Trump and the Opioid Grants: What Will Happen Next?








The front page article in the January 9, 2017 issue of Alcoholism and Drug Abuse Weekly is the jumping-off point for this blog entry. This excellent article outlines in plain language how the $ 1 billion Cures Act allocations were supposed to be used.

But on January 20, 2017, President Trump placed a sixty-day freeze on regulatory actions and executive orders that have been published but not yet taken effect. I scoured the internet to try to figure out if Obama’s Cures Act falls into this category. I’m still not certain it does.

The Cures Act, passed in late December as one of President Obama’s last actions had strong bipartisan support. Under this act, the Substance Abuse and Mental Health Services Administration (SAMHSA) is to administer funding for grants to each state. These grants are called State Targeted Response to the Opioid Crisis Grants, or Opioid STR for short.

The amount allotted to each state isn’t based on opioid overdose death rates, but rather on treatment gaps in each state. “Treatment gap” is a term for how many people need addiction treatment in a state compared to how many people are actually getting it. The bigger the gap, the more money that state will be allotted out of the $1 billion pot, to be disbursed over two years.

The states with the biggest treatment gaps are California, due to receive nearly $45 million, and Texas and Florida, both to receive around $27 million.

If dollars were spent based on per capita overdose death rates, the three top states would be West Virginia, New Hampshire, and Kentucky. This, of course, led to some criticism of the way money allocations were decided. Some people feel that the states that need money most desperately won’t get a big enough piece of the money pie.

As the ADAW article points out, some people feel the method of allocation is unfair to states where action has already been taken to treat substance use problems, out of their own state budget. By proactively treating problems, these states won’t qualify for as much of this federal money as states that ignored their opioid problem.

Other complaints are that states which decided not to expand Medicaid will now be awarded more than their share of this federal money, since their treatment gap is wider due to fewer citizens with substance use disorder who qualify for Medicaid to pay for substance use disorder treatment.

Probably no method of dividing the money can be perfectly fair to all states. I think the Cures Act does as good a job as is possible under the circumstances.

However, I am troubled by one aspect of this money distribution.

Each state can spend their federal money as they see fit.

In the ADAW article, H. Westley Clark, past director of SAMHSA’s Center for Substance Abuse Treatment, said, “State attitudes towards agonist medications will be a controlling factor.”

Oh dear. This could be bad.

States which have held a strong bias against methadone or buprenorphine as treatment for opioid use disorders may decide not to spend money on this evidence-based form of treatment.

But now, with President Trump’s sixty-day moratorium on new legislation, no one knows what will come to pass. There are so many uncertainties.

In the January 23, 2017 issue of ADAW, the front page article outlines how the repeal of the Affordable Care Act (ACA) could adversely affect the treatment of opioid use disorders. As we know, Trump campaigned on a promise to kill this healthcare Act. No one knows what he will decide to do, or how it will affect the 30 million people who have health insurance through the ACA now.

As the ADAW article points out, much of the gains in funding for treatment of substance abuse and mental health illnesses came from the ACA, and from the Mental Health Parity and Addiction Equity Act which preceded it. This last Act made it illegal for insurance companies to cover physical health problems while denying coverage for mental illness and substance abuse. Other laws made it illegal to refuse coverage for pre-existing illnesses. Denial of coverage for pre-existing conditions was common practice until relatively recently. When insurance companies could pick and choose who they wanted to insurance, patients who needed health insurance the most couldn’t get it.

Would canceling the ACA affect patients with substance use disorder who are already in treatment? Yes, of course, though I’m not sure to what degree. I know it would be more of an issue for my patients in office-based treatment with buprenorphine than for my patients enrolled at the opioid treatment program.

In the opioid treatment program setting, I don’t know of any patients with Obamacare who were able to get reimbursed for what they paid to our treatment program. These patients paid out of pocket even if they had insurance. I don’t know what the problem was, but I do know I had some bizarre conversations with physician reviewers. One physician said my patients with opioid use disorder, treated with methadone, needed to go a cheaper route, and get methadone prescribed in a doctor’s office. Of course, this is illegal, and has been since 1914, but that fact didn’t budge the reviewer.

Some of my office-based buprenorphine patients were able to enter treatment only because they got Obamacare. I would estimate I have eight to ten patients on Obamacare at present. They get reimbursed for the office visit and drug screening charges they pay to me, and get their medication paid for at the pharmacy, except for a co-pay.

Some of these patients have high deductibles, and still have to pay out of pocket for part of the year, but once they meet the deductible, have their opioid use disorder treatment paid for.

We’ve had the usual difficulties with prior authorizations with these patients, but it’s been no more difficult than patients with traditional insurance.

What would happen to my patients with Obamacare if it suddenly disappears? I assume most couldn’t afford treatment and would drop out. Data about patients who leave treatment for any reason shows relapse rates in the 85-90% range, so most of these people would go back to active addiction. I’ve become very attached to these patients, and this idea breaks my heart.

About a month ago, I was talking to Kristina Fiore, a reporter for the Wall Street Journal, who has done some outstanding reporting on the nation’s opioid use disorder epidemic. She called me for some background information for an article she was researching. Near the end of our conversation, she said something to the effect that everyone is always talking so negatively about our present opioid addiction situation, and she needed to know about reasons for optimism.

I thought about what she said for a few moments. Then I told her the only positive thing I saw was more money being released for desperately needed treatment.

Now, even this one positive aspect feels very uncertain.



12 responses to this post.

  1. Tennessee appears to be cracking down. We are seeing more and more patients from the Tri-Cities area. Border pharmacies are seeing more patients as the TN pharmacies refuse to stock buprenorphine. I have heard that some WalMart pharmacies are refusing to stock.


  2. Posted by Alison Insinger on January 31, 2017 at 6:25 pm

    Thanks, saw it. Yes will send that to you – the Cures/ACA updates. Alison



  3. In regards to patients being reimbursed for methadone treatment in OTPs, we have several patients that are getting reimbursed. The OTP just has to know which papers and codes to give them, and the OTP staff also often has to help the patient navigate the insurance maze. Most OTPs just aren’t willing to do that. On another note, my OTP in Chatsworth, GA is about to be the first in the state to be in-network with Blue Cross Blue Shield of Georgia and bill those policies directly under a weekly, bundled case rate. So things in the OTP world are starting to be MUCH better (for OTPs willing to do the work in figuring it out), but I worry about what the future holds under the Trump Administration.

    Zac Talbott
    Program Director/Sponsor
    Counseling Solutions Treatment Centers


    • Maybe my people could call your people for some pointers?? I really think our staff has tried their best, and we do give our patients ICD-10 and CPT codes…


  4. Posted by Mikael Langner on February 1, 2017 at 8:05 am

    The maze of reimbursement is part of why only 10% of people who need substance use disorder treatment actually get it. I also recently came across a disability lawyer website, which shows that people filing for disability give 25% of their retroactive disbursements, up to $6000, to the lawyer’s office. The medical reimbursement system is large and complex, to be sure, and as Zac, says, there are bright spots, but as Jana says, the brightest spot now seems to be quickly fading under the new political paralysis brought about by the executive branch freeze. It is heartening that Zac, practicing in Georgia, one of the sickest states in the United States, ranking 41 out of 50 per this article (, seems to be getting their act together.

    Mikael Langner, M.D.


  5. Posted by Alan Wartenberg MD on February 1, 2017 at 2:05 pm

    I think the fates of both Dr. Price and Senator Sessions may send a clearer signal. Price is opposed to agonist treatments (and to the subsidization of psychiatric treatment in general) and Sessions is opposed to any and all efforts at decriminalization. Every Republican said warm and fuzzy things about “meeting the opioid crisis head-on” but essentially all of them, including Trump, still believe they can arrest and 12-step (cheap treatment – it’s free!!) their way out of this.


    • Posted by Kim Comstock on February 2, 2017 at 1:49 pm

      I think the republicans get their warm fuzzies from the prison systems/big business. Their policies will keep those prisons busy.


  6. Posted by Nancy Friel on February 1, 2017 at 5:51 pm

    I am a substance abuse therapist in Sacramento California. What you describe as MAT benefits under Obamacare in your state are exactly the reverse here in California – who the heck knows why. California’s version of MediCaid is MediCal, and MediCal has always covered 100% of the cost of methadone treatment in an NTP. Thus, when the ACA rolled out in California three years ago, thousands of people who were previously ineligible for MediCal obtained coverage, and the result was an almost doubling of census of methadone clinics, providing recovery that was previously unaffordable and saving countless lives. Our Sacramento area methadone clinics are bursting at the seams with patients, thanks to the ACA. Whereas, in California under MediCal, suboxone treatment is not fully funded, making it a more expensive option not affordable for many. There are ‘low cost’ suboxone clinics, but out of pocket costs are in the neighborhood of $150 – $300 / month. Anyway, if the ACA is repealed without a replacement benefit that ensures that CA beneficiaries who are currently on MAT maintenance do not have any lapse in coverage, thousands of people will leave treatment, and we all know what that will result in – almost universal relapses and some preventable deaths from overdoses.

    If you are still talking to journalists, have them call methadone providers in California for the story here. I am so afraid of what will happen if people lose their coverage for MAT if the ACA is repealed.


    • WOW that is great!!
      My state didn’t chose to expand our Medicaid program, so many people didn’t qualify for Medicaid or ACA care. And yes, we are a “red state.”


  7. Reblogged this on My Sharing Blog.


  8. Posted by Kris on March 9, 2017 at 9:29 pm

    I’m currently in treatment and have been for a year now… I heard grumbles of losing health coverage for mental health and substance abuse programs and patients.. now the grumbles are clear voices and getting louder.. regardless if you agree with methadone or subozone programs as effective treatment plans or don’t agree that mental health problems are serious but.. many will be relapsing and losing psychiatric meds and crime will rise so will over dose and suicide relates deaths… it’s sad to think about and see coming


  9. Posted by Judy on October 26, 2017 at 6:20 am

    I think that doctors need to learn the laws on drugs. Then be refreshed every 5-10 years at least.


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