Maryland is particularly beset by the opioid crisis. We ranked among the top five states for opioid-related overdose death rates between March 2020 and March 2021, according to data from the National Center for Drug Abuse Statistics. Overdose deaths in the state have increased at an annual rate of about 5% during the past three years.
To their credit, lawmakers have marshaled vast resources to address the crisis. The state’s fiscal 2022 budget included $978 million for mental health and substance abuse services, including $296 million for substance use disorder services and $231.8 million for mental health and substance use disorder treatment for the uninsured. Still, more than six drug overdose deaths per day occur in Maryland — 3 1/2 times that of the state’s homicide rate.
Despite our best efforts, Maryland’s response to the opioid crisis is falling tragically short. Since the opioid crisis began, initially with overdose deaths caused by prescription opioids in the 1990s and later with overdose deaths from heroin in the 2010s, our approach to addiction treatment has changed little. Based on best practices refined in recent years, we can and must improve the delivery of care for those with a substance use disorder.
Reimbursement for case management would help in this regard. Coordinating the delivery of care and other services on behalf of a patient is commonly practiced throughout health care but not for addiction treatment in Maryland. The state’s fee-for-service model precludes reimbursement for anything but prescriptions and provider visits.
Because the life of a person with a substance use disorder is often in disarray, a case manager can help a patient manage everyday challenges — a hectic work-life schedule or the lack of transportation — that can undermine their recovery. In Virginia, where the overdose death rate is about 12% lower than the national average according to NCDAS, providers are reimbursed $270 a month for each Medicaid patient for case management. In Maryland, where the overdose death rate is about 85% higher than the national average, providers are not reimbursed for case management.
Patients can benefit from the use of new technologies. Data analytics is emerging as a critical tool in addiction treatment, as it is in other fields of medicine. As documented in the peer-reviewed Journal of Addiction Medicine, my colleagues and I have partnered with scientists at the National Institute on Drug Abuse to develop machine learning algorithms to help patients achieve recovery more efficiently.
Providers can now predict a patient’s adherence to treatment and allocate resources accordingly. Patients who are likely to be less adherent to treatment are encouraged to engage in intensive outpatient counseling and psychiatry, for example. Data can now be used on a patient-by-patient, visit-by-visit basis to improve outcomes.
The focus needs to be on treatment, not punishment. Sick people don’t usually act well. Patients with a substance use disorder, many of whom also have pronounced mental health needs, are frequently discharged from treatment if they test positive for drugs — the very reason they are seeking help. If a patient with diabetes was turned away by their primary care physician for having high blood sugar levels, it would constitute malpractice.
That’s not to say that patients aren’t responsible for their behavior. Hanna Pickard, distinguished professor of philosophy and bioethics at the Johns Hopkins University, emphasizes the importance of “responsibility without blame.” Patients with a substance use disorder do have control over their decisions, but shaming and punishing them can often prove counterproductive. Providers need to be steadfast in supporting their patients — especially when they experience a setback.
If the deaths of six people or more from the same cause on a given day were reported by the media, how could it not be front-page news? And how could the citizens of Maryland not be compelled to act proportionally? It’s well beyond time for us to improve the efficacy of our response to the opioid crisis.
Dr. Enrique Oviedo is a triple board-certified psychiatrist who serves as medical director of MATClinics.