RICHMOND, Virginia — Fawn Ricciuti started using opioids a decade ago, when she was enrolled in a New Jersey pain management program. What followed is the kind of story that’s been told thousands of times over the past few years as America’s opioid epidemic has grown: Her casual use of opioid painkillers over time turned into full-blown addiction.
Her doctors eventually tried to wean her off painkillers, arguing that her dosage was too high. While that led her to use fewer opioids for a while, she’d still buy opioid painkillers from the street, she said, to manage pain stemming from painful disorders, including scoliosis. The drug use turned more recreational as she began using opioids with her ex-boyfriend, who’s also the father of her son. Pretty soon, the drugs consumed her life.
But unlike the stories commonly told in the news and coroners’ reports, Ricciuti did not overdose and die. Early in 2017, she got on buprenorphine (common brand name: Suboxone), which does not produce a euphoric high when taken as prescribed. She said that the drug, paired with group therapy, helps her treat not just the cravings and withdrawal that come with addiction and dependence but also, along with chiropractic, the pain that led her to use opioid painkillers in the first place.
Withdrawal “is like going from being how you are now to the worst flu you can think of within hours,” said Ricciuti, who’s 33 and now lives in the Richmond, Virginia, area. “Now I don’t have to stress about whether I have something [drugs] for the morning and how I’m going to get something in the afternoon.”
When I spoke to Ricciuti at one of the Richmond clinics run by Daily Planet Health Services, she said that addiction treatment, paid for through Medicaid, let her start getting her life in order — allowing her to focus more on her family and search for more sustainable work.
“I have a better relationship with my daughter, my mom,” she said. “If I hadn’t gone to treatment,” she went on, “my daughter wouldn’t be able to do soccer because I couldn’t guarantee that I could pick her up at 5:30 to get her home every day.”
Ricciuti reflected on her other ambitions. “Do you know what water ice is?” I said no. “Oh, man, it’s so good. But yeah, I want to open a water ice place down here. It’s kind of like Italian ice that you run through blenders, so it’s soft-served.” She added, “I got a business idea. I just want to do a couple classes and make sure that I have everything set so I’m not jumping into something over my head.”
Here’s the thing: Ricciuti’s success story isn’t unique. Despite much of the despair that surrounds the opioid crisis, the medication she’s on has been known to work for opioid addiction for decades. And it’s not the only one; two others, methadone and naltrexone, can work better for some people than buprenorphine.
Studies show that the medications reduce the all-cause mortality rate among opioid addiction patients by half or more and do a far better job of keeping people in treatment than non-medication approaches. In France, the government expanded doctors’ ability to prescribe buprenorphine in 1995 to confront an opioid epidemic — and overdose deaths declined by 79 percent from 1995 to 1999 as the number of people in treatment went up, according to a 2004 study published in The American Journal on Addictions.
Despite the evidence, the medications are commonly stigmatized as just “substituting one drug with another.” But the problem with addiction isn’t drug use per se. The problem is when drug use turns compulsive and harmful — creating health risks, leading someone to neglect family and children, driving someone to commit crimes, and so on.
The studies, France’s example, and Ricciuti’s story show that the opioid crisis and addiction are not insurmountable. But America hasn’t fully embraced the solutions that we know can work. According to a 2016 report by the surgeon general, only 10 percent of people in the US with a drug use disorder get specialty treatment, which the report attributed to a lack of access to care. Even when treatment is available, other federal data suggests that fewer than half of treatment facilities offer opioid addiction medications.
But how do you fix this — and build up addiction treatment in the US? Virginia offers one example. By treating addiction primarily as a public health issue and bringing treatment into the rest of the health care system through Medicaid, the commonwealth has managed to make buprenorphine, other medications, and treatment in general more accessible to patients — and it’s seeing more stories like Ricciuti’s as a result.
What Virginia has done
Addiction treatment providers are notoriously underpaid by health insurers across the US. That leads to big shortages in supply, because it makes it very difficult to start a sustainable addiction treatment facility. What Virginia did was use the big health plan it has control over — Medicaid, which covers low-income people — to boost reimbursement rates to addiction treatment providers.
The state started the program, the Addiction and Recovery Treatment Services (ARTS), in April 2017. Although ARTS is still fairly new, independent evaluations from researchers at Virginia Commonwealth University (VCU) have already found some promising results.
After the program went into effect, the percent of Medicaid members with an opioid use disorder who received treatment went up by 29 percent from April to December 2017 compared to the same period the previous year. At the same time, emergency department visits related to opioid use disorders went down by 31 percent. That was more than double the 15 percent reduction in emergency department use among all state Medicaid members during the same time frame.
The researchers also calculated what they would expect emergency department visits to look like with and without ARTS. The model suggested that ARTS really is to credit for the bulk of the drop in emergency department usage.
Peter Cunningham, a professor at VCU and co-author of the evaluations, cautioned that “as we get more data and we are able to look at this over a longer time period, things might change or we might find other trends.” But the findings suggest that a boost in treatment led to a reduction in emergency department visits related to opioid misuse — a strong indicator that there’s less untreated addiction and fewer overdoses among state Medicaid beneficiaries.
“We were pleasantly surprised to see such a rapid response,” Jennifer Lee, director of Virginia’s Medicaid program, told me.
Along with bringing Medicaid reimbursement rates for addiction treatment up to average commercial rates, the state also took other steps to ensure the quality of treatment that’s provided. Under ARTS, access to evidence-based anti-addiction medications like buprenorphine is financially incentivized with higher rates. In residential treatment, the state is also moving to mandate access to such medications — in part to meet requirements for a federal Medicaid 1115 waiver that it got for ARTS, which allowed the commonwealth to use Medicaid to pay for more treatment.
“We wouldn’t allow providers to treat diabetes in inpatients without providing insulin,” Neuhausen said.
Virginia also trained health care providers on providing addiction treatment — to ensure that more people across the state actually had an addiction treatment service in their area. And to help combat the overprescription and misuse of opioids, the state established new Medicaid guidelines for painkiller prescriptions, setting rules and extra layers of approval for lengthier prescriptions.
As part of ARTS, the state has also started to pay more for case managers and care coordinators who help patients with problems that go beyond their addiction, such as housing, employment, and other health care needs.
This is meant to strike the balance in policy responses that experts have called for: a mix of more treatment, fewer opioid prescriptions (while keeping the medications available to those who really need them), and addressing nonmedical contributors to addiction like unemployment and homelessness.
All of this did cost the state money. The 2016 General Assembly allocated $5.2 million for 2017 and $16.8 million for 2018 for the program. But Neuhausen argued that the results — fewer medical and social costs as a result of opioid addiction — should end up saving money in the long run.
The scope of this program, however, is limited, because Virginia is not (yet) a Medicaid expansion state. Instead of reaching potentially all adults up to 138 percent of the federal poverty level, the state’s Medicaid program only covers low-income children, pregnant women, working parents, seniors, and people with disabilities. This limitation may explain why the program alone hasn’t reversed state overdose deaths, which are on track to go up by 14 percent in 2017, even as it has an impact within the Medicaid population.
Virginia officials acknowledge other gaps in the ARTS program, with efforts underway to boost access to treatment in certain parts of the state, particularly in the rural southwest. The state also plans to begin attaching payments to outcomes over the next two or three years, in the hopes of providing a financial incentive for better treatment.
When asked about what Virginia is doing, outside experts said it looks promising. Patrice Harris, chair of the American Medical Association’s Opioid Task Force, said that she’s “very excited” about ARTS.
Tami Mark, a health economist at the research foundation RTI International, concurred. “Insurance coverage is critical for providing access and high quality,” she told me. “And you can see that being played out in Virginia as a great example.”
Bringing addiction treatment into health care
The core idea behind ARTS is to integrate addiction treatment into the rest of the health care system — not just to make treatment more accessible, but to actually improve the quality of treatment as well.
Aubrey Gholson, 59, has seen the transformation in Virginia firsthand. Gholson is on private insurance through his construction job. But as Medicaid has boosted addiction treatment throughout the state, people like Gholson have benefited.
“Rubicon was just a detox. After that, you’re back in the street, but you’re clean, you have a few days’ clean time under your belt,” Gholson said. “That don’t help. That really don’t help a whole lot of people.”
Gholson relapsed, eventually ending up in prison due to drug-related crimes — stealing to get money for drugs.
Today, Gholson is getting treatment at the Daily Planet Health Services, where Ricciuti also gets care. Walking through the halls of the clinic, a visitor would think it indistinguishable from other health care facilities. The walls are white, decorated with inspirational posters promoting good health and hope. There are rooms for doctors’ exams, and even a fish tank.
The clinic offers an array of health services beyond addiction, including dental care. And, crucially, the clinic offers buprenorphine — which Gholson has been on since last August, helping him focus on his work as well as his wife and granddaughter.
“I’m really thankful for this clinic,” Gholson said. “I think it saved my life.”
But even what was once the Rubicon has been transformed, looking much closer to Daily Planet Health Services, in part thanks to the ARTS program. The residential treatment campus was taken over by the Richmond Behavioral Health Authority (RBHA), a quasi-government agency, in the mid-2010s. In the years since then, it’s built up the facilities, renovating them to lose the mental asylum look for a more modern, clean medical style. And RBHA provides and encourages the use of buprenorphine for long-term treatment, not just the five-day detox approach that the previous owners used.
Jim May, who oversees addiction services at RBHA, told me that he wants this to be “the biggest and the best program” — something that he could send his own family to if they had addiction problems. But “if [ARTS] had not been on the table, we probably would not have pursued this venture, or not in the same way that we did. It would have been a much smaller-scale takeover. We wouldn’t have been jumping in with these huge renovations right off the bat.”
There’s a reason the old Rubicon looked the way it did: Historically, addiction treatment has been segregated from the rest of the health care system — and that’s led to horrible results. Instead of being funded through health care programs like Medicare and Medicaid, much of the federal funding for addiction treatment has come through limited-time grant initiatives. And medications for addiction treatment are regulated above and beyond more traditional medicines; for example, methadone can only be dispersed in highly restrictive clinics, and buprenorphine can only be prescribed to a limited number of patients for each doctor and requires a waiver to prescribe.
All of this has worked to make addiction treatment segregated, unregulated, less affordable, and less accessible.
“It’s been siloed,” Mark, the health economist, said of addiction treatment. “So if you look at the surgeon general’s report on addiction, a big theme is to try to integrate … treatment to stop treating it as something separate from the rest of medical care.”
Addressing addiction treatment through health insurance, like Medicaid, ties it to the rest of the health care system — money flows to medical facilities and doctors, with health care–centered rules and regulations attached to the dollars.
Jay Unick, a professor at the University of Maryland, argued that by bringing people with substance use disorders into the overall health care system, you can also address other problems that often come with addiction — mental health issues, infectious diseases from needle use, and so on. “These are exactly the kinds of things that health insurance solves,” he said.
Mishka Terplan, the medical director at Virginia Commonwealth University Health’s MOTIVATE Clinic, characterized ARTS as “modernizing addiction treatment services through a payment structure.” As the addiction medicine consultant for the state Medicaid program, he has supported better reimbursements for comprehensive addiction treatment — to help fully address what he described as the “bio-psycho-social-spiritual” elements of substance use disorders.
Sitting in some of Terplan’s appointments with patients, I saw how all of this looks in action. The main focus of Terplan’s discussion with patients was addiction — particularly, their prescription for buprenorphine. But because Terplan is a doctor at an integrated health care clinic, he also covered a range of topics, from smoking cessation to post-pregnancy care to not standing up too quickly if a patient has concerning blood pressure levels. In the end, the patients walked away with a prescription and treated their illness just like they would any other medical condition.
More than anything else I saw in Virginia, these typical doctor visits seemed like the fruition of treating addiction as a medical condition. Any insurance system could help achieve this, but Virginia is leveraging Medicaid to do it.
Medicaid’s big role in fighting the opioid crisis
Access to addiction treatment in the US is abysmal. Evidence-based addiction treatment is in short supply — the White House’s opioid commission, for example, found that 85 percent of US counties have no specialty opioid treatment programs that provide medications for opioid addiction. The treatment that is available, meanwhile, is often very expensive and doesn’t accept insurance or isn’t covered by insurance (private or public), costing patients potentially thousands of dollars out of pocket.
An approach like Virginia’s can help address both of these problems. Through the higher reimbursement rates, the ARTS program encourages existing treatment providers to accept insurance and can also attract new providers since the services will now seem more financially sustainable. For consumers, this means more potential providers — and, by covering them through Medicaid, much more affordable services.
Unlike limited-time grant programs, which many nonprofit addiction centers currently rely on, Medicaid coverage means sustained coverage, since it’s tied to health plans that will be around for years to come.
“I like to think of grants as a way to test out a new service line and see if we like it,” May said, noting that one of RBHA’s clinics for women was built up in large part with grants. “But now we’re going to sustain it with Medicaid.”
Daily Planet Health Services told a similar story: It paid for $1.7 million in uncompensated care in 2016, when 71 percent of its patients were uninsured. If it can get even a few of its patients on Medicaid and paying more for their services, it can fill that big gap in its budget.
Another provider, Pinnacle Treatment Centers, said that it’s expanding in Virginia because of the ARTS program. “That’s exactly what’s allowing us to add more types of services,” CEO Joe Pritchard told me.
All of this comes on top of the role that Medicaid is already playing in addressing addiction. According to a 2014 study by Mark and other researchers at Truven Health Analytics, Medicaid paid for about 25 percent — $7.9 billion of $31.3 billion — of projected public and private spending for drug addiction treatment nationwide in 2014. That made it the second-biggest payer for drug addiction treatment spending after all local and state government programs.
Medicaid alone can’t solve all the problems with addiction treatment in America. After all, it covers only a limited pool of low-income patients.
But Lee, Virginia’s Medicaid director, argued that “Medicaid is part of the solution to the opioid problem.” She’s touted ARTS’s success as an example of why Medicaid should be expanded. That expansion is an option available to states through the Affordable Care Act (“Obamacare”), through which the federal government pays for at least 90 percent of the expansion to include all people up to 138 percent of the federal poverty level (for an individual, an income up to $16,753 a year in 2018). The Virginia legislature has been discussing the expansion for the past few months, but it’s unclear so far if lawmakers will agree to a deal.
“What we’ve seen in the ARTS program is, again, incredible results,” Lee said. “But we’ve only been able to offer it to our currently enrolled Medicaid members. And with Medicaid expansion, we’d be able to then offer this great benefit to 400,000 more individuals.”
Every level of government could do better on this issue
None of this is to say that Virginia has solved its opioid crisis. State officials themselves cautioned that they still have a lot of work to do, pointing to a continuing increase in overall overdose deaths over the past several years in the state.
But to proponents of ARTS, the program is proof that we do have evidence-based ways to address the opioid crisis. It’s just a matter of using these tools.
“It’s not an absence of knowledge,” Terplan of the MOTIVATE Clinic said. “It’s an absence of will.”
To this end, providers on the ground said that practically every level of government could do more to expand access to treatment.
On the state level, the most common demand was that Virginia should expand Medicaid. This has been a debate for years in the commonwealth, but whether it will actually happen remains up to the legislature.
Providers also said that Medicaid’s reimbursement rates for addiction treatment could still be higher. Even under the boosted ARTS benefit, Medicaid doesn’t always cover the full cost of services. As RBHA CEO John Lindstrom told me, “You don’t get rich on Medicaid rates.” Boosting rates could also attract new providers that accept Medicaid — which is particularly needed in certain parts of the state, like the far southwest.
The federal government could support the higher reimbursement rates through its own management of the Medicaid program. But this would likely cost more money. And while experts estimate that the opioid epidemic will require up to tens of billions of dollars a year over many years to solve, Congress has appropriated only limited-time boosts here and there to address the crisis — none of which add up to tens of billions or anything close to that amount.
Meanwhile, the federal government continues to impose major restrictions on medications for opioid addiction. To obtain waivers that allow them to prescribe buprenorphine, doctors have to go through an eight-hour training. Nurse practitioners and physician assistants have to attend a 24-hour training. And even with the waivers, each of them can only prescribe the medication to a limited number of patients under federal rules.
Providers agree that some regulations are important for buprenorphine since it is an opioid that can be diverted for misuse. But on the ground, the rules still feel too stringent — which may actually contribute to more illegal buprenorphine trafficking, given that research suggests the biggest reason people turn to illicit means of obtaining buprenorphine is lack of legal access to it for medication-based treatment.
The federal government also imposes strict regulations on methadone, due to fears that it too, as an opioid, could be diverted for misuse if it were more accessible. Virginia, like many local and state jurisdictions across the country, imposes additional restrictions on where methadone clinics can open, based on proximity to schools and day cares. Providers said this makes it difficult to open a methadone clinic in a dense urban area like Richmond.
“I wish we had methadone as an option available to our patients here,” Terplan said. “But I cannot open a methadone clinic here.”
Doctors and other providers could make some changes in their daily practices to try to get people into care — by, for example, trying to get their buprenorphine waivers and adding addiction screening to, say, annual checkups.
The goal is to make addiction treatment as available as possible. People can’t be forced to accept a treatment that they don’t want. But when they finally decide to seek help, they need to have a place to reach out to. “We say, ‘We’re here. We’re ready when you’re ready to make that jump,’” Paul Brasler, the behavioral health coordinator for Daily Planet Health Services, told me.
Underpinning all these issues is a broader cultural problem: stigma. After decades of treating drugs largely as a criminal issue, many Americans, including some health care providers, still see drugs as a personal and moral issue, not a medical one. This defies the approach advocated by all major public health organizations, from the American Medical Association to the World Health Organization. But it remains pervasive — to the point that it’s not uncommon for me to get emails after most opioid stories about how overdose deaths are really “Darwin’s theory in action.”
Nancy Wallace, a nurse practitioner at Daily Planet, pointed to stigma as a major problem. She said that while restrictions around medications may push away some providers from offering treatment, “I think it’s more about prejudice.”
Virginia offers a model — through Medicaid, a program that all states have and can leverage — around many of these issues to help end the current drug overdose crisis.
At least for Ricciuti, the results speak for themselves: Her story could have ended like the thousands we’ve seen over the years, where painkiller use builds over time to heroin use and eventually culminates in a deadly overdose — orphaning her children and leaving loved ones heartbroken. Instead, Ricciuti is spending more time with her kids and looking ahead.
“Before, I could only think about what I’m going to do over the next two or three days. There was no way I could plan ahead weeks, months, or years into the future,” she said. “Now I can think more long-term.”