State Efforts to Support People in Recovery
September is National Recovery month, a time during which we celebrate and support people in recovery and their resiliency. Recovery is broadly defined by the Substance Abuse and Mental Health Services Administration (SAMHSA) as the “process of change through which individuals improve their health and wellness, live self-directed lives, and strive to reach their full potential.” Recovery is different for everyone and can include community and peer support, clinical and institutional treatment, and prescribed medications.
States have taken a variety of policy approaches to support provision of evidence-based treatments for substance use disorders (SUD) and individuals in recovery. This article explores how states can lower barriers to treatment, support at-risk populations, and provide wraparound services and supports to those in recovery.
Supporting Pregnant and Parenting People
Pregnant and parenting people with SUD experience fatal drug overdoses at an alarming rate; drug overdose has emerged as a leading cause of death among pregnant and postpartum people, and the overdose death rate among these populations jumped by 81% between 2017 and 2020. States, whose Medicaid programs cover close to half of U.S. births, can play a significant role in preventing these deaths by increasing the range of Medicaid-covered SUD treatment services and expanding eligibility for such services among pregnant and parenting people.
Through a State Plan Amendment, West Virginia has increased eligibility for Medicaid coverage up to 12 months postpartum, joining the growing list of states that have taken similar policy action. West Virginia Medicaid also now covers the complete range of SUD treatment services included in the American Society of Addiction Medicine (ASAM) Continuum of Care for pregnant and parenting people.1 Expanding Medicaid coverage for these services for people 12 months postpartum ensures that new parents do not lose access to treatment and recovery services if they lose Medicaid eligibility 60 days after birth, the point at which coverage ends under federal law in the absence of state-level policy change. West Virginia is one of a handful of states that also covers care for Medicaid eligible newborns diagnosed with or at risk for Neonatal Abstinence Syndrome (NAS) at its pediatric residential treatment nursing facilities.
Lowering Barriers to Care
Despite the proven efficacy of medications for opioid use disorder (MOUD) as treatment for opioid use disorder (OUD) and overdose prevention, a recent national survey found that only 22.1% of people with OUD received MOUD. Several factors contribute to this low engagement in treatment, including prior authorization requirements, lack of transportation, and limited provider capacity. States can mitigate provider capacity challenges by training prescribers to screen for OUD and start treatment in high-traffic healthcare settings, such as hospital emergency departments.
The California Bridge program (CA Bridge) is an initiative that equips emergency departments with prescribers trained to provide round-the-clock access to medication for addiction treatment and substance use navigators, who work with stabilized patients with OUD on post-discharge harm reduction and treatment services. What started as a pilot program in 2018 has expanded into 85% of California’s emergency departments, and the successful model is being adopted in other states. Importantly, CA Bridge serves patients who commonly have co-occurring mental health conditions and engage in polysubstance use. Many of these patients also experience housing insecurity and are either uninsured or are covered by Medi-Cal. CA Bridge engages these individuals at their initial – and perhaps only – interphase with the health care system and provides them with the support and resources to remain in treatment.
Increasing Access to Stable Housing
Stable housing can present a significant barrier for individuals with SUD who are in recovery; people transitioning out of institutional treatment may find their former homes to be incompatible with recovery. Individuals experiencing homelessness or housing insecurity also frequently struggle to engage in treatment, while those successfully receiving treatment may be denied stable housing, as transitional housing may require sobriety as a condition of tenancy, and subsidized housing can exclude people with a history of substance use. States can empower people with SUD and in recovery by investing in supportive housing models that address housing and other social needs first. Studies have shown that once individuals have stable and safe housing, they experience improvements in mental health and retention in treatment, as well as less time spent in residential treatment.
Through state legislation, Indiana has implemented the Indiana Housing First Program, a Housing First Model that safely and sustainably addresses the housing needs of people with serious persistent mental illness (SPMI) and/or SUD without requiring sobriety or engagement in treatment. In addition to rental assistance, the program also provides optional supportive services to help individuals remain housed, including employment support and training, treatment for SUD, and transportation support, among others. The majority (71%) of program participants have successfully transitioned into permanent housing within two years of beginning the program.
Providing Treatment to Justice-Involved Populations
People with SUD are overrepresented in carceral settings – 59% and 63% of individuals entering prison and jail, respectively, have a SUD. Individuals who enter the justice system with a SUD will likely experience painful and potentially life-threatening withdrawal symptoms once incarcerated, and, in the absence of treatment, are at increased risk of fatal overdoses upon release. State investment in provision of SUD treatment to incarcerated populations can result in better treatment retention and a decrease in overdose deaths upon release.
Maine began providing medications for opioid use disorder (MOUD) to its incarcerated populations beginning in 2019 pursuant to Governor Mills’ Executive Order, which aimed to prevent drug-related deaths among justice involved individuals. What began as a pilot program providing treatment to a limited number individuals diagnosed with OUD who were within three months of their release dates has since expanded state-wide and now offers treatment to any individual currently incarcerated, regardless of sentence length. Importantly, the Maine Department of Corrections (MDOC) strives to prevent any gaps in treatment for people entering prison, both from the community and from county jails, as well as connecting individuals with community-based treatment providers prior to release. Maine’s efforts have helped to better integrate and destigmatize treatment for substance use disorders, as treatment for behavioral and physical conditions are provided together. MDOC has also worked with the state’s Medicaid program, MaineCare, to ensure eligible individuals have their benefits activated immediately upon release, preventing any treatment disruptions.
States are also taking steps to support individuals with SUD as they reenter their communities; California recently had its Section 1115 Re-Entry Demonstration Waiver approved, under which MediCal can cover SUD services to incarcerated individuals 90 days prior to their release. Fourteen additional states have similar waiver requests pending with CMS, and other states seeking authority to provide these services should review the State Medicaid Director Letter released earlier this year for guidance.
The examples discussed above are only a snapshot of the innovative policy work happening at the state level. Across the country, states are implementing impactful and results-driven initiatives that support people with SUD who are in recovery. Despite the progress made and successes to date, the annual death toll due to drug and other substance use remains high, and stimulant use and polysubstance use has continued to increase over the past several years. States must remain vigilant in removing barriers to treatment and increasing access to care and supportive services in order to save lives.