One of the best ways to help patients with a substance use disorder is to become active in state politics, said multiple physicians at the recent American Society of Addiction Medicine (ASAM) State Advocacy Summit. The summit brought together a wide spectrum of clinical experiences and practices to provide practical tips and examples of how to get more involved and change policies. Some of the highlights:
For Edwin Chapman, MD, who treats more than 200 patients in the District of Columbia, starting an office-based buprenorphine clinic used to be about treating mainly heroin addiction, but now nearly all of his patients are exposed to illicit fentanyl prior to beginning care. Dr. Chapman has found that buprenorphine doses greater than 24 milligrams “were much more effective in negative urines and comfort for the patients and retention rate.” But Medicaid and the PBMs continued to require prior authorization for a large portion of the prescriptions. They also continue to try to force Dr. Chapman to change the dose. “I’ll keep fighting the fight because my patients are doing better. And we have to understand that we’re treating not just individual patients, we’re treating entire communities.”
One of the ways Dr. Chapman fights back is highlighting his experiences in public presentations through ASAM, the American Medical Association (AMA), the Georgetown University Law School’s O’Neill Institute for Global and National Health Law, and other forums. He also regularly emails D.C. officials to inform them of what he is seeing in his practice and invites them to visit with him at his practice or virtually. “Public officials need to hear and see what’s happening on the ground, so I show them,” said Dr. Chapman.
In addition to reaching out to policymakers, advocacy in support of effective policies to help pregnant persons who use drugs requires working through the clinic, hospital, state regulatory agencies and making sure our patients’ needs are at the forefront, said Ruchi Fitzgerald, MD, a family physician board certified in addiction medicine in Illinois. “One of the things that we learned is that if we don’t understand the Department of Child Welfare (DCFS) policies, we cannot really work with our patients and really help them achieve their goals and really provide anticipatory guidance about what to expect when their babies are born, or with their prior interactions with the DCFS system.”
Similar to Dr. Chapman, Dr. Fitzgerald regularly engages with state and local policymakers to help them understand what her patients are facing.
David Kan, MD, who is board certified in psychiatry, forensic psychiatry, as well as addiction medicine, highlighted that physician advocacy can help policymakers better understand and support controversial issues—but that it might take multiple legislative sessions. “Two major initiatives that we’re working on pursuing is getting [California] to endorse contingency management for stimulant use disorder,” said Dr. Kan. “Unfortunately, the bill that finally got the governor’s desk got vetoed, so we’ll probably be coming back with that, once again.”
Dr. Kan also discussed advocacy in support of overdose prevention facilities, also known as safe injection facilities and safe consumption sites. “I’ve been serving as the main expert witness, and this is going on year number five, I believe. We had a bill, SB 57, that would authorize the piloting of supervised consumption sites. And if we look at the data for supervised consumption sites, it’s very good, meaning that it allows it prevents overdose and it gets people into treatment.”
Being an advocate doesn’t matter where you are or what your state might allow or not allow, said Cara Poland, MD, a board-certified addiction medicine physician in Michigan, who explained that it took her and the state ASAM chapter seven years to have Medicaid expand treatment for alcohol use disorder.
Dr. Poland also said that “when the lay public asks me what I do, yes, I have been known to say, I treat pregnant people who inject heroin. And that gets all sorts of different responses. But it’s a great conversation opener for the fact that people with addiction are not unlike any other pregnant person and their support system, that they’re doing things to improve their health to improve the health of that baby. And that’s often the place that we started the conversation. And for this individual, it’s just that they’re trying to decrease their substance use, as well as improve their diet, increase their activity level, all those good things that pregnant people do.”
By providing the services that her patients are ready for, Dr. Poland highlighted that “over 80% of our patients come back for their six-week postpartum well-woman visit,” considerably higher than the national average.
As Chief Medical Officer for a four-state, 46-site, outpatient treatment network serving 11,000 patients, Shawn Ryan, MD, has one foot in the clinical world while also serving as Chair of ASAM’s Legislative Advocacy committee.
“I try to draw analogies that are pretty simple,” said Dr. Ryan. “I ask, for example, would anybody in the state of Ohio be happy with only one out of five Medicaid patients with diabetes getting evidence-based care? Of course not—there would be riots in the street. So then I talk about how we should not be satisfied that only one out of five patients with opioid use disorder (OUD) get medications to treat OUD.”
Dr. Ryan said that his strategies have been effective when testifying in Congress, in Columbus, Ohio, and also in more local settings. “We not only have to meet our patients where they are,” said Dr. Ryan, “we have to understand that it is up to us to help policymakers understand what our patients need.”
Dr. Chapman explained that he was an early adopter of electronic medical records, and he’s also implemented telehealth services to connect his patients with a wide variety of behavioral health and other resources. “Because every day, a patient will walk in my office with a new problem, either they lost their housing, somebody died and they’re depressed. How do I get those services to them without giving a paper referral that I know will not be followed through on. So using telehealth can actually connect those services, but they have to be paid for. And they have to be really bundled in a system like the one envisioned by the jointly-released ASAM-AMA Patient-Centered Opioid Addiction Treatment (P-COAT) alternative payment model. So it’s been difficult to really sit down with both federal and local officials to understand that we’re actually saving money globally.”
On one hand, said Dr. Chapman, “We’re saving money in the criminal justice system; we’re saving money in terms of infectious diseases. We’re saving money with pregnant patients.” On the other hand, some of those savings do not accrue to the insurance company. So the insurance companies do not always understand that. So those savings accrue to all of us, but not necessarily to the insurance company bottom line. I think we have to really press the economics of what we’re doing and how much money it saves.”
Dr. Ryan echoed the need to be clear in what physicians need, highlighting that talking about “dosing curves” won’t be helpful with most legislators. Talking about transforming practices across all states, increasing broadband access, and supporting physician investment in those technologies to increase access to care for patients—those are elements that many policymakers can understand. “We have to be clear that part of our advocacy role is to think about the pragmatism of what’s necessary to see patients in a functional, legal, sustainable business model,” said Dr. Ryan.
Being pragmatic does not mean, however, shying away from the evidence. Rather, in policy discussions, physicians need to stress the evidence, said Dr. Poland. “Let’s talk about what you’re hearing from other people or what you’ve experienced personally and whether or not that aligns with the medical evidence because when we’re when we’re talking about policy, we need to use as much evidence as we can and not use our personal opinions.”
To emphasize the point, Dr. Poland said that when she talks with legislators, she explains how a pregnant person needs support for themselves, their fetus, their family and probably others. “Having an SUD is challenging enough, so the question has to include how can we help support healthy choices that are grounded in evidence?”
For Dr. Fitzgerald, the advocacy to support her pregnant patients with an SUD can be very humbling, “because it’s a very slow process that involves just a lot of collaboration and understanding different values from different state regulatory agencies.” This includes sometimes having to be the one to explain the effects of policies on pregnant patients as well as opportunities, for example, to use federal grants that could help pregnant patients and their families. “We’ve had some successes, and we have had some, you know, it’s not been successful, sadly, and we’ve seen some real harm done. But we’re hopeful for the future and definitely not going to stop in this kind of ongoing gap that takes place in the state of Illinois.”
Dr. Kan summed up some of the major points raised by each physician—the need to rely on evidence, make it understandable, and make clear that SUD can affect anyone. “I always tell a story. I tell a story of the patients who struggled. The patients who left treatment and died of overdose. And I tried to personalize it, including the fact that this disease affects the richest and most privileged, as well as those who do not have privilege,” said Dr. Kan, who stressed the importance of being available to talk with local officials, state policymakers as well as national officials. “Within your county, there’s county level policies, whether it be zoning requirements, those type of things. Start small, because when addiction medicine physicians leave our offices, and we show up, policymakers and their staff recognize your time is precious, and you speak as a physician, and that is meaningful. You speak on behalf of those with no voices. And understand that clearly because the legislators will hear you because the people affected can’t speak for themselves. And those officials often go on to state and national politics. Everyone can make a difference.”
Dr. Poland ended the session on a similar note, urging physicians to “bring people’s stories. Bring real life to the disease of addiction. Bring humanness into it. And when you use those stories, use those stories to back up the evidence that you have.”