Is SAMHSA’s investment in SUD treatment & CCBHCs increasing access to OUD medications?

By Ned Presnall, LCSW

Editor’s note: Read the companion piece to this article here.

From 2012 to 2016, federal investment in substance use disorder (SUD) treatment remained virtually unchanged at about $2 billion in grant funding each year. In response to rising overdose death rates, this investment has more than doubled since 2017 (Table 1). 

Most of this increase is accounted for by two grant programs: The State Targeted Response to the Opioid Crisis and the State Opioid Response. The 2021 American Rescue Plan Act generated $1.5 billion of extraordinary one-time funding.
 

Table 1. Increased federal investment to address opioid-involved deaths

In addition to its investment in SUD treatment services, SAMHSA has ramped up its investment in community mental health centers certified to provide integrated SUD and mental health treatment (CCBHCs). Initiated in 2016 with $25 million in planning grants, SAMHSA’s 2023 budget request for CCBHCs exceeds $500 million.¹⁰

My colleagues at St. Louis University and I wanted to answer a very simple question: Has SAMHSA’s unprecedented investment in SUD treatment and CCBHCs led to widespread access to buprenorphine and methadone for persons with OUD? 

These medications are the most effective treatments for preventing opioid-related death,¹¹ and for many years they have been inaccessible to a large part of the SUD treatment population.¹² There is some public data available to answer this question. Each year, SAMHSA’s National Survey on Substance Abuse Treatment Services (N-SSATS)¹³ provides agency-level service data, and its Treatment Episodes Data Set (TEDS)¹⁴ describes treatment episode characteristics, including the use of OUD medications. According to these sources, there has been a sharp increase since 2015 in the number of treatment programs offering buprenorphine or methadone, but the number and proportion of patients receiving MAT has remained fairly flat (Table 2).
 

Table 2. Agency and episode-level estimates of medications for OUD (MOUD) used in outpatient settings^13,14
 

NSSATS and TEDS data are not collected on CCBHCs but the National Council on Mental Well Being published 2018¹⁵ and 2021¹⁶ reports indicating that 92 percent of CCBHCs have trained or hired clinicians who can prescribe buprenorphine and that 89% offer one or more forms of Medication Assisted Treatment.

To test the accuracy of these data sources and to characterize the lived experience of people seeking buprenorphine and methadone treatment, we conducted two “secret shopper studies” –one of publicly-funded SUD treatment programs¹⁷, and the other of CCBHCs.¹⁸ In each study, we posed as the family member of someone with OUD seeking treatment. We asked about the availability of buprenorphine in SUD treatment programs and of buprenorphine or methadone in CCBHCs. We called each agency twice during business hours (when necessary) and collected data on the agencies from our conversations and through any return messages. 

In one study, we sampled and surveyed 520 of the 2350 publicly-funded SUD treatment programs listed as buprenorphine maintenance providers in SAMHSA's Treatment Locator.  Among these programs, 26% did not answer or return our calls and another 19% did not offer buprenorphine treatment. Only 23% of the agencies we contacted offered a buprenorphine provider visit at intake (remember, we only contacted agencies listed as providing buprenorphine maintenance). Based on these results, we were able to adjust the overall estimate of buprenorphine availability in publicly funded SUD treatment programs from 35% to 26%, with only 6% offering buprenorphine prescriber visits on the day of intake. 

At the time of our data collection, in 2021, there were 313 agencies listed as CCBHCs in SAMHSA’s treatment locator. Of the 83% (257) we contacted, 34% said that they offered buprenorphine or methadone treatment and 3% (7) indicated that a patient with OUD could see a buprenorphine or methadone provider at their first visit to the clinic. 

There are two important take-aways from these results. First, the lived experience of OUD patients seeking treatment is considerably less optimistic than the agency-level reports. Buprenorphine availability is over-reported and there exist significant barriers between availability and access. Many agencies are difficult to reach, and many others require non-medical appointments prior to visits with a buprenorphine prescriber. Second, the massive investment in OUD treatment delivery since 2016 has not led to widespread buprenorphine and methadone availability. This latter point should give policy-makers significant pause. Why hasn’t doubling the federal block grant or using targeted CCBHC “integration” grants translated into widespread buprenorphine and methadone access?

We believe that the answer is fairly simple. The vast majority of OUD funding has been distributed through the same channels as the annual block grant–in non-competitive federal grants to Single State Agencies (SSAs). SSAs contract with treatment programs or regional entities which have wide discretion over the types of treatment they provide. In other words, much of the funding has gone to the same agencies which failed to adopt buprenorphine and methadone treatment in the decade prior to the OUD grants. In the case of CCBHCs, the provision of buprenorphine and methadone was strongly encouraged but not required as a condition of funding, and, as a result, only a minority of CCBHCs offer these medications.

For contrast, compare another much smaller SAMHSA grant: Medication Assisted Treatment – Prescription Drug and Opioid Addiction (MAT-PDOA). Initiated in 2016, MAT-PDOA was a competitive $11 million grant with clear and measurable requirements–to start patients with OUD on maintenance medication and to retain them in treatment.¹⁹ Expanded in 2018 and 2021, SAMHSA has invested $148 million in the MAT-PDOA program–a small fraction of the OUD dollars which have come to states in the form of largely non-competitive, unrestricted treatment grants. 

Now that Congress has begun to appropriate funds to address the opioid crisis, it must hold SAMHSA, state SSAs, and treatment providers accountable for making buprenorphine and methadone universally accessible. This goal will likely require stricter grant requirements and increased investment in medical settings such as federally qualified health centers and rural health clinics – agencies with the medical workforce necessary to make buprenorphine and methadone universally available to persons with OUD.

Author Bio: Ned Presnall is the owner and director of Plan Your Recovery, an addiction treatment clinic in St. Louis, Missouri. He is a research collaborator at Washington University in St. Louis and St. Louis University.

References:

1. Overdose Death Rates. National Institute on Drug Abuse Accessed June 20, 2022. https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates
2. National Vital Statistics System, Provisional Mortality on CDC WONDER Online Database. Data Are from the Final Multiple Cause of Death Files, 2018-2020, and from Provisional Data for Years 2021-2022, as Compiled from Data Provided by the 57 Vital Statistics Jurisdictions through the Vital Statistics Cooperative Program. Centers for Disease Control and Prevention, National Center for Health Statistics. Accessed June 20, 2022. https://wonder.cdc.gov/controller/saved/D176/D296F030
3. Budget of the United States Government. Appendix: Detailed Budget Estimates by Agency. Department of Health and Human Services. U.S. Government Printing Office. https://www.govinfo.gov/app/collection/budget
4. Planning Grants for Certified Community Behavioral Health Clinics. SAMHSA; 2015. https://www.samhsa.gov/grants/grant-announcements/sm-16-001
5. FY 2018 Certified Community Behavioral Health Clinic Expansion Grants. SAMHSA; 2018. https://www.samhsa.gov/grants/grant-announcements/SM-18-019
6. Certified Community Behavioral Health Clinic Expansion Grants. SAMHSA; 2020. https://www.samhsa.gov/grants/grant-announcements/SM-20-012
7. Certified Community Behavioral Health Clinic Expansion Grants. SAMHSA; 2020. https://www.samhsa.gov/grants/grant-announcements/SM-21-013
8. Certified Community Behavioral Health Clinic Expansion Grants. SAMHSA; 2022. https://www.samhsa.gov/grants/grant-announcements/SM-22-002
9. Certified Community Behavioral Health Clinic Improvement and Expansion Grants. SAMHSA; 2022. https://www.samhsa.gov/grants/grant-announcements/SM-22-012
10. FY 2023. Justification of Estimates for Appropriations Committees. Department of Health and and Human Services. SAMHSA; 2022. https://www.samhsa.gov/sites/default/files/samhsa-fy-2023-cj.pdf
11. Pierce M, Bird SM, Hickman M, et al. Impact of treatment for opioid dependence on fatal drug-related poisoning: a national cohort study in England. Addiction. 2016;111(2):298-308. doi:10.1111/add.13193
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13. National Survey of Substance Abuse Treatment Services (NSSATS): Substance Use Facilities Data. SAMHSA https://www.samhsa.gov/data/data-we-collect/n-ssats-national-survey-substance-abuse-treatment-services
14. Treatment Episodes Data Set Admissions (TEDS-A): Client-Level Substance Use Data: Admissions. SAMHSA https://www.samhsa.gov/data/data-we-collect/teds-treatment-episode-data-set
15. Bridging the Treatment Gap. National Council for Mental Wellbeing; 2018. https://www.thenationalcouncil.org/wp-content/uploads/2022/03/CCBHC-Addictions-Treatment-Impact-survey-report-updated-8-29-19.pdf
16. Leading a Bold Shift in Mental Health and Substance Use Care: CCBCH Impact Report. National Council for Mental Wellbeing; 2021.
17. Presnall NJ, Butler GC, Grucza RA. Consumer Access to Buprenorphine in Publicly Funded Specialty Treatment Programs for Opioid Use Disorder, (2022, July 27) https://papers.ssrn.com/sol3/papers.cfm?abstract_id=4139779
18. Presnall NJ, Butler GC, Grucza RA. Consumer access to buprenorphine and methadone in certified community behavioral health centers: A secret shopper study. J Subst Abuse Treat. 2022;139:108788. doi:10.1016/j.jsat.2022.108788
19. Fendrich M, Becker J, Ives M, Rodis E, Marín M. Treatment Retention in Opioid Dependent Clients Receiving Medication-Assisted Treatment: Six-Month Rate and Baseline Correlates. Subst Use Misuse. 2021;56(7):1018-1023. doi:10.1080/10826084.2021.1906276