Building a Substance Use Disorder Ecosystem of Care
- Recent opioid settlements are the second-biggest cash settlement in history
- 70% of the money has to go directly toward opioid remediation
- States must allocate resources to evidence-based, comprehensive care
Opioid settlement money is starting to trickle in, offering hope to Americans battling the ongoing opioid epidemic. Millions have died, and we continue to lose almost 300 people a day to opioid abuse. In one year alone, 40.3 million people reported living with a substance use disorder— that’s twice the population of Texas. The sad truth is that four out of five Americans who need treatment for illicit drug use do not receive it.
How do states ensure that the multi-billion-dollar settlements go toward evidence-based treatment for opioid abuse?
- Access to Medication Assisted Treatment (MAT)
- Evidence-based practices (EBPs) with cultural relevance
- Cognitive Behavioral Therapy (CBT)
- Contingency management behavioral therapy
- Peer support for crisis prevention and recovery
- Linkages to a continuum of care
The opioid settlements are the second-biggest cash settlement in United States history. In November 2022, CVS, Walgreens, and Walmart settled for $13.8 billion. $26 billion will arrive from drug manufacturer Johnson & Johnson and distributors McKesson, AmerisourceBergen, and Cardinal Health. $4.5 billion is expected from Teva pharmaceuticals, $1.7 billion from Mallinckrodt, and much more from other pharmaceutical companies, including the infamous manufacturer of Oxycontin, Purdue Pharma.
Winning opioid lawsuits is a landmark achievement, but the real battle has just begun. This is evident from the tobacco settlements of the nineties. More than 90% of the settlement money was spent on balancing the budget, not on preventing smoking or treating smoking-related medical problems.
The new settlements attempt to correct this issue. They stipulate that 70% of the opioid settlement money must go towards opioid remediation.
Opioid addiction is multi-faceted, and ideally, states must:
- Prevent overdoses
- Reduce drug diversion
- Minimize off-label or illegal opioid use
- Offer treatment and recovery programs for individuals living with substance use disorder
- Expand Medicaid coverage to help low-income, uninsured populations
Now, as more than 30 states are figuring out how to allocate the opioid settlement, several challenges exist.
Substance use disorder is a chronic condition, just like diabetes or hypertension. But many residential/rehab programs focus on only 12 weeks of therapy, which may not fully address the root cause of an individual’s SUD. Programs need to be sustained and comprehensive, and offer all-round care to those who need them.
The good news is that there are proven, evidence-based therapies to combat substance use disorder. States may use them to lower overdoses, prevent relapses, and reduce addiction rates.
Medication-assisted treatment (MAT) is a proven way to treat addiction and substance use. In fact, the World Health Organization (WHO) deems MAT one of the most effective ways to treat opioid dependence with drugs. 
Some common medications used by MAT programs include methadone and buprenorphine. These drugs activate opioid receptors in the brain, reduce cravings and withdrawal symptoms without the ‘euphoria,’ and prevent relapses.
Studies show that MAT programs help:
- Lower opioid use and overdoses
- Improve retention in treatment programs
- Reduce criminal activity and risky behavior
- Strengthen supportive community ties 
The cornerstone of a successful MAT program is its focus on treating the individual as a whole and not just a few symptoms. MAT is most powerful when medication is provided with counseling, behavioral therapy, and social support. [5,6]
EBPs, or evidence-based practices, in healthcare are meant to integrate clinical expertise, the latest research in a field, and patient values and preferences.  No matter how well-intentioned, many EBPs only work well at a community level if they are culturally relevant.
EBPs may fail when they are not adapted to meet people where they are — using their language, beliefs, cultures, and behavior. For example, an EBP may be designed based on a research model like the ‘Western Biomedical Model.’ But this may not work in a community that integrates their spiritual beliefs with medicine unless the program incorporates these beliefs.
Another sensitive topic is mental health counseling. Many cultures have their own deep-rooted stigmas and beliefs regarding mental health and counseling. A program that does not communicate with these communities in the language they are used to may not be successful.
Certified Community Behavioral Health Clinics (CCBHCs) are specially designed to offer mental health and substance use disorder services. This type of mental health support is beneficial. Expanding their reach can go a long way toward helping communities plagued by the opioid crisis.
Opioids like heroin, oxycodone, fentanyl, and morphine alter brain functions. Opioid use can impair working memory (short-term memory), which in turn, can increase impulsivity and risk-taking behavior. Additionally, societal stigmas, strong emotions of shame and guilt, and social conditioning can make it harder to achieve sustained recovery.
Cognitive Behavioral Therapy (CBT) has been proven to help people living with substance use disorder. They help people:
- Identify triggers
- Manage cravings
- Refuse drugs
- Avoid high-risk situations and habits that may lead to self-harm
- Manage stress better
- Improve self-perception
- Enhance self-control
- Offer positive coping mechanisms [8,9]
The biggest advantage of CBT is that while most drug rehabilitation programs typically last 12 weeks, CBT can help create lasting change.
Recovery is about progression, not perfection; contingency management helps motivate people throughout their path to recovery.
Contingency management is a therapy that encourages people toward positive change through rewards. Reports by the Surgeon General, National Academies, the American Society of Addiction Medicine (ASAM), and WHO show that contingency management effectively treats opioid use disorder when used with medication. [8,10]
Contingency management has demonstrated success with:
- Higher abstinence levels
- Greater engagement with treatment
- Improvements in social and personal functioning (versus without contingent management or counseling)
Rewards for positive behavior can include vouchers for milestone achievements. These vouchers can be exchanged for gift cards, movie tickets, privileges like the ability to take medication home, and others.
To run an effective contingent management program, states need the right local-level resources to:
- Offer rewards consistently
- Match rewards with the difficulty level of achievements. For example, 1-year sobriety needs different recognition than 1-month success.
- Personalize rewards based on an individual’s needs and struggles
“The opposite of addiction is not sobriety. The opposite of addiction is human connection” – Johann Hari
A supportive peer group can be incredibly valuable for people with substance use disorder. However, peer support programs around the country face several challenges. Peer support specialists need to train budding peer support providers in basic counseling, recognizing signs of relapse or self-harm, de-escalation techniques, and much more. This type of skill-based training requires a steady stream of resources.
There is also a limited number of peer support groups across communities. While opioid addiction does not discriminate against socioeconomic status, race, sex, age, or other criteria, there are severe inequities in treatment. 90% of African Americans and 92% of Latino individuals with substance use disorder did not receive addiction treatment. [11,12]
As a result, while opioid addiction spreads like wildfire, the availability of peer support groups is limited. States must invest in expanding peer support communities for effective opioid remediation.
Continuum of care refers to all the services an individual needs to reduce substance dependence. This includes emergency services for crises, medical care, in-patient treatment for people with severe addiction issues, outpatient treatment facilities, visits to clinics for continuous monitoring, behavioral therapy, and 24/7 community support.
Additionally, opioid users may require legal help, preventive screening, maternity support, and management of comorbidities. For those who are incarcerated, the transition from prison to regular life can be jarring and fraught with anxiety and challenges. Care during this critical period can help prevent overdoses, self-harm, and substance-abuse-related deaths.
Integrated substance use disorder support like CHESS health can help. CHESS health offers an evidence-based approach to combat substance use disorder. State and local governments, health plans and payers, and behavioral health providers can use CHESS Health to offer support to communities ravaged by the opioid crisis, and prevent its spread.
CHESS Health’s Connections app, in particular offers:
- Digital cognitive behavioral therapy (CBT) trainings
- Online, moderated discussion groups with peers, secure messaging with clinicians, and peer recovery support specialists to provide 24/7 support
- Recovery progress tracking through daily and weekly check-ins, sobriety tracking, and treatment planning functions
- Appointment and medication reminders to improve adherence
- Video, audio, and written content to motivate and educate individuals
To learn more, connect with our team for a demo.
- SAMHSA releases 2020 National Survey on Drug Use and Health | SAMHSA