Ensuring Evidence-Based Treatment for Substance Use Disorders

The use of heroin, other opiates, and inappropriate prescription drugs are currently a major public health problem in this country. According to the Centers for Disease Control and Prevention (CDC), national death rates from prescription opioid pain reliever overdoses quadrupled during 1999 to 2010, whereas rates from heroin overdoses increased by less than 50%.1 Between 2010 and 2012, U.S. drug poisoning deaths involving heroin doubled, and although death rates from opiate pain medications had declined overall, they remained more than twice as high as heroin overdose death rates. 1 Although the highest overdose mortality rates remain in older age groups, the 15- to 24-year-old age cohort saw an 86% increase in deaths by heroin overdose from 2008 to 2010.1

In New York City specifically, heroin-related deaths increased 84% between 2010 and 2012.2 And, according to the city’s Department of Health and Mental Hygiene, heroin was involved in 52% of all overdose deaths in 2012.2 This problem is not confined to inner cities, and involves people of all ages in small towns and rural settings.

The impact of opioid use has had a significant impact on increasing health care costs and adverse outcomes. Between 2004 and 2011, drug-related visits to emergency rooms have soared and resulted in a 423% increase in these costs.3 Reasons cited for the increase in drug-related emergency room visits include illicit drug use (which increased 21%), misuse and abuse of pharmaceuticals (increased 56%), and to adverse reactions to medication (increased 46%).4

In order to address these rapidly evolving challenges, insurance plans are developing new programs and provider partnerships to improve the outcomes of care. Optum has established teams of clinical experts who are focused on identifying, evaluating, and refining clinical approaches to help this population. This includes anticipating and proactively responding to high-risk situations; identifying and helping to shape industry-leading best practices for the care of these conditions and actively working to break down barriers that fragment care. Partnering with local provider networks also support the expanded use of evidence-based treatments for substance use disorders. Another key is empowering consumers and their families through education and resources designed on the principles of recovery and resiliency.

Shaping Industry Best Practices

Optum has adopted an evidence-based, best practices approach to address the problems of heroin and opioid use, and prescription drug abuse for their covered populations. The primary goal is to engage members in treatment moving from acute interventions to long-term recovery solutions addressing each member’s strengths, weaknesses and barriers to treatment. All substance use disorder benefit requests are reviewed based on medical necessity criteria set by Level of Care Guidelines and/or Coverage Determination Guidelines (and where applicable, criteria established by the American Society of Addiction Medicine [ASAM]). Similar to medical care, an individual’s previous clinical and psychosocial experiences are considered in determining the best treatment choices and outcomes. All treatment plans and care are also individualized to each member’s specific needs, and are overseen by a board-certified addictions provider.

Partnering with Local Provider Networks

Strategies that support person-centered care for the effective treatment of substance use disorders requires the development of networks of providers and facilities that offer the full continuum of evidence-based care, including Medication-Assisted Treatment (MAT). Withdrawal management and recovery-based treatments integrate MAT with an overall long-term treatment plan that includes individual, group and family therapies, treatment for co-occurring psychiatric and medical disorders, and interventions that target psychosocial barriers to recovery. Recovery coaches and peer support services help promote individual well-being and foster resiliency. Care coordination is also provided to help integrate care between multiple providers and facilities.

Optum supports contracting with local certified substance use treatment facilities that offer the full range of evidence-based treatments and alternatives, including all FDA-approved MAT options. Effective networks of providers and facilities that offer this comprehensive spectrum of services reduce or eliminate the need for people to travel to other destinations for care, as well as support the critical role of community integration in the process of care. Other strategies that promote improved outcomes of care include: access to intake and screening within 24 hours of referral or member outreach; coordinated services between treatment providers, facilities, and care managers who are accustomed to developing person-centered recovery plans; Medication-Assisted Treatment which is used as a tool to address cravings, and support program engagement and retention; and expedited transitions across levels of care that support established treatment plans and individual progress towards recovery goals.

Empowering Consumers and Families

Care coordination is also provided to help educate and engage consumers and their families regarding what treatment options are available and how to access treatment. Person-centered treatment planning is essential to promote consumer safety and goal-directed outcomes. This treatment planning involves establishing measurable and achievable goals, multidisciplinary treatment strategies, and a phased approach to care that fosters recovery, resiliency, and community engagement. Comprehensive assessments include medical, psychosocial, and motivational evaluations. Evidence-based services should include counseling, self-help and peer support, and Medication-Assisted Treatment, as indicated.

Person-centered care is respectful and responsive to the needs of those served and their families. This includes education that supports improved engagement in care and activation for the changes necessary to achieve individual recovery goals. Peer support and other locally based resources foster improved long-term health outcomes and sustained community-based recovery and resiliency.

Ensuring Evidence-Based Outcomes

Heroin and opioid use and prescription drug misuse are significant public health challenges and require integrated strategies that must include a full range of evidence-based services, including Medication-Assisted Treatment. Care must also be coordinated across all health providers and services to promote whole-health goals and outcomes. Equally important, treatment must have a person-centered approach that is locally based to effectively promote community integration and ongoing recovery supports.


  1. Rudd RA, Paulozzi LJ, Bauer MJ, et al. Increases in heroin overdose deaths—28 states, 2010 to 2012. The Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report 63(39):849–54. 2014.
  2. Unintentional Drug Poisoning (Overdose) Deaths in New York City, 2000-2012. New York City Department of Health and Mental Hygiene Epi Data Brief, updated January 2014.
  3. Meier B, Marsh B, The Soaring Cost of the Opioid Economy. NY Times, Sunday Review, June 22, 2013.
  4. Rates reflect increases in illicit drug use and misuse/abuse of pharmaceuticals from 2004 to 2011, and increases in adverse reactions from 2005 to 2011, as reported in: Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (2013). Treatment Episode Data Set (TEDS): 2001-2011. State Admissions to Substance Abuse Treatment Services. BHSIS Series S-68, HHS Publication No. (SMA) 14-4832.

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