/EHS to monitor and update patient records (for those looking for an entry-level EHS, PracticeFusion is a free system)
• Provision of Care Management Services
• Subscribing to a State-led Drug Management System
• Acceptance of Third-Party Insurance

It should be noted that only around 10% of those who wish to seek treatment can find qualified providers to allow for it.  As a result, there are cases where medication diversion does occur, and there is a black market for the drug for self-treatment purposes.

Treatment with buprenorphine has been proven effective in opioid addiction, decreasing mortality by approximately 50%. Patients treated with buprenorphine show improved social functioning with increased retention in treatment (67% at one year) compared to drug-free treatment (7% to 25% at one year), reduced criminal activity, lower rates of illicit substance abuse, and reduced risk of HIV and hepatitis infection.

SAMHSA provides more information on Buprenorphine

Suboxone

• Suboxone is a brand name for a hybrid that is three parts Buprenorphine and one part Naloxone.
• Suboxone is more difficult to misuse because it will cause the patient to enter opioid withdrawal if it is misused in any way, such as injection.

Probuphine

• Probuphine is an implant that contains the medicine buprenorphine. Probuphine is used to treat certain adults who are addicted to (dependent on) opioid drugs (either prescription or illegal). Probuphine is part of a complete treatment program that also includes counseling and behavioral therapy.
• Because Probuphine contains buprenorphine, it may cause physical dependence.
• Four implants are inserted under the skin of your upper arm during a procedure done in your physician's office or Opioid Treatment Program (OTP).
• The implants remain in your arm for six months.
• After the six-month period, your doctor must remove the implants.
• If you wish to continue Probuphine, your doctor may insert new implants to continue treatment.
• The implants can be removed sooner if you want to stop treatment.
• Patients must continue to see their doctor at least every month while on Probuphine therapy.
• For more information visit their website.

Methadone

• Methadone, sold under the brand name Dolophine among others, is used in MAT to help with detoxification or as part of maintenance therapy or Opioid Replacement Therapy.
• Methadone is an opioid replacement. It works by changing how the brain and nervous system respond to pain. It lessens the painful symptoms of opiate withdrawal and blocks the euphoric effects of opiate drugs such as heroin, morphine, and codeine, as well as semi-synthetic opioids like oxycodone and hydrocodone.
• Methadone is to be prescribed as part of a comprehensive treatment plan that includes counseling and participation in social support programs.
• Methadone can only be dispensed at SAMHSA-certified outpatient treatment programs or in hospitals in an emergency.
• Methadone has been used to treat chronic pain, however, this use is limited because of the serious risk of dependence and overdose.
• Link to SAMSHA page on Methadone

Naltrexone

• Naltrexone is a nonaddictive medicine that serves as an opioid receptor antagonist and not an opioid replacement, unlike methadone and buprenorphine. It is a primary ingredient in the treatment of alcohol and opioid dependence. Naltrexone blocks certain receptors in the part of the brain that triggers dopamine release so they cannot be activated. Dopamine release reinforces the vicious and compulsive addiction feedback loop. When we block these areas of the brain, the craving for alcohol and opiates is eliminated or significantly reduced. The pleasure is very limited and the uncontrollable cascade of relapse is much less likely, if alcohol is consumed after the implant procedure, in addition, if opiates are consumed after the procedure, there are no effects.
• Naltrexone is administered in a long-active, injectable formulation administered once a month.
• Naltrexone does not prevent withdrawal symptoms so it is recommended for patients who do not have opioids in their system.
• Link to SAMSHA page on Naltrexone (The 30-day injectable version is commercially known as Vivitrol)

Naloxone

• Naloxone is an opioid antagonist used to reverse opioid overdose
• Naloxone (commercially known as Narcan) is available in intravenous or intramuscular injection and nasal delivery options. Intramuscular injection or intranasal delivery is safe for administration by any person.
• Naloxone works within minutes and effects last for up to an hour. Multiple doses may be required depending on the severity of respiratory depression.
• Naloxone does not produce tolerance or dependence.
• Link to SAMSHA page on Naloxone

Find information on physical ailments often diagnosed in MAT patients. Also known as common comorbidities, these include viral hepatitis, HIV, and AIDS.

Medications Used in Addiction Treatment**

Sept 2017	Where it can be provided	FDA indications	Effectiveness	Administration
Methadone	OUD. Licensed opioid treatment programs Pain. Any Drug Enforcement Agency (DEA)-licensed prescriber	OUD and pain management	74% to 80%	OUD. Daily pill, liquid, and wafer forms; injectable form in hospitalized patients unable to take oral medications Pain. Injectable, transdermal, and buccal film
Buprenorphine and buprenorphine/naloxone	Prescribed by community physicians and dispensed by pharmacies, available in some opioid treatment programs. Physicians receive federal waivers after eight hours of training; nurse practitioners and physician assistants require 24 hours. Patient panels are capped at 30, 100, and 275 per provider (depending on experience and setting). Any DEA-licensed provider can prescribe buprenorphine for pain.	OUD and pain management (depending on formulation and dose)	60% to 90%	OUD. Daily sublingual, buccal, film, and tablet, or six-month intradermal device Pain. Injectable, transdermal, and buccal film
Naltrexone	No restrictions	Opioid and alcohol use disorders	OUD. 10% to 21%	Daily pill or monthly injectable
Naloxone (used only for overdose reversal, not addiction treatment)	Any setting: prescribed or dispensed by a clinician, furnished by a pharmacy without a prescription (legal in several states), dispensed by lay staff in community settings (by standing order), or carried by law enforcement or other first responders.	To reverse respiratory suppression in suspected opioid overdose	May require high doses for extremely high-potency illicit drug use (fentanyl and carfentanyl)	Intranasal spray, or intravenous, intramuscular, or subcutaneous injectable

Extensive research has demonstrated the effectiveness of opioid agonist treatment (methadone and buprenorphine) in opioid use disorder. A meta-analysis of 50 studies showed methadone's retention rate ranging from 70% to 84% at one year, buprenorphine ranging from 60% to 90% at one year, with both treatments resulting in significant reductions in overdose death, illicit drug use, criminal activity, arrests, risk behaviors, HIV and hepatitis C incidence, as well as improvements in health status, functioning, and quality of life.
 

Stages of MAT with Buprenorphine

Induction

"Induction is the first stage of buprenorphine treatment and involves helping patients begin the process of switching from the opioid of abuse to buprenorphine. The goal of the induction phase is to find the minimum dose of buprenorphine at which the patient discontinues or markedly diminishes use of other opioids and experiences no withdrawal symptoms, minimal or no side effects, and no craving for the drug of abuse."

New non-pharmacological approaches to treat opioid withdrawal could provide alternative pathways to help a patient manage withdrawal symptoms as they transition into MAT. The BRIDGE® is a noninvasive, percutaneous electrical nerve field stimulator developed to target pain. An article published in 2018 in The American Journal of Drug and Alcohol Abuse shared significant promising results in using the BRIDGE to help people transition to MAT. The neurostimulation rapidly and dramatically reduced the COWS scores of the participants, and 64 of the 73 people successfully transitioned to MAT.
Some training programs suggest that Clonidine or Ondansetron may be used to ease the withdrawal symptoms during induction.

Stabilization

"The stabilization phase has begun when a patient is experiencing no withdrawal symptoms, is experiencing minimal or no side effects, and no longer has uncontrollable cravings for opioid agonists. Dosage adjustments may be necessary during early stabilization, and frequent contact with the patient increases the likelihood of compliance."

Maintenance

"The longest period that a patient is on buprenorphine is the maintenance phase. This period may be indefinite. During the maintenance phase, attention must be focused on the psychosocial and family issues that have been identified during the course of treatment as contributing to a patient’s addiction."

Medically Supervised Withdrawal (Detoxification)

As an alternative to the three stages above, the goal of using buprenorphine for medically supervised withdrawal from opioids is to provide a transition from the state of physical dependence on opioids to an opioid-free state, while minimizing withdrawal symptoms (and avoiding side effects of buprenorphine). Medically supervised withdrawal with buprenorphine consists of an induction phase and a dose-reduction phase. The consensus panel recommends that patients dependent on short-acting opioids (e.g., hydromorphone, oxycodone, heroin) who will be receiving medically supervised withdrawal be inducted directly onto buprenorphine/naloxone tablets. The use of buprenorphine (either as buprenorphine monotherapy or buprenorphine/naloxone combination treatment) to taper off long-acting opioids should be considered only for those patients who have evidence of sustained medical and psychosocial stability.

Impactful Federal, State, and Local Policies

New 2018 SAMHSA Guide for Medications for Opioid Use Disorder

This latest, detailed 330-page report can be downloaded for free. 

Available Tools and Resources

The Provider's Clinical Support System offers a module for CME credit on the Stigma on Maintenance Treatment. This can address the primary perceived and actual stigmas from patients as well as follow professionals.

BupPractice
This is a DATA 2000 accredited resource for providing either an 8-hour training for Physicians or a 24-hour training session for Physician Assistants and Nurse Practitioners, both for $199 per full series. It also offers up to 9 AMA PRA Category 1 Credits, and is further supported by the ASAM (American Society of Addiction Medicine).

SAMHSA Treatment for Homeless
This document shows current resources for those attempting to handle behavioral health topics, particularly in homeless populations, as well as strategies to develop one's own programs.

Where Can Clinicians Get Training and Support? Buprenorphine training sessions are offered at several locations and websites. The training takes about eight hours and can be attended in person, online, or a combination of both. Buprenorphine waiver training can be valuable to any clinician (medical or behavioral) as it covers the basics of opioid addiction and how buprenorphine works. Clinicians can only prescribe buprenorphine for addiction after receiving certified training and a Drug Enforcement Administration (DEA) waiver. However, any DEA-licensed clinician can prescribe buprenorphine for pain. Training opportunities are posted on the following websites: Substance Abuse and Medical Health Services Administration (SAMHSA), American Academy of Addiction Psychiatry (AAAP), American Osteopathic Academy of Addiction Medicine (AOAAM), and Providers’ Clinical Support System (PCSS).24-27 Some sites also offer other tools and resources. PCSS offers online mentorship, and Project ECHO28 offers video and monthly case review. The Clinicians Consultation Center at UCSF offers expert clinical advice, Monday through Friday, 7 a.m. to 3 p.m. PST.29 Substance Use Warmline: (855) 300-3595. 

Promising Practices

New & Expanded Treatment Options

Connecticut

Connecticut's Department of Mental Health and Addiction Services (DMHAS) recently received two federal grants, one of which is meant to go to medication-assisted treatment, the other toward prevention efforts. DMHAS is also collaborating with the Connecticut Community for Addiction Recovery on a new program that will enable people who were saved from overdose through the use of naloxone to work with a recovery coach who can connect them to services and a support network.

Vermont

Vermont's Health Home for Opioid Addiction has employed a "Hub & Spoke" system in handling the Opioid Crisis, called the "Care Alliance for Opioid Addiction," which has seen some success in treating addicted individuals while helping lift the burden of care from singular doctors and clinics. The system is composed of the following parts:

• The Hub, a designated provider of specialty addiction treatment, is designed as an Opioid Treatment Program which is operated by Community Behavioral Health Agencies.
• The Spokes are health care teams led by physicians who can prescribe Buprenorphine and are regulated as Office Based Opioid Treatment providers.

Payment infrastructure for providers are structured after already existing Medicare and Medicaid Structures, which are documented in the Vermont Global Commitment To Health Section 1115 Demonstration Fact Sheet

• • An evaluation of the Care Alliance for Opioid Addiction has shown that people in treatment for opioid addiction reported a 96 percent decrease in opioid use, and a 100 percent drop in overdose incidences, according to a new report from the Vermont Department of Health released 1/22/18.
  • Additional findings include:
    • 92% drop in injection drug use.
    • 89% decrease in emergency department visits.
    • 90% reduction in both illegal activities and police stops/arrests.
    • Zero participants in treatment had overdosed in the 90 days leading up to the study interview, compared to 25% who had overdosed in the 90 days before entering treatment.
    • Family conflict, feelings of depression, anxiety and anger decreased, and participants reported being much more satisfied with their lives.

More information can be found at:

Emergency Department Treatment Protocols

In a Yale Randomized trial, it was found that individuals who receive Buprenorphine while getting medical care within an emergency room are more likely to adhere to treatment protocols and have a better chance at ceasing opioid use when compared to those who have received referrals to receive the treatment, or those who received motivational support.This can be an initiation point for treatment of opioid dependence and can be followed up by primary care facilities. This has shown to decrease the need for in-patient facilities. This can be attributed to engaging patients at the optimal point of access.

National Healthcare For Homeless Council

As one may assume, there is cross-over between the homeless and addicted communities. The National Healthcare for the Homeless Council has as a result, released a policy brief that may be of some use for both policy makers and health care providers alike. Within the brief, a basic strategy is considered as follows when treating addicted and homeless/addicted patients:

  • Establish stability. Stable housing is central to attaining treatment goals as it provides patients with stability, a sense of safety, an increased ability to meet basic needs, and an opportunity to have increased control over their lives and environment. Securing stable housing as early as possible is key to the treatment and recovery process.
  • Address comorbidities using integrated care. Untreated medical and/or other behavioral health conditions may complicate MAT. The most successful interventions are provided through integrated care models of interdisciplinary teams made up of medical, mental health, substance use, and social service providers. Each discipline should not only be co-located, but should work collaboratively as a team with multiple services offered in the same visit.
  • Treat the whole person. Substance use disorders cannot be treated apart from addressing the needs of the whole person in the context of his or her environment. In addition to addressing comorbidities, assistance in accessing food, clothing, shelter/housing, financial assistance, counseling, job training, employment services, and other needs as identified must be included alongside MAT.
  • Take a harm reduction approach. Harm reduction therapy is an evidence-based practice that supports and respects a person’s experience and treats them with dignity, which is especially important for persons experiencing homelessness who regularly interact with systems and situations that limit self-determination and lack respect. Harm reduction therapy relies on collaboration, respect, and stage-based interventions that acknowledge self-defined positive change. Harm reduction therapy focuses on client-defined priorities and acknowledges that any improvement that reduces harm is beneficial. The key to harm reduction therapy is low barrier, integrated care that is trauma informed and respectful of the collaborative therapeutic relationship.
  • Utilize evidence-based best practices. In addition to harm reduction, using other evidence-based best practices such as the use of peer specialists, motivational interviewing, and individual and group therapy can help patients maintain recovery and have successful treatment outcomes.
  •Be patient centered. Building trust and developing relationships is essential to providing high-quality care and achieving good health outcomes. Engaging in patient centered care based on a patient’s individual needs, strengths, goals, and timeframe rather than on a pre-determined benchmark for outcomes is one way to build relationships and empower patients in the process. Patients should be actively involved in setting goals and planning their treatment.
  •Be flexible. There is no one-size-fits-all treatment that will work for all patients. While MAT recommends a combination of medication and behavioral health therapy, treatment should be flexible and individualized to the patient’s needs, especially the frequency/schedule for therapy. For some, medication alone and regular consultation with a primary care provider is enough to maintain and recover from addiction, while others may need the additional supports provided by behavioral health therapy.

 

Opioid Treatment Program Directory

Select this directory to view the opioid treatment programs in each state

Moving from Stigma to Science

Pennsylvania and New Jersey

The Department of Behavioral Health and Intellectual Disability Services of Pennsylvania has taken actions to ensure that halfway houses and other rehabilitation facilities cannot turn away individuals using MAT as a means of treating Opioid Abuse.  Underlying problems still exist in restrictive medication regimen practices, insurance coverage, and Public-Private partnerships, which require support to overturn previous hard-lined policies. An evidence-based approach has shown that introduction of MAT, especially with Buprenorphine, has had an increased mitigation effect on relapse and a higher chance of long-term recovery.

National Healthcare For Homeless Council

The National Healthcare for the Homeless Council also has recommendations of policy that not only controls the prescription of opiates, but also the treatment of opioid addiction. They are as follows:

Remove the cap on the number of patients a physician can treat with buprenorphine. Existing limits are arbitrary and create barriers to accessing treatment. While put in place to mitigate diversion, cap limits may inadvertently aid diversion by limiting the supply of MAT, leading to individuals pursuing self-treatment by purchasing diverted drugs. Ironically, there are no limits to the number of patients a physician can prescribe other opioid drugs that present a much greater risk of causing addiction, overdose, and death (e.g., Methadone, Oxycodone, Hydrocodone, and Fentanyl). Removing the caps will allow providers to determine the number of patients they are able to treat based on the capacity of their practice and other factors, thereby increasing access to treatment.

• Expand prescribing rights to all clinicians who are eligible to prescribe Class III, IV, and V CDS drugs. Limiting prescribing rights to physicians creates an additional barrier to accessing treatment and is incongruent with the existing scope of many clinical practices. Expanding prescribing rights to Nurse Practitioners, Physicians Assistants, and other clinicians who are authorized to prescribe Class III, IV, and V CDS drugs will expand treatment opportunities and decrease barriers to care. Clinicians who can prescribe opioids for pain should also be able to prescribe buprenorphine to treat the addictions that sometimes result.
• Require training to prescribe all opioids, not just buprenorphine. Specialized training is required to prescribe buprenorphine, but no other drug (opioid or otherwise) requires this as a condition of practice. Given the lower risks associated with diversion of buprenorphine, and the elevated risk associated with many opiates that can be prescribed with few restrictions, training should be extended to the prescribing of any opioid and focus on administering and monitoring prescriptions and understanding the nature of addiction. In addition, prescribers should have greater access to technical assistance and resources to develop plans to identify and avoid diversion.
• Enforce parity laws. Substance abuse treatment and other behavioral health services should be just as easy to access as primary care services. Parity laws are in place to ensure insurance plans treat these services equally, and should be enforced. Health insurance practices that require prior authorizations for opioid treatment should be scrutinized, especially when they create barriers to behavioral health care that do not exist for primary care. Just as there are no prior authorizations required for opioid drugs prescribed for pain management, there should be no prior authorizations required for MAT. Addiction is a time-sensitive condition to treat, and presenting for treatment is a big step for patients; even a delay of one day can be the difference in someone getting treatment or not.
• Reduce stigma and treat addiction as a disease. The main barrier to any type of treatment for persons experiencing homelessness is a lack of stable housing. In addition, drug screens are often required when accessing housing, and employers often require drug screens for employment. Landlords and employers need to accept buprenorphine prescribed as part of a MAT plan as a medical treatment process, and not have it count negatively against a person by including it as a prohibited substance. Addiction needs to be seen as a disease and not a moral failing, and engagement in MATs as a health care intervention should not be a liability to accessing housing or employment.
• Train all health care disciplines on addiction. Expanding awareness of addiction and providing substance abuse education for medical students, residents, practicing physicians, and all other health care providers is essential. Curricula which treat substance use conditions similarly to other chronic disorders and provide more adequate basic preparation need to be implemented. In addition, continuing education opportunities to learn about evidence-based practices for the treatment of SUDs need to be provided, and programs to support the adoption of MAT, screening, brief intervention, and referral to treatment need to be identified and implemented.

Financial Incentives for MAT training

Neighborhood Health Plan (NHP) of Massachusetts has announced a series of initiatives to increase access to substance use disorder treatments. This non-profit health plan is providing financial incentives to encourage more prescribers to train and be certified to prescribe buprenorphine products. NHP will reimburse prescribers $500, which is roughly the cost of required training, for earning their certification in buprenorphine product dispensing. Prescribers can receive an additional $2,000 if they provide documentation showing that at least 10 patients have been treated after becoming certified. This financial incentive has become increasingly popular, as NHP has received several inquiries about the program from prospective prescribers within days of its announcement. Other initiatives include hiring recovery coaches to work with patients as part of their follow-up care as well as waiving member copays for naloxone. "Pharmacists will be reminded to notify plan members that they are eligible for free naloxone supplies when they pick up high-dose narcotic painkilling prescription medications." Another initiative is to offer a benefit design that encourages plan members to seek alternatives to opioid medications. NHP waives copays for alternative treatments to prescription painkillers including chiropractic care, acupuncture, and physical therapy.

Canadian Guidelines

This document has details on the MAT Methadone guidelines from Canada

Sources