Advocacy and Public Policy Efforts of the American Academy of Addiction Psychiatry

INTRODUCTION

Since its inception in 1985, the American Academy of Addiction Psychiatry (AAAP) has been dedicated to training the workforce to treat persons with substance use disorders (SUD) and providing public education and advocacy for evidence-based SUD care and antidiscrimination policies. This article focuses on the work AAAP has accomplished in advocacy for, and in construction of, recent federal laws that promote parity for treatment of SUD in health insurance benefits. Our priorities have focused on enhancing access to evidence-based treatments for co-occurring substance use and mental health disorders and supporting robust research funding to improve addiction recovery and prevent SUD. Our means for achieving these goals have included: increasing the number of trained addiction psychiatrists through AAAP’s work in developing both the Addiction Psychiatry subspecialty and the accreditation of Fellowships in Addiction Psychiatry to address workforce needs; increasing reimbursement for clinicians who treat these patients; maintenance of quality control and risk management in an era emphasizing cost containment; and enhancing collaborative relationships between psychiatry and primary care, including leading interorganizational education and clinical support endeavors with national addiction and other medical and health profession organizations. The direct training and support of physicians and other health professionals in medication treatment of opioid use disorder and provision of technical assistance has been supported by AAAP’s successful leading of consortia of many aligned health professional organizations in the garnering of large federal grants. The following reflects selective highlights of AAAP’s advocacy and policy efforts that exemplify our mission.

LAWS RELATED TO INSURANCE ACCESS AND HEALTH CARE REIMBURSEMENT

In recent years, major bills positively impacting health insurance benefits for addiction-related treatment have been the Wellstone-Domenici Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008,¹ the Patient Protection and Affordable Care Act of 2010 (ACA),² the Comprehensive Addiction and Recovery Act (CARA),³ and the 21st Century Cures Act.⁴ MHPAEA was passed aiming to reduce potential discrimination in benefits in health insurance coverage for mental health and extended the parity requirements over that of the original Mental Health Parity Act of 1996 to include equitable coverage for SUD, such as requiring that vendors of carve-out addiction services provide services in parity with medical services of other vendors under a group health plan.¹ The ACA extended the MHPAEA to cover the individual insurance market and small businesses, thereby reducing the burden for SUD-related treatment, since under MHPAEA about a third of people covered in the individual market had no SUD treatment coverage.⁵ For the first time, SUD was given the status as an essential health benefit (EHB; one of only 10 so defined), meaning that SUD services are required to be covered at parity by health insurance issuers and by large group health plans that choose to include mental health/SUD benefits in their benefit packages, as well as by individual and small businesses.^2,5 Considerable advocacy by health professional organizations, including AAAP, and collaborative efforts of these organizations and those representing community-based treatment providers assisted in the inclusion of SUD as an EHB. Coverage under ACA may apply neither quantitative limitations in the number of visits or days of treatment, nor nonquantitative limitations such as prior authorization or stepped treatment intensity, unless they are also applied equivalently to the package’s medical and surgical benefits.⁵

CARA, which was passed in 2016, supported national training in the use of naloxone, provided grants to expand educational efforts regarding opioid use, and implemented a series of efforts to lessen the current opioid epidemic.³ AAAP exercised an opportunity to mark up the bill, adding, as aligned with its mission, the needed recognition of the prevalence of other mental disorders among those with SUD, and the need to screen for and treat those disorders as part of appropriate addiction recovery efforts among civilians and veterans, as well as in criminal justice settings. Almost all of the mark-ups supplied by AAAP survived the reconciliation process in concept if not in actual language and are included in the law; clearly of benefit to the public, and in particular, the recipients of covered addiction care. In addition, the added language, based in current published epidemiology of SUD, is a clear example of AAAP’s promotion of evidence-based policy.

The 21st Century Cures Act was enacted in 2016 with strong bipartisan support and authorized 500 million dollars in 2017 and 2018 for state responses to opioid crisis, as well as funding for the National Institutes of Health to conduct research on addiction treatment and early intervention.⁴ With the ACA and this legislation, access to buprenorphine-waivered physicians has increased, as well as reimbursement and spending on buprenorphine, proving that policy decisions can greatly shape the delivery of SUD treatment.

EVOLUTION OF PRIVACY LAWS AND ADVENT OF ELECTRONIC HEALTH RECORD

AAAP’s policy committee has actively advised on balancing patient privacy protections with provision of safely coordinated health care. As originally articulated in 1975 in the Code of Federal Regulations Chapter 42, part 2 (42CFR2), the treatment of SUD shall be held to a higher standard of confidentiality protections in order “to ensure that a patient receiving treatment for a substance use disorder in a part 2 program (ie, a federally-assisted program such as an opioid treatment program) is not made more vulnerable by reason of the availability of their patient record than an individual with a substance use disorder who does not seek treatment.” This federal code reflected the enduring discrimination and cultural stigma against persons living with SUD, especially evident against those with drug use disorders. In 2010, AAAP cowrote a consensus statement entitled, “Confidentiality of Patient Records and Protections Against Discrimination: A Joint Statement by the American Society of Addiction Medicine, the American Academy of Addiction Psychiatry, the American Osteopathic Academy of Addiction Medicine, and the Association for Medical Education and Research in Substance Abuse.” In brief, the following positions were asserted: (1) all patients should be educated and asked to provide informed consent for the release of basic health information (diagnoses, medications, known allergies, and laboratory results) to collaborating, active providers on health care teams; (2) a patient who does not consent will be counseled regarding risk, and providers of nonemergency health care would retain the right to not enter into a provider-patient relationship if they determine the risk to be against ethical medical practice; (3) all other release of medical records will require consent specifying entities to receive information, purpose of release, and time duration of release, and will prohibit the release of records received from outside institutions (ie, “re-disclosure” of historical health records is prohibited); (4) prescription monitoring databases should only be accessible to current treatment providers and pharmacies; (5) breach of confidentiality rules should result in severe consequences to deter such breaches; and (6) health care providers and health insurance providers may not discriminate in health care delivery to those with SUD (https://www.aaap.org/about/policy-statements/). Since that original consensus, national efforts to update 42CFR2 with “final rules” have been necessary as electronic health information is increasingly integrated and accessible. Problematic gaps in fidelity to the spirit of 42CFR2 are evident as electronic systems evolve to provide rapid access across providers and in some cases, necessary law enforcement access to control drug trafficking and drug poisoning deaths.^6,7 Ongoing legislative efforts to protect nonspecialists providing care to persons with SUD, and clarifying the applications of 42CFR2, have been proposed recently by the Department of Health and Human Services.⁸ However, AAAP expressed concern in a letter of response that some of the proposed changes to 42CFR2 would threaten its patient confidentiality protection by significantly expanding legal access to patient care records under broadly interpretable criteria regarding suspected drug trafficking and/or criminal investigations, even when the patient has not been formally charged with such a crime. AAAP also opposed release of a patient care record to those investigating a Drug Enforcement Administration-waivered prescriber for corrupt prescribing or “drug trafficking,” without fully informing the patient about the investigation’s rationale and requiring that the patient provides written, informed consent to the release of his/her treatment records for this purpose.

SPECIAL POPULATIONS

AAAP has continually advocated for the rights of special populations within the criminal justice system. Much of these efforts have focused on preventing criminalization of addiction during pregnancy and advocating for treatment of affected women. In 2017, AAAP coauthored an amicus brief in the US Court of Appeals 7th Circuit case of Loertscher v. Anderson.⁹ In that case, Ms. Loertscher sought treatment at a county health facility, where her caregivers discovered that she was pregnant. Because she tested positive for methamphetamine, amphetamines, and marijuana, a state court ordered Ms. Loertscher to report to an alcohol and drug use treatment center for assessment. She did not comply with the order and was incarcerated. In its amicus brief, AAAP explained to the court that there is no scientific basis for subjecting a pregnant women with SUD to punitive action and that exerting state control over them does not further public health interests.

In 2018, in conjunction with the American Psychiatric Association, AAAP published a press release addressing a situation in which a county attorney in Montana had announced the intent to issue restraining orders against pregnant women who were found to be using substances and the threat of jail time. Once again, AAAP argued for treatment of these women rather than incarceration. That same year, AAAP submitted an amicus brief to the Supreme Court of Pennsylvania¹⁰ for a case in which the primary question was whether an existing state child welfare law allowed substance use during pregnancy to be considered child abuse. AAAP argued that such a determination would deter pregnant women with SUD from seeking care and sharing relevant information with their caregivers. In 2019, AAAP filed an amicus brief stating that judicial review should be granted in the case of United States v. Flute in the Eighth Circuit.¹¹ Ms. Flute’s child died shortly after birth and tested positive for cocaine and other prescription and over-the-counter drugs. She was charged federally with involuntary manslaughter. AAAP argued in its brief that medical science does not support the expansion of the federal manslaughter statute to prosecute substance use during pregnancy.

AAAP has also served as a voice in defending the rights of other individuals with SUD who are involved in the criminal justice system. In 2017, AAAP coauthored an amicus brief in the Massachusetts case of Commonwealth v. Calvin Horne.¹² Mr. Horne had been previously convicted of possession of cocaine with intent to distribute and appealed the decision. The prosecution in his initial trial had argued that since Mr. Horne did not have the stereotypical appearance of someone addicted to cocaine as reported by an expert witness, he must have been intending to sell the cocaine he was found in possession of by police. AAAP and others argued that such negative profiling was unreliable and highly prejudicial to individual defendants. The Massachusetts Supreme Court agreed and vacated the judgment.

In the 2019 Massachusetts Supreme Court case of Commonwealth v. Plasse,¹³ AAAP filed a brief on behalf of Ms. Plasse. Ms. Plasse had previously been placed on 1-year probation after pleading guilty to shoplifting. She violated probation several times for positive drug screens, being terminated from a sober home, and other reasons. After a final violation, the judge sentenced her to 2 years in the House of Corrections, which was the maximum sentence allowed under the statute and longer than the prosecutor had recommended. The judge said this was not to punish Ms. Plasse, but to ensure that she went through an addiction treatment program. AAAP argued that the judge had no authority to incarcerate Ms. Plasse for her own welfare and that increasing her sentence in a correctional facility would actually hinder her recovery due to the poor addictions care delivered there. In the 2019 Massachusetts Supreme Court Case of Commonwealth v. Julie Eldred,¹⁴ the court was tasked with deciding whether a district court had the legal authority to incarcerate Eldred after she tested positive for fentanyl, thus violating a condition of her probation. AAAP filed a brief arguing that this punitive response to relapse—a known and predictable feature of SUD—would not deter those with SUD from using and would reduce the likelihood they would seek treatment for their SUD while under court supervision.

Moving forward, AAAP will continue to use its voice as a leading organization in the care of those with SUD to ensure that our criminal justice system treats fairly individuals with SUD, and improves its efforts at rehabilitating these individuals rather than imposing punitive measures unlikely to serve justice or public health.

TRAINING AN ADDICTION HEALTH CARE WORKFORCE

According to the 2018 National Survey on Drug Use and Health, only 2.4 million of the 21.2 million Americans with SUD received specialty addiction treatment services, highlighting a significant treatment gap.¹⁵ While poor remuneration for addiction services and variable access to these services exacerbate this situation, a primary driving force behind the treatment gap remains a persistent education gap. Well-trained addiction providers are scarce, and widespread stigma among health care providers towards individuals with SUD, and towards the use of evidence-based medications such as opioid agonist therapies, persists in spite of significant scientific advances in our understanding of SUD and our capacity to provide effective treatments for SUD. Stigma has been identified as a barrier for both patient access to evidence-based SUD care¹⁶ and clinician willingness to provide SUD care.¹⁷ Additionally, SUD curricula remain underrepresented in clinician training programs.¹⁸ Efforts to decrease the SUD education and treatment gaps have centered on fostering educational and practice-based opportunities for all levels of medical training.

Postgraduate addiction subspecialty training is critical for the development of an expanded and competent addiction workforce. Currently, the American Board of Medical Subspecialties (ABMS) recognizes both Addiction Psychiatry (AP) and Addiction Medicine (AM) as medical subspecialties granting board certification relating to addictions and their treatment. AP has been recognized since 1993, and AM earned ABMS recognition in 2016. Since AP and AM occupy a similar educational and clinical space, with fellowships and faculty often coexisting at the same institutions, coordination, and collaboration among these medical subspecialties and specialists offers a tremendous opportunity to shape institutional and clinical attitudes and agendas in the service of improving the treatment and education gaps. AAAP and the American College of Academic Addiction Medicine have recognized the complementary nature of their respective subspecialties and therefore have undertaken efforts to collaborate at multiple levels including coparticipation in one another’s annual meetings, creation of model curricula, and support relating to regulatory and other educational requirements.

Recognizing the success of loan repayment/forgiveness programs in expanding workforces in other medical fields where treatment gaps existed (eg, primary care, family medicine, and mental health), AAAP has also played a key role in legislative advocacy to ensure that addiction treatment providers are afforded the same loan relief benefits that other medical specialties have enjoyed. As a result of collaborating with multiple other medical associations and organizations, H.R. 6 (the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act or SUPPORT for Patients and Communities Act)¹⁹ included stipulations that amended the Public Health Services Act to authorize eligible loan forgiveness up to $250 000 to clinicians working in an eligible substance use treatment setting.

RESPONSE TO THE OPIOID CRISIS

AAAP has been a leading organization in developing innovative initiatives to combat the opioid crisis. One of AAAP’s major accomplishments is the SAMHSA-supported Provider Clinical Support System (PCSS) grant. PCSS is designed to provide free and accessible training and mentoring to prescribers and allied health professionals looking to identify and provide treatment for individuals with opioid use disorder (OUD). AAAP has been continuously awarded funding for PCSS for nearly a decade. Collectively, PCSS currently represents over a million health professionals and has worked with multiple organizational partners. PCSS recently increased the involvement of key partner organizations such as the Addiction Technology Transfer Center (ATTC), which has extensive expertize in training allied health and behavioral health specialists. The new PCSS plans to provide buprenorphine waiver training at no cost to thousands of physicians, nurse practitioners, physician assistants, and medical students; increase resources and tools, expand PCSS Implementation into emergency departments and develop a curriculum to train implementation specialists and operationalize the team of implementation leaders; and expand training content into other critical areas of clinical importance such as poly-substance use, co-occurring mental health disorders, as well as greater attention of social and economic barriers to successful OUD treatment.

The other key initiative headed by AAAP is the state targeted response (STR) network-technical assistance-opioid response network (ORN). STR grant funds are awarded to states and territories through a formula based on unmet need for opioid use disorder treatment and drug overdose deaths.²⁰ This SAMHSA-supported grant provides technical assistance to all US states and territories that received STR funds to expand access to effective prevention, treatment, and recovery. The grant was funded in January 2019 and was quickly launched in February 2019. The outstanding team of Core Collaborators have demonstrated expertize in addiction, evidence-based prevention, treatment and recovery supports, delivery of culturally appropriate technical assistance, implementation (including sustainment), and evaluation. Drawing from the PCSS partners, a large group of partner organizations were included. As outlined in the proposal the main objectives of this proposal are to provide education and training around evidence-based practices and implementation strategies to increase the number of prescribers and allied health professionals identifying, evaluating, and treating OUD and associated conditions, and to increase the provision of prevention services and recovery support services through peers as well as professional providers. To date, the ORN has responded to over 1300 requests and impacted a minimum of 2.8 million people (either directly or indirectly).

These initiatives, along with many other educational and training projects (as outlined in an accompanying article), have assured AAAP’s leadership role in battling the opioid epidemic. While there remains much work to be done, AAAP is poised, along with its many active members and partners, to find effective solutions to mitigate the suffering associated with OUD and other SUD.

In related legislative activity, AAAP has been engaged in support of S.2892, the Opioid Workforce Act of 2019, sponsored by Sen. Maggie Hassan (D-NH), which would provide funding for an additional 1000 residency positions focused on addiction treatment.

CHANGING LANDSCAPE OF CANNABIS LAW

As of the Summer 2019, 10 states and Washington, DC have passed laws allowing both medical and recreational use of cannabis.²¹ An additional 23 states and Puerto Rico (1) allow medical cannabis programs of varying design.²² Finally, since 2013, 13 states (some of which also allow medical cannabis) have authorized the use of cannabidiol (CBD), primarily for use in research studies and for treatment of patients with seizure disorders.

Despite the majority of states passing legislation and policies to allow access to medical and/or recreational, or nonmedical, use of cannabis and cannabis-derived products, there has been little coordination with the medical establishment, especially mental health and addiction specialists, to mitigate potential harms of legalized access.²² Given the controversial nature of cannabis policy, regional variation in professional norms, and inevitable differences practitioners may reasonably have regarding the appropriate public role of AAAP, in 2018 the AAAP Cannabis Special Interest Group and the AAAP Public Policy Committee collaborated to outline key elements of proposed model state legislation. The model was created to guide state decisions regarding both medical and recreational cannabis initiatives, and to minimize addiction risk and negative mental health effects at the population level. Membership feedback on the six proposed key elements of state legislation was incorporated through an online survey. The following six key elements were publicly released by AAAP to inform any potential statewide initiative to legislate or amend expanded legal access to cannabis:

1. Legal recreational use of cannabis should be limited to adults aged 21 or older (some states may consider the age of 25). Similarly, any potential marketing or advertising of cannabis and cannabis-derived products to youth and young adults should be banned.

2. As there is currently no psychiatric indication for “medical cannabis,” states should not include such indications (eg, PTSD, anxiety, depression, opioid use disorder) as qualifying conditions. Similarly, advertising touting the use of cannabis for treating mental health conditions should be banned.

3. Any expansion of legal use should include strategic public awareness campaigns and packaging alerts about potential harms from use,²³ especially heavy or daily use, or use of high-potency and edible products, such as risks of addiction, psychosis, and worsening of mood and anxiety symptoms. Targeted campaigns to prevent cannabis use during pregnancy and breastfeeding are warranted given the increasing prevalence of cannabis use among pregnant women living in the United States.²⁴

4. State-level regulation, including allocation of funds for purchase of high-grade analytic equipment, is critical for quality control measures to ensure proper chain of custody, testing, and labeling of cannabis-derived products so that users have accurate information about what they are ingesting. Mechanisms to audit and impose penalties for infractions or fraudulent practices should be built into initial legislation.

5. Regulations are needed to guard against impaired driving and innovative approaches with dedicated funding from cannabis sales are needed to respond to this vital public safety issue.

6. States should maintain a public registry supported by revenue from cannabis sales that reports annually on adverse outcomes associated with medical and recreational cannabis product sales and/or consumption.

CONCLUSION

Public policy constantly evolves in step with changing cultural perceptions of SUD, evolving regional drug use trends and public health consequences, and evolving matters related to the legalization and regulation of addictive substances. AAAP is actively involved in numerous advocacy efforts across the nation impacting health care access, quality of care, public education, and expanding health care workforce. AAAP also strongly advocates for antidiscrimination laws to protect vulnerable people living with SUD. Organizations such as AAAP have the opportunity to influence state and national law by advocating for legislation that reduces drug-related harms, promotes public awareness of safety information, and decreases the stigma of addiction.