Opioid Treatment Levels of Care: Managing Optimal Outcomes That Align with Plan Policy
by Micah Hoffman, MD, DABPN, FAPA
AllMed Behavioral Health Medical Director
Over the past 25 years, the opioid crisis has escalated, reaching a grim new high last year with 100,306 overdose deaths in a 12-month period.1 For providers and healthcare organizations on the front lines, identifying appropriate treatment for members with opioid use issues can be a complex calculus. A treatment plan must factor in—and balance—limited, unevenly distributed resources, the member’s individual circumstances and history, and plan policy criteria to maximize the likelihood of a positive outcome. Leveraging the extensive clinical experience and guidance of a board-certified psychiatrist can be key to steering treatment in the right direction.
Identifying the Level of Care That Fits Best
A variety of treatment options and levels of care exist, though availability varies significantly by region:
Medication-assisted therapy transitions members to safer alternatives such as Suboxone for maintenance of their opioid addiction. This can be done safely at an outpatient level of care, making it easier and more readily available to members. This relatively low level of care typically works best for members who are using only one substance and have no comorbid medical problems nor psychiatric problems that will be difficult to manage in outpatient care. A complication in terms of care delivery is that physicians are required to obtain a federal waiver, which requires eight hours of training, to be licensed to prescribe Suboxone.2 In addition, a practitioner needs to have a level of comfort with managing, in their clinical practice, all the complexities that come with treating opioid addiction. These complications limit the availability of Suboxone treatment, but where there are practitioners who provide it, they are a great asset to their communities.
Residential treatment or partial hospitalization (also known as day rehab) may be a better fit, at least temporarily, for members who have failed lower levels of care, are using more than one substance, have comorbid medical problems, or have complex psychiatric disorders. Programs of this type can dose Suboxone and provide psychotherapy and close medication management.
The highest level of care is inpatient admission for medical detox. Every plan and hospital system approaches the decision about which level of care is appropriate differently. The reality is that opioid detox typically does not require inpatient level of care, but every case is unique. Patients may have complex comorbid medical problems that require monitoring, or they may need monitoring if more than one substance is involved.
Given the inconsistent availability of treatment and the complexities inherent in each case, healthcare organizations are focused on finding effective, efficient ways to identify the level of care most likely to yield a positive outcome. This is where AllMed can help. Drawing on the knowledge and training of our board-certified psychiatrists, we guide plans and providers in identifying the nearest, most appropriate treatment that aligns to plan policy.
How We Help
As part of our review process, we look closely at each member’s individual history and experience—How many times has this person been to treatment? Are they at life-threatening risk for withdrawal because of co-occurring substance abuse? Depending on the answers to these questions, it may be appropriate to consider inpatient medical detox or residential level of care.
For members who don’t have a co-occurring substance abuse disorder nor any comorbidities, it may be more appropriate to recommend a standard outpatient program. Here, too, the clinical experience of our psychiatrists comes into play. We dig deeper, considering what other circumstances in the member’s life might affect their recovery—looking, for example, at whether the home environment is conducive to recovery. A situation where others in the home are injecting heroine offers a case in point. In such circumstances, the member might meet the criteria for a residential level of care.
Our evidence-based determinations take into account availability of resources in the patient’s geographic area, so that members in crisis receive the most appropriate treatment available as quickly as possible. Due to the tremendous variability in resources and funding from state to state, these recommendations can vary widely and call for a familiarity with local programs.
At AllMed, our experts take a multifactorial approach to arriving at determinations, balancing a member’s withdrawal potential, co-occurring medical problems, psychiatric symptoms, and level of motivation with the available resources. We work as an extension of your team, collaborating closely with providers to optimize member care within the language of the plan.