The areas that have been the most impacted by the opioid overdose crisis are also the ones with the least access to life-saving care. Groups Recover Together, a leading outpatient provider of opioid use disorder (OUD) treatment, offers care where needs are greatest: in rural counties with high Medicaid enrollment.

We recently connected with Groups’ Chief Outcomes and Medical Officer, Dr. Jacob “Gus” Crothers, to discuss their mission of expanding access to high-quality OUD treatment, the importance of leveraging hybrid care models, the benefits of value-based contracts, and the opportunities that arise when treatment providers are transparent about outcomes.

What are some of the most common barriers addiction treatment providers face today? 

Many barriers come to mind. First, many state regulations are restrictive and out of touch with the evidence. The addiction field is evolving quickly, and state regulations, although well-intentioned, are out of date the minute they are codified. I’m unaware of any other field of medicine (aside from reproductive health) where lawmakers feel so strongly about legislating how medical and clinical professionals should practice. Most treatment providers I know wish regulators and legislators would leave the practice guidelines to the various professional societies (ASAM, National Quality Forum, etc).

Second, different arms of state and federal government have contradictory positions and priorities. There are tons of examples: At the federal level, SAMHSA and the CDC push for low-barrier approaches to treatment while the DEA simultaneously introduces safeguards that run counter to those low-barrier approaches. Each department is just doing its job, but there is no unified order of priorities. At the state level, public health departments and health plans want increased access to care but then make it extremely laborious to obtain licensure and credentialing and navigate the bureaucratic requirements required to expand access.

Third, fee schedules incentivize non-impactful services over impactful ones. Your typical fee schedule reimburses 3x more for a 10-second urine drug screen than for an hour of counseling, peer support, or care coordination. There is a role for toxicology testing, of course, but it won’t give anyone the skills to find or stay in recovery.

How can the pervasive stigma surrounding addiction treatment be effectively addressed and reduced? And why is reducing stigma an important part of improving treatment?

The best weapon against stigma is hope. When people feel that addiction is a death sentence or an incurable situation, then stigma spreads. When people feel hope for recovery and know that effective treatment is available and accessible, stigma naturally fades. The HIV epidemic can teach us a lot here. Although there is still stigma, the emergence of effective antivirals went a long way to reduce the fear and stigma of the diagnosis. In the addiction world, we also have effective medications and great outcomes for those who stick to their treatment, but most of what you hear about in the press is bad news about overdose and death. We need to share more stories of recovery to inspire hope and change the public’s perception of the effectiveness of treatments like MOUD combined with therapy and peer support.

Reducing stigma is critical because the stigma is often as impactful as the condition itself.

A substantial portion of the population who may benefit from addiction treatment is unable to access it due to a lack of health insurance, access to providers, or cultural or even institutional stigma. What approaches would you recommend to ensure everyone knows their options?

At Groups, we did a great deal of education around the 2023 Medicaid redetermination process. We alerted our patients, whom we call members, in each state before the deadlines for signing up for Medicaid in group sessions and through email and SMS. We held webinars to educate members about the process and their health insurance options more broadly. 

We also facilitate partnerships with local health departments, criminal justice departments, and departments of corrections so folks transitioning out of ER or jail/prison systems can access treatment immediately.

Finally, our hybrid online or in-person treatment offerings and flexible group times allow members to access recovery in whatever way suits them best.

As you well know, it takes an average of 10 years from the onset of addiction symptoms before someone seeks out treatment. Do you have recommendations for making earlier initiation of treatment more accessible?

Local community partnerships are necessary to help people access treatment in their moments of need. We also need more education for general practitioners to recognize and treat early symptoms of addiction.

On the policy level, we need to accept that many (possibly most) individuals self-medicate with “street buprenorphine” or “street methadone.” We also need to understand that this behavior can be an important (albeit imperfect) step on the pathway to recovery. If we criminalize this behavior and overemphasize diversion prevention measures through strict regulations that limit access to medication, we may exacerbate this situation by making formal treatment even harder to access. If state and federal regulatory agencies adopted the philosophy that self-medication decreases the use of higher-risk opioids and introduces more people to the benefits of treatment, they would be able to provide aligned, streamlined policies that balance the inherent tension between access to MOUD and diversion prevention of MOUD. Given the size of the OUD treatment gap, it’s my opinion that access to treatment should be the clear priority for the foreseeable future. 

How can addiction treatment providers contribute to better outcomes and experiences for all people with substance use disorders?

Addiction treatment providers can contribute to better outcomes and experiences by being transparent with outcomes data and sharing findings about what’s working. As addiction becomes increasingly complex to address, our field needs to work together to share processes and outcomes so we can all get better results for the individuals and communities we care for.

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‍BIO: 

Dr. Jacob “Gus” Crothers, MD
Chief Outcomes and Medical Officer, Groups Recover Together

Dr. Crothers completed medical school and residency at Tufts University. While there, he designed and implemented a resident-led group visit model for the treatment of opioid use disorder (OUD). The program continues to serve as a national model for integrating addiction medicine education into residency training. Dr. Crothers pursued his addiction medicine board certification at the Yale-affiliated APT Foundation, where many of the original studies of buprenorphine were completed. While continuing to practice part-time, Dr. Crothers served as Medical Director of Grand Rounds and scaled their clinical reach to over 5 million individuals in his five years of tenure. Dr. Crothers has served as the Chief Outcomes and Medical Officer at Groups since 2019.