Bad Medicine: TriCare’s Noncoverage of Evidence-based Opiate Maintenance Therapy

This week, The New York Times gave heart-wrenching accounts of newborn babies enduring opiate drug withdrawal because of their mothers’ addictions. The story provided only one cause for optimism: Both babies and their painkiller-dependent mothers can benefit dramatically from being maintained on medications such as methadone or buprenorphine.

Unless, of course, these mothers were members of a military family, in which case such essential, life-saving care would be denied to them.

The most effective treatment for opiate addiction — long-term buprenorphine or methadone maintenance — is not covered by the Department of Defense’s TRICARE insurance program. The program limits methadone and buprenorphine prescriptions to short-term detoxification, and its regulations state, “Drug maintenance programs when one addictive drug is substituted for another on a maintenance basis (such as methadone substituting for heroin) are not covered.” The premise that prescribing opiate substitutes is no different from uncontrolled opiate abuse goes back to the anti-methadone hysteria of the 1970s. Since then, opiate-substitution treatment has become a staple of modern addiction medicine, particularly with the addition of buprenorphine in 2002. Unlike methadone, burenorphine can be prescribed for maintenance by patients’ regular primary physicians, outside traditional venues of addiction treatment, which had long posed forbidding barriers for many patients.

In fact, many of the best clinical trials of methadone and buprenorphine were conducted in Veterans Health Administration studies with former military personnel as patients. The treatment is so established that in 1997, the National Institutes of Health called for an end to the unnecessary regulation of these medications and for these medications to be included in public and private insurance coverage. These treatments are now standard within the addiction field, are FDA-approved and have been used to treat opiate dependence disorders for several decades. Long-term methadone and buprenorphine maintenance are now available to patients through Medicaid, through many state-funded programs, and, increasingly, through private insurance.

For military families, the military’s obduracy means denial of this treatment altogether. The program provides health insurance to almost 10 million military personnel, retirees, and their families and is at the front lines in addressing many physical and mental health challenges among active-duty and retired military personnel — challenges ranging from post-traumatic stress disorder to the aftereffects of battlefield injuries.

In part, this reflects simple bureaucratic inertia, but the military’s broader discomfort with dealing openly with substance abuse may also play a role. Too little has changed in military culture since Vietnam, when generals asserted that there was little or no drug use among U.S. troops until careful research showed that almost half of personnel had used heroin. Lt. Gen. David Fridovich was publicly supported by military brass when he admitted his painkiller addiction in USA Today earlier this year, but other soldiers muttered under their breath that the military shouldn’t air such dirty laundry.

Congress seems to have learned the lessons of that history: The Department of Defense authorization included a provision for the Institute of Medicine to independently review military addiction policies. A year ago, eight members of Congress sent a letter to Defense Secretary Robert Gates asking for a change in this antiquated regulation. It hasn’t been done.

At an Institute of Medicine panel last week, TRICARE’S restriction on buprenorphine and methadone maintenance was a key topic. (The Institute of Medicine is a nonprofit body that advises policy- and lawmakers). That’s because denial of care is now an especially serious problem. More than 20 percent of soldiers and Marines report they have misused prescription drugs, mostly opiate pain relievers, in the previous year. The army reports that one in three service personnel in its wounded-warriors units is addicted to pain medication. Prescription painkiller abuse is becoming more widespread, partly because of the continued strains on service personnel and their families of multiple deployments and continuing combat operations around the globe. As noted in excellent stories by the Boston Globe’s Joseph Kahn and USA Today’s Gregg Zoroya, some veterans have returned with substance-use disorders arising from the painkillers they needed as a result of battlefield wounds.

Effective addiction treatments relieve the suffering of individual patients and their families, but they also benefit society. Substitution therapies greatly reduce street drug use. Maintenance treatments reduce the likelihood that patients will steal to support their drug addiction, and increase the likelihood that patients will be gainfully employed. These treatments also reduce the probability that patients will contract HIV or spread this infection to others by sharing needles or using other unsafe practices. Maintenance treatments also improve birth outcomes when pregnant women are dependent on heroin or prescription painkillers.

In effect, TRICARE is trying to address the military’s 21st-century addiction epidemics using narrow tools and a narrow mind-set that much of the addiction-medicine field left behind long ago.

Improving access to such effective, evidence-based therapies is a key component of President Obama’s drug policy and of last year’s health-care reform. This is also a key challenge facing our nation’s military. In many areas, TRICARE does an excellent job caring for active-duty and retired military personnel and their families. Yet for no valid reason, it continues to reject the most effective, evidence-based maintenance treatments for opiate addiction.

Confirmation of Dr. Jonathan Woodson as the assistant secretary of defense for health affairs offers a natural opportunity to reform TRICARE’s addiction therapy policies. Outdated regulations should no longer block humane and sensible interventions.

This post first appeared at The American Prospect.

Keith Humphreys is a Professor of Psychiatry at Stanford University and served as Senior Policy Advisor in the White House Office of National Drug Control Policy from 2009-2010.

Harold Pollack is Helen Ross Professor of Social Service Administration at the University of Chicago.