Increased funding and health care reform are key to drug treatment accessibility

Drug policy has experienced an interesting shift recently. Along with legalization of medical and recreational marijuana, many states are also reducing penalties for nonviolent drug offenses and placing greater focus on treatment for drug users. The emphasis on treatment and rehabilitation for drug users is the result of many factors, including recognition that the drug war has not reduced drug use, a desire to reduce the prison population and save money, and a surge in the rate of overdoses from opioid and heroin use. What remains to be seen is whether the current popularity of drug treatment will become a more permanent feature of drug policy. In this Baker Institute Viewpoints series, which runs through Friday, five experts on drug policy examine the question, “Is the current emphasis on treatment in drug policy a short-term trend or is it here to stay?” The fourth commentary follows. Previous entries covered the stigma surrounding substance use, changing attitudes about the drug war and the user population, and government support of treatment as a fiscal measure.

“Is the recent emphasis on treatment in drug policy a short-term trend or is it here to stay?”

I hope this interesting question reflects a sustained shift in the way we treat drug addiction, but I am only cautiously optimistic. While funding for substance-use treatment and prevention at the federal level has increased in recent years and is projected to increase again for FY2015, results at the local level are mixed. Federal funds for substance-use treatment and prevention in FY2013 were approximately $9.2 billion and are forecast to rise to $10.9 billion in FY2015, which represents an increase of 18.4 percent over three years.¹ While this is promising, the amount of funds spent on both law enforcement and interdiction are not decreasing significantly. If there were to be a genuine shift from enforcement to treatment, I would expect to see enforcement efforts decrease significantly, providing even more increases for treatment and prevention.

As promising as the federal funding numbers are, responses at the local level are mixed across the United States. For example, though Maine has faced growing numbers of heroin addicts seeking treatment in recent years, the number of inpatient residential treatment beds has remained relatively flat; demand is increasing, but services have not kept pace. Meanwhile, the governor of Maine proposed slashing treatment funding by more than $4 million in 2011 and has more recently proposed to increase enforcement.² A similar scenario can be seen in Ohio, where federal grant money is proposed to be disbursed over 18 months rather than 12 months in order to address budget shortfalls, even with an increasing heroin problem that claimed the lives of 1,000 Ohioans last year due to overdoses.³

In contrast, Maryland recently passed historic legislation that aims to make it easier for those suffering from addiction to obtain treatment. The bill includes efforts to reduce the misuse of prescription drugs and addresses insurance policies regarding the pre-authorization process and reimbursement of those seeking treatment.⁴ Policymakers hope these changes will not only help curb illegal access to opioids, but also provide easier access to treatment for those already battling opiate addiction.

While the examples above represent only a tiny fraction of localities across the nation, they demonstrate some of the challenges faced by local jurisdictions in offering services such as substance-use treatment and mental health care, despite increases in federal funds and media attention. Addiction carries a heavy stigma, and it is difficult to convince the general public that it is more cost-effective to invest in treatment now, rather than pay the exponential increase in health care and criminal justice costs later. This is especially true with opiate addiction, which is most successfully treated with a combination of drug replacement therapy (e.g., methadone, suboxone, etc.) and long-term residential treatment.⁵ These treatments, however, are expensive, requiring substantial investments from communities. Even if a majority of the general public buys in to this approach, around election time we are once again reminded that politicians have long used “tough on crime” as a successful campaign slogan and will likely continue to do so.

Perhaps a shift more meaningful than a change in public opinion is greater access to health care coverage to help offset the significant costs of treatment. I once worked for a 24-hour psychiatric helpline in a major metropolitan area for the area’s largest hospital system. Looking back, I would estimate that 25 percent of the calls were seeking treatment for alcohol, 25 percent for heroin, 25 percent for crack/powder cocaine and the remainder for mental health issues alone (not dual-diagnosis). The first question I would ask a caller was, “Do you have any type of insurance that will help you pay for treatment?” If they said yes, I would tell them to come to one of our emergency rooms for an evaluation by a psychiatric triage nurse, and if they said no, I would open a large black binder with referrals to providers who accepted self-pay or worked on a sliding scale. I soon realized that those callers whom I referred out would either never pick up the telephone or would make that call and be told there was a six-month wait. In either case, those individuals would more than likely give up and purchase more drugs (if it was a substance-use issue) or continue suffering (if it was a mental health case).

An eye-opening moment came when I received a call from someone seeking inpatient treatment for substance use. The woman had insurance, and while we were not a provider under her plan, I knew that another local hospital was and referred her there. My supervisor questioned this decision and told me that I should have referred the woman to our own emergency room for evaluation, despite the fact that this would come at a significant cost to the patient. Her reasoning?  “Always refer them to our ER so we can at least charge the insurance for the evaluation.” To me, this illustrates a fundamental problem in how we handle substance use and mental health disorders and the challenges faced by those seeking treatment.

In my opening remark, I stated that I was cautiously optimistic about the future of drug treatment and that my optimism stems from recent changes in health care laws. By removing some of the barriers to treatment, such as prior authorizations and preexisting conditions, the Affordable Care Act — while by no means perfect — should provide many more people the opportunity to receive treatment instead of being led through the dreaded black binder full of self-pay providers with six-month waiting lists.