HJLR May/Jun 2019

Healthcare Journal of LITTLE ROCK I  MAY / JUN 2019 51 MAT. The expert panel preferred the term medication based treatment (MBT) over medication assisted treatment (MAT) be- cause it believed medication to be the core element of effective therapy for OUD. The report strongly supported MBT for prison- ers, and questioned the science behind re- quired waivers for community prescribing of MAT agents. The panel also questioned the need for behavioral health counseling as a requirement for MBT initiation. In short, the NAS panel recommended wider use of and fewer barriers to obtain MAT for all patients with OUD. The scope of the opioid crisis has created an urgency for population-based interven- tions at scale, but the need does not come without challenges. Evidence to support program design is often lacking. Demand for services frequently outstrips a well-trained workforce. Lack of available behavioral health professionals has led to the use of MAT without addiction support counseling, which many feel is critical to changing destructive habits. Prescribing health professionals also have had to obtain specific certifications to administer MAT to a population of patients. Those standards are being relaxed, as are the expectations for monitoring of individual pa- tients. It may take years before we understand the strengths and weaknesses of liberalized treatment standards. Many state Medicaid programs only pay for 8 or 16 milligrams a day of buprenor- phine/naloxone. Others allow 24 milligrams per day. InArkansas, some prescribing physi- cians prescribe a maximumdose as per Med- icaid rules, and a second prescription that a patient can get by paying cash to achieve daily doses of 32 milligrams or more of buprenorphine/naloxone. Buprenorphine is found in 60 percent of drug busts, and is the number one drug of diversion in prisons. To insure appropriate prescribing, adherence, and detection of potential abuse of MAT drugs, many insur- ance entities created prior authorization (PA) procedures. However, some physicians find such information gathering burdensome, and the prior authorization process could delay the start of MAT treatment, which allows for patients to slip out of the health care system and revert to black market opioid purchas- ing. As a result, some systems have stopped prior authorization completely, while others require PAapproval after the starter prescrip- tion. Aconsiderable disagreement remains on finding the appropriate balance to achieve patient and program accountability. Developing programs for incarcerated pa- tients also raises challenges. Most inmates with OUD do not receive MATwhile incarcer- ated. Many judges now prescribe injectable extended-release naloxone as a condition of parole as an attempt to reduce recidivism post-release from jail. Programs have been put in place to start weeks before parole. The monthly injections are to be sustained for a period of time after discharge from jail, but problems have arisen. Many prisoners have difficulty connecting with health profession- als after their release. Relapse rates are high after patients stop the drug. Most disturbing are the reports of high rates of fatal overdoses in patients who have been treated with this medication. Nationwide between 2013–2016, Medicaid spending for MAT drugs doubled to nearly a billion dollars. In 2016, Arkansas Medicaid spent 10 percent of the dollars expended in Louisiana andAlabama for MAT agents alone. Growth in spending will likely accelerate throughout the country and in Arkansas as more patients receive treatment because of earlier and easier access to therapy. The costs of the program and the uncertainties regard- ing long-term outcomes will remain a focus of health care debate for years to come. n Reference National Academies of Sciences, Engineering, and Medicine.(2019) Medications for Opioid Use Disorder Save Lives.Washington,DC:The NationalAcademies Press. WilliamGolden, MD Arkansas Medicaid Medical Director Buprenorphine, a medication used to treat opioid use disorder, is found in 60% of drug busts and is the #1 drug of diver- sion in prisons. Nationwide between 2013-2016, Medicaid spending for MAT drugs doubled to nearly a billion dollars. MAT FACTS: