Congress needs a broader approach to address opioid epidemic

Congress needs a broader approach to address opioid epidemic
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When it comes to addressing the opioid crisis, the United States is falling far short. Only 10 to 26 percent of those with an opioid use disorder are getting care. And among that group, only a bit more than a third are getting the most effective care, with one of the three FDA-approved medications — buprenorphine, methadone and naltrexone, known collectively as Medication Assisted Treatment, or MAT.

But while policymakers are justifiably focused on the opioid crisis, a bill that the House will consider won’t direct new federal resources where they’re most effective. In fact, it might undermine efforts to improve the full continuum of care for people with substance use disorders (SUDs).

That’s because the bill would expand opioid disorder treatment in an unbalanced and potentially counter-productive way by simply letting Medicaid pay for that treatment in specialty residential and inpatient facilities. That is, it would scale back the prohibition — known as the Institutions of Mental Disease (IMD) exclusion — on using federal matching funds in Medicaid to pay for care in facilities with more than 16 beds that treat mental diseases.


Opioid use disorder is a chronic recurring condition. However, effective treatment can involve a broad continuum of services that range from institutional care to pharmaco-therapies to psychosocial and rehabilitation services.

That’s why, under both Presidents Obama and Trump, the federal Centers for Medicare & Medicaid Services (CMS) has given states waivers from the IMD exclusion if they improved their community-based services. Eleven states already have waivers, while 12 others have proposals pending for them.

CMS’ guidance to the states in 2015, for instance, conditioned such waivers on states “developing comprehensive strategies to ensure a full continuum of services, focusing greater attention to integration efforts with primary care and mental health treatment, and working to deliver services that are considered promising practices or have fidelity to evidence-based models consistent with industry standards.”

The House bill, by contrast, doesn’t tie federal funds for IMD care to improvements in community-based services. Thus, it would weaken states’ incentives to pursue these needed improvements. And without incentives to improve access to treatment more broadly, narrowing the IMD exclusion through legislation may simply encourage greater use of expensive inpatient treatment, including for people for whom it may not be the best option.

Access to treatment is particularly limited in rural areas, and waiving the IMD exclusion will do little to address that problem. Forty percent of rural counties lack a SUD treatment facility that provides outpatient care and accepts Medicaid. Rural counties are much likelier to lack access to outpatient SUD facilities that accept Medicaid, particularly in Southern and Midwestern states.

While some people certainly need inpatient or residential services, increasing bed capacity in in those facilities will sometimes mean expanding the wrong services. That’s especially true because many of the facilities providing residential and inpatient care for opioid use disorders don’t offer any form of medications for addiction treatment (MAT), the gold standard for treating opioid use disorder.

Most of these facilities provide detoxification services, but detoxification is only the first stage of addiction treatment, according to the National Institute of Drug Abuse’s Principles of Effective Treatment. By itself does little to facilitate long-term recovery.  

Indeed, it may increase the potential for overdose if patients do not remain in treatment since, with detoxification, their tolerance for opioids is significantly reduced. In fact, recent data suggest that inpatient detoxification is an important predictor of overdose, largely because many who receive inpatient care aren’t then connected to community-based treatment programs or put on a medication, leaving them extremely vulnerable to relapse and overdose.

The House bill is troubling in other ways. While it focuses exclusively on opioid treatment, an estimated 64 percent of people seeking care for an SUD use multiple substances.

For those with an opioid use disorder, 41 percent had an alcohol use disorder and 43 percent had another drug use disorder. About 30 percent suffer from depression. Some 90 percent of people with these illnesses are treated in an outpatient setting.

All in all, the House bill could do more harm than good. Focusing the IMD policy narrowly on opioid use disorder fails to recognize the basic truth that most people with an SUD misuse multiple substances.

In fact, the House bill will likely result in an increase in the reported prevalence of opioid use disorder as a result of efforts to give people who don’t fit the narrow policy access to needed care.

We strongly suggest that if Congress wants to change Medicaid IMD exclusion, it should do so in a way that promotes a greater state capacity to provide the full continuum of care, thus working in concert with CMS’ guidance.

Michael Botticelli is director of the Grayken Center for Addiction Medicine at Boston Medical Center and was previously the Director of National Drug Control Policy. Richard G. Frank is the Margaret T. Morris Professor of Health Economics at Harvard University.