Recovery-Oriented Addiction Treatment Policy in the Context of the ACA and Opioid Epidemic

Background and Purpose: Given the urgent nature of the opioid epidemic, considerable attention has been placed on the effectiveness of the national addiction treatment system and the accessibility and quality of substance use disorder services. The Affordable Care Act (ACA) has produced dramatic changes in the organization, funding, and accessibility of treatment. Less attention has been placed on the roles of the recovery advocacy movement and recovery-oriented policies that are client-centered and accommodate multiple pathways to wellness in shaping addiction treatment systems transformation. This study uses semi-structured qualitative interviews with policy stakeholders in addiction treatment, recovery advocacy, and healthcare to understand how recovery-oriented policies, ACA reforms, and the opioid epidemic shape the current addiction treatment system.

Methods: Data for this study derive from two projects: (1) the National Drug Abuse Treatment System Survey (NDATSS) State Case Studies and (2) Addiction Recovery Stakeholder Project. In total, 86 interviews were conducted with 107 stakeholders from July 2016 to February 2018. NDATSS State Case Studies were conducted in eight states with stakeholders including administrators from Single State Agencies, Medicaid, and Insurance Exchanges; treatment providers; advocacy groups; and Medicaid Managed Care Organization and Qualified Health Plan representatives—with the objective of understanding states’ addiction treatment policy priorities such as ACA implementation and efforts to address the opioid epidemic. Addiction Recovery Stakeholder Project interviews were conducted with federal, state, and community stakeholders whose work related to addiction recovery-oriented policies and services including government administrators, advocacy groups, community-based organizations, and technical assistance providers—with the objective of understanding how recovery-oriented policies and services have been planned and implemented in the context the current health policy environment. All interviews were conducted via telephone, recorded, and transcribed. Transcripts were analyzed using a theme-based and axial coding approach to understand patterns across stakeholder types. Analytic memos were concurrently developed to interpret results.

Results: Policy stakeholders describe the “perfect storm” of ACA implementation and the opioid epidemic providing opportunity for larger systems transformations including the adoption of recovery-oriented policies and funding of recovery supports. The inclusion of peers, as policy decision-makers and service providers, is a priority in many states and Medicaid financing for recovery supports is a growing consideration. Several perceived barriers exist, including the ACA’s focus on health financing reform not aligning with recovery-oriented principles favoring community-based initiatives and supports. With the urgency of the opioid crisis, policy focus has been on addiction treatment, including medication therapies, which has shed light on the tension between abstinence-based and harm reduction supporters in the recovery advocacy community and the continued limits to recovery support service funding.

Conclusion: Addiction treatment policy stakeholders generally value the importance of services being client-focused but understanding and ownership of recovery-oriented policies and commitment towards recovery-oriented systems transformation vary among stakeholder types. Given these differences in understanding and approach and the urgency of the opioid epidemic, more training and technical assistance could be offered to ensure that services are accessible and client-centered and that policies are recovery-oriented and have positive impacts on clients’ long-term recovery.