Temporary Grace: the CURES Act

 

 

 

 

 

 

The 21st Century Cures Act, signed into law by President Obama late in his presidency, provided money to help people with opioid use disorder get treatment. In April of this year, states got this money, in the form of STR (state targeted response to the opioid crisis) grants. Eighty percent of this money is to be spent for treatment, meaning more people with opioid use disorder should be able to access treatment.

And this is happening.

In North Carolina, the money was allotted to LME/MCO organizations. These organizations also manage our Medicaid dollars in various regions of the state. As I understand it, these organizations help to decide which treatment programs receive CURES dollars.

Our opioid treatment program (OTP) immediately applied for access to this money for patients. Since we’ve already gone through the vetting process to be approved to accept Medicaid patients by our LME/MCO agency, it didn’t take long to become approved for CURES dollars.

We’ve admitted around eighty people on the CURES grant who had no other way to pay for treatment. To qualify for CURES, they needed to apply for Medicaid, and then bring in the refusal letter, saying that they didn’t qualify to receive Medicaid. (Being a red state, in North Carolina a person can be making very little money at their job and still not qualify for Medicaid.)

These eighty people, instead of having to pay their daily treatment fee, have it paid for them through the CURES grant.

This is fantastic. This is wonderful. We’ve re-admitted many patients who were in treatment with us in the past, but who dropped out for financial reasons. We’ve admitted patients with long-standing opioid use disorder who have never been able to afford treatment. It is thrilling to see these patients stop using opioids and start to engage in treatment. The great majority of patients admitted under CURES have shown improvement.

It’s not all been roses, though. Some of these patients are extremely ill with long-neglected mental and physical health issues. It’s been a challenge to find places to refer them for primary care. Some patients have burned bridges with many of the primary care doctors in the area. Others with serious health issues refuse to see a doctor. Substance use disorder isn’t the only disease with denial. I sense these patients are often scared to hear a bad diagnosis from a doctor, and prefer to ignore their ailments.

Some people admitted with CURES dollars have severe mental illness, to the point that it can interfere with treatment and affect other patients. We’ve tried to strike a balance between helping patients with serious mental illness, while still maintaining a safe and comfortable treatment program for our patients. Often these patients refuse to be referred to the facility that contracts with our LME to provide mental health care. In other words, their mental illness interferes with their ability to get care for their mental illness. It can be terribly frustrating. I’m not a psychiatrist, and I’m not qualified to help them with these serious conditions.

We’ve admitted a handful of homeless people with opioid use disorder under the CURES grant. Our small town has one facility that will house people for up to two weeks, so at best that’s a very short-term solution. We can refer them to neighboring towns, but they don’t have transportation to dose with us every day, so they must transfer their care for opioid use disorder to another facility approved for CURES money. Some homeless people would rather live outside in a familiar area than move to a different town. With winter coming, it’s a grave concern.

Our patient census shot up relatively quickly, and our OTP has growing pains. We are struggling to hire more personnel, particularly to reduce wait times for dosing. I don’t have time to see every patient as I would like to, so the company I work for is looking for a physician extender to help me.

As is human nature, some people try to take advantage of grant money. I’ve had a few “patients” start on sublingual buprenorphine, only to see them attempt to divert their dose. When I confront them, and tell them I’m no longer willing to prescribe buprenorphine but would be willing to switch them to methadone, they get angry and leave. I believe – but can’t prove – these people intended to get buprenorphine to sell on the black market, where it goes for around $30 for an 8mg tablet.

We also must live with the uncertainty that this grant could be snatched away by a president intent on undoing everything the last president did. I tell patients benefitting from the CURES grant to look at this opportunity as a temporary thing, and that if possible, they need to try to find a way to pay for treatment themselves if the grant falls through. I hope it doesn’t, but the future of healthcare overall is in a period of transition, and opioid use disorder treatment is no exception.

Our whole staff feels more stress, and I try to remind them – and myself – of the larger picture. Experts say only 10-20% of people with opioid use disorder are presently getting help for their illness, and now with CURES, I believe that we are reaching a chunk of those who haven’t had care in the past.

It’s an opportunity that I’ve never seen in the sixteen years I’ve worked treating opioid use disorder. Despite our growing pains, we will continue to do all we can to access treatment dollars for people who can’t afford it otherwise. This CURES program should have this same effect across the country, enabling people with opioid use disorder enter treatment, often for the first time.

 

6 responses to this post.

  1. Recently I was speaking with an acquaintance, along with a friend—acquaintance is a Physician’s Assistant.

    Person works in addiction medicine and also cares for buprenorphine patients/prescribes it. I try to keep my buprenorphine status to myself pretty often—that never seems to work out these days as it is just becoming more and more relevant.

    Some sh*t-thing came up about opioids and lobbyists or something and I was oo the closet in a flash.

    Anyway, this person who seems like a very nice person advocates straight-up, from what they’re seeing day-to-day—that if you’re stable on your dose to cut it back and to put some away in a safe, locked so animals and children cannot get it. They said the political climate is too unstable—unprecedented and they’re looking at us.

    I hate to live that way. But we had fires come within less than a mile of our homes recently and I didn’t have water in the car, I ran out of gasoline in the middle of the night with two little frightened dogs and my sister who struggles with autism and thrives on stability—all counting on me. HTF gas station with working pumps so we could escape fire. Put cash together and literally prayed gasoline gods and and goddesses would escort us to gas station 2-3 miles away in heavy traffic with zero gasoline. Somehow we made it but 100+ people in line for 1-2 working pumps. Miraculously we made it out of the fire line due to human kindness and the divine.

    After all that I don’t know if I want to run out of bupe when the man who is more talkative than me but red has a double mood swing.

    I’ve been scared oo my mind since 9 November. I thought when I went to fill my meds that month red lights would flash and I’d get a honking/negative/wrong answer, game show sound and be back to being treated like a junkie by the pharmacy staff as in the past when I picked it up pre-Obama.

    But so far, by Divine Grace, my medication has been covered. I know that is not true for everyone. Personally I have to pay oo pocket for my doctor’s appointment and I gladly scrounge the money together however I have to.

    I have Kaiser and I love them for what they do for me. They used to cover my appointment when I had coverage through my husband through a program called “CDRP” but when he passed away they threw me off that like right away and told me to get a private doctor.

    I have Kaiser for everything but buprenorphine—they have no involvement with that and that’s fine with me. KP is fabulous in everything they do but I’m just not in love with their helicopter/abstinence/1930’s approach, it didn’t work for me personally but ¡YAY! for it and everyone it works for.

    I didn’t like being drug tested every 15 minutes and ridden like a horse. It *made* me use illicit drugs so much more. I do realize no one can make me do anything and I am completely responsible for my choices I was joking.

    With the private doctor who treats me like an adult and kind of like a human, the truth just falls out of my mouth when I see him. He assumes the best if he assumes at all—I literally quit wanting to use outside stims and finally figured out what the issue is—and got it treated by a psychiatrist. I haven’t sought or used illicit drugs in over a year and that was not intentional—and it’s a long time. Thanks Dr!

    That was a long story—I’m sorry—you may mod it out but this is what I’m hearing and real-life happenings. Thanks Dr. Burson for your humanity. I think a lot of people see it but I don’t think that is why you’re doing amazing things—I think you’re driven by your humanity—not for praise.

    Reply

  2. Posted by Trudy Duffy on October 22, 2017 at 1:42 pm

    Thank you for keeping us informed and educated about what is working and not working. I wish Washington were listening to you.

    Reply

  3. Posted by Sue on October 22, 2017 at 3:41 pm

    Have followed your blue g for years now and have been on both sides of the OUD fence. I too went through MAT and got well after a battle that nearly ruined me and my family. The ACA finally allowed me access to health hcare. These are very interesting political times. I have returned to my occupation and furthering my education to help others with access to treatment. Your blog seems to always be on the frontier of this and I enjoy reading your blog. Has always inspired me!

    Reply

  4. Posted by Icecutter on October 22, 2017 at 8:15 pm

    It is good to see that there is at least a start towards helping addicts who cannot afford MAT get some relief. We have a long way to go and I thank you Dr. Burson for letting us know about this.

    Reply

  5. Posted by Alan Wartenberg MD on October 23, 2017 at 1:18 pm

    The difficulty with the money from the CURES program and others is that it is a double-edged sword in the absence of being able to access the ENTIRE health care system, not just treatment with “MAT.” The vast majority of people who come in have both medical and psychiatric problems that need treatment and are beyond the scope of the average treatment program. What is happening with the ACA and the attempts to “replace” it with lousy non-coverage will be the undoing of all the good that may come of the all the advances in paying for treatment of OUDs. I don’t want to look a gift horse in the mouth either, but we are on very shaky ground unless the ACA gets repaired and strengthened – this despite a Republican majority and president who believe that their core belief MUST be the dismantling of everything associated with Obama.

    Reply

  6. Posted by Jessica Eaddy on October 23, 2017 at 6:20 pm

    Thanks for explaining the STR grant and how it works in NC! Is the other 20% in NC going towards naloxone distribution and prevention? Or is it unspecified?

    Reply

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