Medicaid program expands access for addiction treatment, but the death toll continues to rise

The exact feeling is hard to describe, she said. Is it a thought or a feeling? Is it just simply a craving?

When she first started getting regular treatment 13 months ago and taking Suboxone, a drug often used to treat opioid addiction, she had the urge in the middle of the day. Then, it was almost like she was just missing her routine. Calling around for some Percocet, a prescription opioid, trying to figure out how she was going to find it and pay for it and get it, was a habit in and of itself.

Now, it’s just the mornings that are a struggle. She’s made changes in other parts of her life: She’s cut out people she knows aren’t good for her and her two kids, she takes her Suboxone religiously and couples that with therapy sessions at the Daily Planet, a federally qualified health center in Richmond, which provides a wide array of health care to patients regardless of their financial status.

“A lot of it is just motivating yourself,” she said. “There’s still temptations. There are days when I wake up and, you know, I’d feel a lot better if I was using or sometimes I’ll have dreams about using and, like, I’ve just got to, you know, think about what I want and make the choice.”

Ricciuti is one of thousands of Virginia Medicaid members who was able to find a provider thanks to the state’s Addiction and Recovery Treatment Services, or ARTS, program. Launched in April 2017, ARTS increased the rates paid for a host of substance abuse treatments for the first time in a decade.

It also expanded inpatient detox and residential treatment benefits to all Medicaid and FAMIS (Family Access to Medical Insurance Security) beneficiaries. Previously, those benefits were available only to pregnant Medicaid members or those under 21.

ARTS was meant to encourage providers to accept more Medicaid patients with substance use disorders, and to open more treatment programs. And so far, it’s working.

A December 2017 Virginia Commonwealth University report found that 10,522 Medicaid members with an opioid use disorder received any type of treatment between April and December of last year, a 51 percent increase over the same time period the year before.

And more treatment centers are opening, too, to accept the wave of Medicaid recipients now seeking treatment.

But any measure of success is overshadowed by the formidable beast that is Virginia’s opioid epidemic, which kills more people every year than guns or car crashes.

Last year, 1,227 people in the state died from an opioid overdose, a 50 percent rise from two years prior, according to preliminary Virginia Department of Health data. Overdose deaths have risen steadily each year since 2012.

The VCU report found that more Medicaid recipients were identified with an opioid use disorder last year after ARTS started, jumping by more than 2,000 from the year before.

It also notes that half of Medicaid members with opioid use disorders did not receive any treatment services last year, or at least none paid for by Medicaid.

Peter Cunningham, a VCU professor in the Department of Health Behavior and Policy who worked on the report, said that might be because word still has to spread about the expanded benefits for Medicaid members. Some may not be seeking help simply because they don’t know it’s available.

“But in general,” he added, “behavioral health care of any type is always a tough sell because there’s stigma. A lot of people are in denial that they have problems.”

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In the first nine months after ARTS launched, the number of emergency department visits related to opioid use disorders in Virginia reduced by 31 percent compared with the previous year, according to the VCU report.

And the number of residential treatment facilities surged after the benefit was implemented, too. There were only four facilities before ARTS, and 78 facilities at the end of last year.

“Except in the far Southwest and other rural areas in the West and Southside, most Medicaid members have access to residential treatment programs within 30 miles of urban areas or 60 miles for rural areas,” the report states.

In the first five months after ARTS began, the number of practitioners treating substance use disorders — which includes alcoholism alongside opioid addiction — rose from 758 to 1,815.

The trends have aligned with fewer opioid pain prescriptions, as well. From April to December of last year, there were 29 percent fewer such prescriptions made to Medicaid members than in the same time period in 2016.

“We have convincing evidence to show that the strategies that we implemented through the ARTS program are working,” said Dr. Jennifer Lee, director of the Department of Medical Assistance Services, which runs Medicaid in Virginia, during a recent event at the Daily Planet to highlight ARTS’ impact so far. “They are making a difference to combat the opioid epidemic in Virginia.”

But since Virginia has not expanded its Medicaid program, there are still thousands living in the Medicaid gap — who do not make enough to qualify for individual market subsidies but make too much to qualify for Medicaid — who may be in need.

“This is an important benefit for Medicaid beneficiaries in Virginia, but one of the biggest challenges in Virginia, unlike those states that have expanded Medicaid, is that not enough of the people who need this great treatment and these great services are eligible,” said Dr. Daniel Carey, Virginia’s health and human resources secretary, during the event at the Daily Planet.

It’s hard to tell how many more people in Virginia would be able to receive substance use disorder treatment should the state expand Medicaid, said Dr. Kate Neuhausen, DMAS’ chief medical officer.

One of the best ways might be to see what happened to nearby states like West Virginia and Ohio when they expanded their Medicaid programs, she said.

According to data from those states’ governments, about 28 percent of West Virginia’s Medicaid expansion population had a substance use disorder in 2016, compared to 32.3 percent in Ohio. If Virginia followed the same trends as those two states, about 120,000 of its potential Medicaid expansion population could have a substance use disorder and thus benefit from ARTS.

While expanding treatment access for Medicaid is an important piece of tackling the epidemic, opioid addiction touches everyone, rich and poor, said Paul Brasler, the Daily Planet’s behavioral health services coordinator.

“We have to throw out this whole notion out that it’s others,” he said. “It’s us.”

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Ricciuti’s story is like that of so many who became addicted to prescription painkillers: It all began with a car accident.

The New Jersey native already had back issues, but the wreck, which happened about 10 years ago, just accelerated her pain. So a doctor prescribed Percocet.

It all spiraled from there. She had no health insurance, so eventually it became easier to just buy the drug illegally, and then once she and her ex-boyfriend moved to the Richmond area, her back was still acting up and Percocets were becoming hard to find and more expensive. So one day, he brought home heroin.

“That’s not normally my thing, but unfortunately when you know that something’s going to take away your pain — and you’re in a lot of pain — you’d do almost anything to avoid it,” she said.

Heroin, she soon realized, is far more addicting than the prescription painkillers — which is saying something, she added, because she already knew all too well how easily the pills hooked her.

And with kids to take care of, she couldn’t afford to go into withdrawal — a debilitating craving with flu-like symptoms when a user tries to stop taking opioids — for days at a time.

“So I kept it up for a while,” said Ricciuti, a Sandston resident. “And eventually it just takes over everything. That’s all you wake up thinking about. I guess I could have been worse, because my first priority is always my kids ... but there comes a time when it’s a coin toss on which one is more important.”

That’s when, in 2016, she realized it was time to seek treatment. She began trying to find Suboxone, which she knew could be used to treat addiction. But not only was the drug — a mix of the synthetic opioid buprenorphine and the overdose-reversal drug naloxone — difficult to find on the street, it was difficult to find a doctor who could accept her as a patient.

Most of the doctors she called had all their Medicaid slots already full, she said.

She searched for about six months, and eventually, in March 2017, she found a doctor. Then, last fall, her Medicaid insurer began calling her asking her to find an in-network provider instead — which was a lot easier at that point because ARTS had already been started. So she began receiving treatment at the Daily Planet, which she says she prefers.

The Daily Planet’s medication-assisted treatment program did not exist before ARTS. The program works because it couples the medication with therapy, Brasler said, which empowers the participants to talk about their challenges and come up with solutions together.

The number of such programs rose from only 38 centers in April 2017 to 76 locations nine months after ARTS started, according to VCU’s report.

But issues remain. The report shows that some with opioid use disorder are receiving the medication part of the treatment, but without the linked counseling, especially in the southwestern part of the Virginia. That’s concerning, Cunningham said, because the state is promoting the model that combines medication with counseling, which has been shown to be the most effective in treating opioid use disorders.

Authorities in Southwest Virginia have complained in recent years that easy access to Suboxone without counseling has led to it becoming the hottest drug sold illegally on the streets there, fueling a market that contributes to other property crimes.

Ricciuti hopes to be part of the Daily Planet’s first peer mentor group so she can encourage others to stay on track with their recovery, too. Having someone to talk to who has been through the same experience can make all the difference in the world, she said.

VCU’s report states that, as of August, only three office-based opioid treatment clinics — which provide medication-assisted treatment coupled with behavioral health therapy — plan to use peer recovery specialists.

“Thankfully, I wasn’t in over my head for too long, and it won’t be too hard for me to get back on track,” Ricciuti said. “But if you’ve been doing it for 10, 20, 30 years, you don’t remember anything else, and having people that know that, you can ask: You’re clean, what do you do now?”