To combat the growing opioid addiction crisis, New Jersey needs additional healthcare professionals trained and willing to provide treatment, easier access to the life-saving medications involved, and more wraparound services like housing and education support.
The recommendations came from experts, including state Human Services Commissioner Carole Johnson and several frontline addiction providers, during a roundtable discussion on opioid treatment hosted on Friday by NJ Spotlight (and moderated by the author). The event was the second in a series of three panel discussions on the state’s opioid crisis; the final session, on October 25, will focus on long-term recovery.
Participants agreed that significant progress has been made in understanding addiction and developing tools to help those with substance-use disorders manage their disease long-term; insurance coverage is also more extensive than in the past. More providers have been educated in opioid addiction issues and the state continues to work to expand access to care, especially for low-income residents.
But for many patients, especially those with Medicaid, it can be a challenge to find a doctor available to properly treat them in a timely way or provide medication-assisted-treatment (MAT), now considered the gold-standard of care. Too many people end up in the emergency room, where staff are ill-equipped to address their needs and unconnected to the support services that are essential for recovery.
Insurance coverage not enough
“As everyone at this panel knows, (insurance) coverage is necessary, but not sufficient,” said Johnson, whose department oversees community behavioral care and the Medicaid program. “We need that full continuum of services,” she said.
There were positive developments to report. Efforts are underway to train more doctors and nurses to assess and properly treat addiction, like Rutgers New Jersey Medical School’s new requirement that all third-year students receive training in MAT protocols. Dr. Erin Zerbo, an assistant professor in the psychiatry department who also runs a Newark practice and works at University Hospital, said next year the school also will offer a new fellowship in addiction medicine.
In addition, all emergency-room staff at Cooper University Hospital in Camden have been trained in modern addiction treatment, a process that increased access to care and also changed the attitude of some staff members who had previously had concerns about dealing with addicts, recalled Dr. Kaitlan Baston, medical director for addiction medicine at Cooper’s Urban Health Institute.
“Just getting that training changed hearts and minds,” she said.
Making it easier for Medicaid patients
And New Jersey wants to make it easier for Medicaid patients to access MAT, Johnson explained. Starting next month, she said long-term treatment programs will be required to accept patients taking these medications — which include minute doses of opioids designed to reduce addictive behavior and therefore remain controversial with some who favor abstinence-based treatment.
“I have a treatment that works for a disease,” said Baston, who runs a busy family clinic in Camden that relies heavily on MAT to assist patients, including pregnant women. “I’m not going to not offer it to patients.”
Johnson also announced that the DHS is looking to remove a requirement that doctors seek advance authorization for these prescriptions for Medicaid patients, a barrier that no longer exists for those with commercial insurance plans regulated in the Garden State. “It’s something we are taking a look at,” she said.
This was good news to Zerbo and Baston, who has three staff members working in her clinic to secure the “prior authorizations” now required for Medicaid members.
It was also welcomed by Dr. Dheeraj Raina, the medical director for substance-use disorder initiatives for Anthem health insurance, based in Chicago; Anthem policies are offered through AmeriGroup in New Jersey.
More needed than ‘just throwing money at it’
Raina said Anthem has also eliminated the requirement for prior authorization for these drugs in its commercial plans nationwide but has met resistance among the leaders of Medicaid programs in certain states who are unwilling to make the same changes for public insurance plans. (In the Garden State, Anthem also provides Medicaid managed-care plans through AmeriGroup.)
Anthem has launched a number of efforts nationwide to expand access to MAT prescribers, Raina said, including an initiative in Indiana that offered doctors a bonus of $1,000 if they ramped up their use of these medicines; that initiative essentially failed. The company has had better luck with a training program it developed to help boost the number of skilled addiction-treatment providers, he noted.
“It’s a bigger task than just throwing money at it,” Raina explained. In fact, some studies have shown that nearly one-third of providers licensed to provide MAT are not using the program at all, he noted.
The biggest barriers remain on the federal level, he noted, where significant restrictions remain on Buprenorphine, one of the most useful MAT drugs — including limits on how many patients a prescriber can treat at one time and a monitoring program — which have left many physicians gun-shy about prescribing these medications.
Emergency-room staff need better training
Baston and Zerbo agreed these changes were important but didn’t do enough to reduce the barriers to proper care and recovery. Emergency-room staff need better training in behavioral health issues, as well as connections to other programs — either to divert patients for more appropriate care elsewhere, and to help them once they leave the hospital. Far too often, they said, patients are sent home and told to follow up with their primary-care doctor a week later, something that may be an overwhelming task for an individual struggling with addiction, mental illness, homelessness and more.
As a result, the same patients return to the ER time and time again after an overdose or when a chronic health problem becomes overwhelming, Baston said. The Camden hospital sees an average of 15 overdoses a day, she said, and one patient was revived with the overdose-antidote Narcan 173 times in one year, just in that emergency room.
“There are so many broken links in the system,” Zerbo said. “We need policies to make this seamless for people.”
That message has not been lost on state officials, Johnson said. Gov. Phil Murphy, who took office in January, has invested new resources in housing, job services and other supports, she noted, and health officials in his administration have focused on addressing the underlying problems created by social determinants of health.
“We are trying to think holistically,” Johnson said.