In recent years, peer recovery support services have become an accepted part of the treatment of substance use disorders, providing a more extensive array of services than typically associated with mutual support groups. Peer providers may help consumers set recovery goals, develop a plan, and work toward and maintain recovery. In this literature review, the last in the Assessing the Evidence Base (AEB) Series, the authors review the evidence supporting peer recovery support services, noting that more research is needed to distinguish the effects of peer recovery support from other recovery support activities.

Residential treatment for substance use disorders shows value and merits ongoing consideration by policy makers for inclusion as a covered benefit in public and commercially funded plans. However, research with greater specificity and consistency is needed.

Objective In 2008 the federal Mental Health Parity and Addiction Equity Act (MHPAEA) passed, prohibiting U.S. health plans from subjecting mental health and substance use disorder (behavioral health) coverage to more restrictive limitations than those applied to general medical care. This require d some health plans to make changes in coverage and management of services. The aim of this study was to examine private health plans’ early responses to MHPAEA (after its 2010 implementation), in terms of both the intended and unintended effects. Methods Data were from a nationally representative survey of commercial health plans regarding the 2010 benefit year and the preparity 2009 benefit year (weighted N=8,431 products; 89% response rate). Results Annual limits specific to behavioral health care were virtually eliminated between 2009 and 2010. Prevalence of behavioral health coverage was unchanged, and copayments for both behavioral and general medical services increased slightly. Prior authorization requirements for specialty medical and behavioral health outpatient services continued to decline, and the proportion of products reporting strict continuing review requirements increased slightly. Contrary to expectations, plans did not make significant changes in contracting arrangements for behavioral health services, and 80% reported an increase in size of their behavioral health provider network. Conclusions The law had the intended effect of eliminating quantitative limitations that applied only to behavioral health care without unintended consequences such as eliminating behavioral health coverage. Plan decisions may also reflect other factors, including anticipation of the 2010 regulations and a continuation of trends away from requiring prior authorization.

Office-based pharmacotherapy offers a promising path to improved access to addictions treatment, but prescribing has expanded little beyond the addiction specialist community.

Recovery housing appears to be an important component in the continuum of care for some individuals. However, replication of study findings with greater specificity and in more settings is needed.

These data provide a deeper understanding of pain diagnoses and burden of pain among active duty soldiers. A substantial proportion of soldiers with pain diagnoses were seen for pain self-reported as only mild, or that did not result in significant restrictions in military duty limitations. However, given the prevalence of multiple pain diagnoses and common reports of moderate or severe pain and long duration, complex interventions may be required to minimize the effect of pain on force readiness. This encounters-based analysis is likely an underestimate of presence of pain, and does not include contextual factors that could better describe the true effect of pain among this population.

Health plans have implemented cost-sharing and administrative controls to constrain escalating prescription expenditures. These policies may impact physicians' prescribing and patients' use of these medications. Important clinical advances in the pharmacologic treatment of addiction highlight the need to examine how pharmacy benefits consider medications to treat substance dependence. The extent of restrictions influencing availability of these medications to consumers is unknown. We use nationally representative survey data to examine the extent and stringency of private health plans' management of naltrexone and disulfiram for alcohol dependence, and buprenorphine for opiate dependence. Thirty-one percent of insurance products excluded buprenorphine from formularies, while 55% placed it on the highest cost-sharing tier. Generic naltrexone is the only substance dependence medication that is both rarely excluded from formularies and usually placed on a lower cost-sharing tier. These findings demonstrate that pharmacy benefits have an impact on access to medications to treat substance abuse.

The federal Opioid State Targeted Response (Opioid STR) grants provided funding to each state to ramp up the range of responses to reverse the ongoing opioid crisis in the U.S. Washington State used these funds to develop and implement an integrated care model to expand access to medication treatment and reduce unmet need for people with opioid use disorders (OUD), regardless of how they enter the treatment system. This paper examines the design, early implementation and results of the Washington State Hub and Spoke Model. Methods: Descriptive data were gathered from key informants, document review, and aggregate data reported by hubs and spokes to Washington State's Opioid STR team. Results: The Washington State Hub and Spoke Model reflects a flexible approach that incorporates primary care and substance use treatment programs, as well as outreach, referral and social service organizations, and a nurse care manager. Hubs could be any type of program that had the required expertise and capacity to lead their network in medication treatment for OUD, including all three FDA-approved medications. Six hub-spoke networks were funded, with 8 unique agencies on average, and multiple sites. About 150 prescribers are in these networks (25 on average). In the first 18 months, nearly 5000 people were inducted onto OUD medication treatment: 73% on buprenorphine, 19% on methadone, and 9% on naltrexone. Conclusions: The Washington State Hub and Spoke Model built on prior approaches to improve the delivery system for OUD medication treatment and support services, by increasing integration of care, ensuring "no wrong door," engaging with community agencies, and supporting providers who are offering medication treatment. It used essential elements from existing integrated care OUD treatment models, but allowed for organic restructuring to meet the population needs within a community. To date, there have been challenges and successes, but with this approach, Washington State has provided medication treatment for OUD to nearly 5000 people. Sustainability efforts are underway. In the face of the ongoing opioid crisis, it remains essential to develop, implement and evaluate novel models, such as Washington's Hub and Spoke approach, to improve treatment access and increase capacity.