Informational Bulletin

DATE: July 11, 2014

FROM: Cindy Mann, Director 

Center for Medicaid and CHIP Services 

Thomas Frieden, M.D., M.P.H., Director

Centers for Disease Control and Prevention 

Pamela S. Hyde, J.D., Administrator

Substance Abuse and Mental Health Services Administration

Nora D. Volkow, M.D., Director

National Institute on Drug Abuse, National Institutes of Health

George F. Koob, Ph.D., Director

National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health

SUBJECT: Medication Assisted Treatment for Substance Use Disorders

The Center for Medicaid and CHIP Services (CMCS) has issued a series of Informational 

Bulletins on effective practices to identify and treat mental health and substance use disorders 

(SUDs) covered under Medicaid.1,2

 Nearly 12 percent of Medicaid beneficiaries over 18 have a 

SUD, and CMCS is committed to helping States effectively serve these individuals.3 The 

purpose of this Bulletin is to highlight the use of FDA-approved medications in combination 

with evidence-based behavioral therapies, commonly referred to as “Medication Assisted 

Treatment” (MAT), to help persons with SUDs recover in a safe and cost-effective manner. 

Specifically, the Bulletin provides background information about MAT, examples of state-based 

initiatives, and useful resources to help ensure proper delivery of these services.

Background

SUDs impact the lives of millions of Americans in the general population, including individuals 

who are enrolled in the Medicaid program. On average, 105 people die every day as result of a 

drug overdoses.

4 Additionally, 6,748 individuals across the country seek treatment every day in 

 1 Additional Informational Bulletins on behavioral health can be found at http://www.medicaid.gov/Medicaid-CHIPProgram-Information/By-Topics/Benefits/Mental-Health-Services-.html 2 http://www.drugabuse.gov/drugs-abuse 3 http://store.samhsa.gov/shin/content/SMA13-4757/SMA13-4757.pdf, p.10 4 Centers for Disease Control and Prevention. Drug Overdose in the United States: Fact Sheet, Home and 

Recreational Safety, accessed on October 28, 2013 from 

http://www.cdc.gov/homeandrecreationalsafety/overdose/facts.html.
Informational Bulletin – Page 2

the emergency department for misuse or abuse of drugs.5 In 2010, drug overdose was the leading 

cause of injury death6 and caused more deaths than motor vehicle accidents among individuals 

25-64 years old.7 The monetary costs and associated collateral impact to society due to SUDs are 

high. In 2009, health insurance payers spent $24 billion for treating SUDs, of which Medicaid 

accounted for 21 percent of spending.

8 9

 Therefore, understanding how MAT could reduce the 

high rates of SUDs and associated costs of medical and SUD treatment is crucial. The use of 

medications in combination with behavioral therapies to treat SUDs can help reestablish normal 

brain functioning, reduce cravings, and prevent relapse.10 The medications used can manage the 

symptoms of substance use withdrawal that often prompt relapse and allow individuals to utilize 

other treatments, such as behavioral therapy. In addition, these medications and therapies can 

contribute to lowering a person’s risk of contracting HIV or hepatitis C by reducing the potential 

for relapse.11 

Medication assisted treatment is the use of FDA-approved medications in combination with 

evidence-based behavioral therapies to provide a whole-patient approach to treating SUDs. 

There is strong evidence that use of MAT in managing SUDs provides substantial cost savings. 

For instance: 

• Persons with untreated alcohol use disorders use twice as much health care and cost twice as 

much as those with treated alcohol use disorders,12 and medications treating SUDs in 

pregnant women resulted in significantly shorter hospital stays for SUD treatment than drugaddicted pregnant women not receiving MAT (10.0 days vs. 17.5 days).

13

 5 Centers for Disease Control and Prevention. Drug Overdose in the United States: Fact Sheet, Home and 

Recreational Safety, accessed on October 28, 2013 from 

http://www.cdc.gov/homeandrecreationalsafety/overdose/facts.html. 6 “Injury deaths are those caused by acute exposure to physical agents, e.g., mechanical force or energy, heat, 

electricity, chemicals, and ionizing radiation, in amounts or at rates that exceed the threshold of human tolerance.” 

From http://www.cdc.gov/nchs/data/nvsr/nvsr54/nvsr54_10.pdf. 7 Centers for Disease Control and Prevention. Drug Overdose in the United States: Fact Sheet, Home and 

Recreational Safety, accessed on October 28, 2013 from 

http://www.cdc.gov/homeandrecreationalsafety/overdose/facts.html. 8 Substance Abuse and Mental Health Services Administration. National Expenditures for Mental Health Services 

and Substance Abuse Treatment, 1986–2009. HHS Publication No. SMA-13-4740. Rockville, MD: Substance 

Abuse and Mental Health Services Administration, 2013.

9 Substance Abuse and Mental Health Services Administration. National Expenditures for Mental Health Services 

and Substance Abuse Treatment, 1986–2009. HHS Publication No. SMA-13-4740. Rockville, MD: Substance 

Abuse and Mental Health Services Administration, 2013.

10 National Institute on Drug Abuse. (September 2009). InfoFacts: Treatment approaches for drug addiction. 

Retrieved from http://www.drugabuse.gov/sites/default/files/if_treatment_approaches_2009_to_nida_92209.pdf 11 National Institute on Drug Abuse. Principles of Drug Addiction Treatment: A Research Based Guide. Third 

Edition, December 2012, http://www.drugabuse.gov/sites/default/files/podat_1.pdf. 12 Holder, HD. Costs Benefits of Substance Abuse Treatment: An Overview of Results from Alcohol and Drug Abuse. 

J. Mental Health Policy Econ, March, 1998.

13 Jones HE, Kaltenbach K, Heil SH, et al:Neonatal abstinence syndrome aftermethadone or buprenorphine 

exposure. New England Journal of Medicine 363:2320–2331, 2010
Informational Bulletin – Page 3

• For individuals with alcohol dependence, MAT was associated with fewer inpatient 

admissions. Total healthcare costs were 30 percent less for individuals receiving MAT than 

for individuals not receiving MAT.14

• Medical costs decreased by 33 percent for Medicaid patients over three years following their 

engagement in treatment. This included a decline in expenditures in all types of health care 

settings including hospitals, emergency departments, and outpatient centers.15 

Studies have shown that prior to alcoholism treatment initiation, total monthly health care costs 

increased and costs substantially increased during the 6–12 months prior to treatment. Following 

treatment initiation, monthly total medical care costs declined and the overall trend was 

downward. Early intervention in the cycle of addiction for younger individuals with SUDs can 

bring costs down as they have lower pre-treatment costs than older adults with SUDs.

16

Medication Assisted Treatment

This section provides an overview of the medications and therapies that comprise MAT. These 

medications fall into two larger categories: medications to treat opioid use disorders and 

medications to treat alcohol use disorders. 

Several medications have been found effective in treating addiction to opioids, alcohol, and 

nicotine in adults.17 There are currently no FDA-approved medications to treat addiction to 

cannabis, cocaine, or methamphetamine. 

Medications to Treat Opioid Use Disorders

Three medications have received FDA-approval for treating opioid use disorders:

• Methadone prevents opioid withdrawal symptoms and reduces craving by activating opioid 

receptors in the brain. It has a long history of use in treatment of opioid dependence in 

adults, and is available in specially licensed methadone treatment programs. In some States, 

opioid-dependent adolescents between the ages of 16 and 18 may be eligible for methadone 

treatment, provided they have two documented failed treatments of opioid detoxification or 

drug-free treatment and have a written consent for methadone signed by a parent or legal 

guardian.18

• Buprenorphine reduces or eliminates opioid withdrawal symptoms, including drug cravings, 

without producing the euphoria or dangerous side effects of heroin and other opioids. It does 

 14 Baser, o., Chalk, M. Rawson, R. etal. (2001) Alcohol treatment dependence: comprehensive healthcare costs, 

utilization outcomes, and pharmacotherapy persistence. The American Journal of Managed Care, 178(8), S222-

234.

15 Walter, L. et al (2006). Medicaid Chemical Dependency Patients in a Commercial Health Plan, Robert Wood 

Johnson Foundation, Princeton, New Jersey.

16 Holder, HD. Costs Benefits of Substance Abuse Treatment: An Overview of Results from Alcohol and Drug Abuse. 

J. Mental Health Policy Econ, March, 1998.

17 This Bulletin will only focus on medications for treating opioid and alcohol disorders. See 

http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Tobacco.html for detailed 

information about treating nicotine disorders.

18 Marsch, L.A. Treatment of adolescents. In Strain, E.C.; and Stitzer, M.L. (eds.) The Treatment of Opioid 

Dependence. Baltimore, MD: Johns Hopkins University Press, pp. 497–507, 2005.
Informational Bulletin – Page 4

this by both activating and blocking opioid receptors in the brain. It is available for 

sublingual (under-the-tongue) administration both in a stand-alone formulation and in 

combination with another agent called naloxone. The naloxone in the combined formulation 

is included to deter diversion or abuse of the medication by causing a withdrawal reaction if 

it is intravenously injected by individuals physically dependent on opioids.19 Physicians with 

special certification may provide office-based buprenorphine treatment for detoxification 

and/or maintenance therapy.20 It is sometimes prescribed to older adolescents on the basis of 

two research studies indicating its efficacy for this population,21,22 and has proven efficacy to 

treat those 16 years and older. More information can be found here and here.

• Naltrexone is approved for the prevention of relapse in adult patients following complete 

detoxification from opioids. It acts by blocking the brain’s opioid receptors, preventing 

opioid drugs from acting on them and thus blocking the euphoria the user would normally 

feel and/or causing withdrawal if recent opioid use has occurred. It can be taken orally in 

tablets or as a once-monthly injection given in a doctor’s office.23

In addition to the above medications for opioid use disorder treatment, naloxone is a medication 

used to prevent opioid overdose deaths. The medication binds to opioid receptors and can rapidly 

reverse or block the effects of other opioids. In doing so, naloxone can very quickly restore 

normal respiration to a person whose breathing has slowed or stopped as a result of heroin use or 

the misuse of prescription opioids.

Medications to Treat Alcohol Use Disorders

Three medications have received FDA-approval for treating alcohol use disorders:

• Acamprosate reduces symptoms of protracted withdrawal (i.e., insomnia, anxiety, 

restlessness, and dysphoria) by normalizing brain systems disrupted by chronic alcohol 

consumption in adults. It is thought to be more effective in patients with severe alcohol use 

disorders.24

• Disulfiram inhibits an enzyme involved in the metabolism of alcohol, causing an unpleasant 

 19 Subramaniam, G.A.; Warden, D.; Minhajuddin, A.; Fishman, M.J.; Stitzer, M.L.; Adinoff, B.; Trivedi, M.; Weiss, 

R.; Potter, J.; Poole, S.A.; and Woody, G.E. Predictors of abstinence: National Institute on Drug Abuse multisite 

buprenorphine/naloxone treatment trial in opioid-dependent youth. Journal of the American Academy of Child and 

Adolescent Psychiatry 50(11):1120–1128, 2011. 20 Substance Abuse and Mental Health Services Administration. Physician Waiver Qualifications. Available at: 

http://buprenorphine.samhsa.gov/waiver_qualifications.html

21 Woody, G.E.; Poole, S.A.; Subramaniam, G.; Dugosh, K.; Bogenschutz, M.; Abbott, P.; Patkar, A.; Publicker, M.; 

McCain, K.; Potter, J.S.; Forman, R.; Vetter, V.;, McNicholas, L.; Blaine, J.; Lynch, K.G.; and Fudala, P. Extended 

vs short-term buprenorphine-naloxone for treatment of opioid-addicted youth: a randomized trial. Journal of the 

American Medical Association 300(17):2003–2011, 2008. Erratum in Journal of the American Medical Association

301(8):830, 2009.

22 Marsch, L.A.; Bickel, W.K.; Badger, G.J.; Stothart, M.E.; Quesnel, K.J.; Stanger, C.; and Brooklyn, J. 

Comparison of pharmacological treatments for opioid-dependent adolescents: A randomized controlled trial. 

Archives of General Psychiatry 62(10):1157–1164, 2005. 23 Fishman, M.J.; Winstanley, E.L.; Curran, E.; Garrett, S.; and Subramaniam, G. Treatment of opioid dependence in 

adolescents and young adults with extended release naltrexone: Preliminary case-series and feasibility. Addiction

105(9):1669–1676, 2010. 24 http://www.ncbi.nlm.nih.gov/books/NBK64035/
Informational Bulletin – Page 5

reaction (i.e., flushing, nausea, and heart palpitations) if alcohol is consumed after taking the 

medication.25 Compliance can be a problem, but among motivated patients this can be very 

effective.

• Naltrexone blocks receptors involved in the rewarding effects of drinking and in the craving 

for alcohol similarly to how it blocks the effects of opioids. It reduces relapse of heavy 

drinking behavior and is highly effective in some but not all patients, where varied outcomes 

could be due to genetic factors. Naltrexone is available in both oral tablet and long-acting 

injectable preparations.26

Behavioral Therapies

To improve outcomes, the medications discussed above are recommended to be combined with 

behavioral therapies. Research shows that when treating SUDs, a combination of medication and 

behavioral therapies is the most effective. Behavioral therapies help patients engage in the 

treatment process, modify their attitudes and behaviors related to drug and alcohol abuse, and 

increase healthy life skills. These treatments can also enhance the effectiveness of medications 

and help people stay in treatment longer. Treatment programs that combine pharmacological and

behavioral therapy services increase the likelihood of cessation relative to programs without 

these services.27 There are a number of treatment strategies that can be used in combination with 

medications to successfully address SUDs. These include: 

• Individual therapy, group counseling, and family behavior therapy each provide different 

types of support for individuals in recovery from SUDs: 

o Individual therapy can help people learn new skills to maintain a substance-free life, 

address co-occurring mental health issues, address the benefits of utilizing 

prescription medication in treatment, and support individuals to pursue meaningful 

work, school and family goals. 

o Group counseling can help reduce a person’s sense of isolation, provide peer support 

and feedback, and develop social and problem-solving skills. 

o Family behavior therapy provides education, allows family members to express their 

feelings and concerns, and helps secure the family’s support for the person in 

recovery. More information on family behavior therapy can be found here. 

• Cognitive-behavioral therapy seeks to help patients recognize, avoid, and cope with the 

situations in which they are most likely to abuse drugs. More information on cognitivebehavioral therapy can be found here. 

• Motivational enhancement capitalizes on the readiness of individuals to change their 

behavior and enter treatment. More information on motivational enhancement can be found 

at here.

 25 Niederhofer, H.; and Staffen, W. Comparison of disulfiram and placebo in treatment of alcohol dependence of 

adolescents. Drug and Alcohol Review 22(3):295–297, 2003. 26 http://www.ncbi.nlm.nih.gov/books/NBK64042/ 27 Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment 

Programs. Treatment Improvement Protocol (TIP) Series 43. HHS Publication No. (SMA) 12-4214. Rockville, MD: 

Substance Abuse and Mental Health Services Administration, 2005.
Informational Bulletin – Page 6

• Motivational incentives (contingency management) use positive reinforcement to encourage 

abstinence from drugs. More information on motivational incentives can be found here.

Information on other behavioral therapies that can be effective when combined with medications 

for SUD can be found here.

Additional Services 

Screening and Management of Co-occurring Physical Health Issues 

A significant number of individuals receiving MAT for SUDs also have physical health issues. 

Many suffer from serious chronic conditions including: diabetes, asthma, HIV/AIDS, Hepatitis 

C, chronic obstructive pulmonary disease, and severe dental problems. SUDs can cause or 

exacerbate these chronic conditions; many of the health problems associated with substance use 

could be managed alongside MAT programs. Providers offering substance use treatment can 

screen for chronic physical health conditions and provide services onsite (with appropriate 

primary care supports in place) or make referrals to community providers. Studies have found 

that integrating care for individuals with a chronic SUD condition with MAT is cost-effective 

and improves patient care.28

Screening and Management of Co-occurring Mental Health Issues 

A significant number of individuals with a SUD also suffer from a co-occurring mental health 

issue; of 21 million adults aged 18 or older in 2012 with a past year SUD, 40.6 percent also had a 

mental illness.29 Understanding SUDs and mental health issues interact with each other is 

important as a co-occurring disorder can complicate recovery if it is not adequately addressed. 

Rapidly identifying and addressing a co-occurring mental health issue can help improve MAT 

outcomes. Similar to screening and management of co-occurring physical health issues, 

providers offering substance use treatment can screen for mental health issues and provide 

services onsite (with appropriate mental health professional supports in place), along with 

referrals to community provider depending on the illness severity and onsite mental health 

capacity. Screening tools can include the PHQ-9 (Patient Health Questionnaire), the GAD-7 

(Generalized Anxiety Disorder), and the Columbia-Suicide Severity Rating Scale (C-SSRS). For 

more information about screening tools, please visit here. 

Strategies for Managing Medication Assisted Treatment

Many state Medicaid programs utilize processes to help manage the prescribing of addiction 

medications and delivery of evidence-based behavioral therapies. States should ensure that these 

strategies are consistent with the Mental Health Parity and Addiction Equity Act, when 

 28 Center for Substance Abuse Treatment. Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment 

Programs. Treatment Improvement Protocol (TIP) Series 43. HHS Publication No. (SMA) 12-4214. Rockville, MD: 

Substance Abuse and Mental Health Services Administration, 2005

29 Substance Abuse and Mental Health Services Administration, Results from the 2012 National Survey on Drug Use 

and Health: Mental Health Findings, NSDUH Series H-47, HHS Publication No. (SMA) 13-4805. Rockville, MD: 

Substance Abuse and Mental Health Services Administration, 2013.
Informational Bulletin – Page 7

appropriate.

30 Medicaid programs may use the following strategies to support access to this 

benefit. 

• Preferred Drug List (PDL): A state Medicaid agency or contracted managed care 

organization (MCO) designates a medication as a preferred or non-preferred drug, indicating 

those drugs that providers are permitted to prescribe without seeking prior authorization for 

payment coverage. If a drug is not included on the PDL, the provider must obtain approval 

from the state Medicaid agency before the drug will be paid for by the Medicaid agency or 

the agency’s vendor. When a new drug enters the market, it typically has a non-preferred 

status until the drug can be reviewed by the Pharmacy and Therapeutics Committee. Before a 

drug’s review and placement on a preferred drug list, a patient’s prescriber is able to 

prescribe a non-preferred drug through a state’s prior authorization process. This allows 

prescriber flexibility to prescribe the most effective medication while ensuring appropriate 

systems measures are in place to manage the benefit. 

• Prior Authorization: In order for a Medicaid beneficiary to have prescribed medications paid 

for by the Medicaid agency or contracted MCO, the prescriber must obtain permission from 

Medicaid or the agency’s vendor. Each state Medicaid program has different policies in 

place for which medications require prior authorization. Prior authorization criteria should 

reflect evidence-based standards for appropriate medical use of the pharmaceutical in 

question.

• Documentation of Behavioral Therapy: A state Medicaid agency or contracted MCO may 

require evidence that the patient seeking an FDA-approved addiction medication is being 

referred to or has already started to receive behavioral therapy services along with their 

medication. Presently, 20 states and the District of Columbia require documentation of 

behavioral therapy with use of buprenorphine-naloxone and 18 states for the use of injectable 

naltrexone.31 Care should be used to avoid making such requirements unduly burdensome 

such that they effectively limit appropriate access to pharmacotherapy.

• Quantity Limits: A state Medicaid agency or contracted MCO may impose quantity limits on 

certain medications as a way to ensure that it is not overprescribed. As many of these 

medications bind to the same receptors in the brain as other drugs, quantity limits exist to 

prevent overprescribing leading to abuse, overdose or diversion of the medications32. A state 

must have developed standards for applying these limits that are evidenced based and include 

the medical necessity criteria used for determining any limit. A state must have developed 

standards for applying these limits that are evidenced based and include the medical 

necessity criteria used for determining any limit. 

• Duration Limits: A state Medicaid agency or contracted MCO may impose duration limits on 

certain medications as a way to ensure that it is not overprescribed. As many of these 

medications bind to the same receptors in the brain as other drugs, duration limits exist to 

prevent overprescribing leading to abuse, overdose or diversion of the medications. Similar 

 30 http://www.medicaid.gov/Federal-Policy-Guidance/downloads/SHO-13-001.pdf 31 Substance Abuse and Mental Health Services Administration. (2013). Medicaid Coverage And Financing Of 

Medications To Treat Substance Use Disorders. Rockville, MD: Center for Substance Abuse Treatment, Substance 

Abuse and Mental Health Services Administration. 32 Quantity limits should comport with MHPAEA requirements sets forth in statute and policies regarding CMS to 

ensure appropriate access to benefits.
Informational Bulletin – Page 8

to quantity limits, states must have the necessary evidence and medical necessity criteria for 

imposing limits on the duration of these medications. Setting limits on the length of 

medication-assisted treatment can affect retention and outcomes. Medication-assisted 

treatment should be continued as long as the treatment is medically necessary and the 

individual participates in treatment as set forth in their treatment plan. 33

• Provider Selection and Credentialing: Both state and federal regulations establish guidance

regarding who can provide certain prescription medications and in what setting the 

medication can be administered. Any additional stipulations imposed by state Medicaid 

agencies or contracted MCO should avoid excluding primary care providers and care sites 

where comorbid problems may be managed concurrently when otherwise established 

guidance regarding access and safety are satisfied.

• Drug Utilization Reviews: The drug utilization review (DUR) process occurs prospectively 

and retrospectively of a drug being dispensed. The prospective DUR, which occurs prior to a 

drug being dispensed, may involve a Medicaid agency or its claims processor reviewing 

documentation of claims against a clinical database containing an individual’s prior 

pharmacy history to determine whether any problems or issues exist, including duplication of 

prescriptions and incompatibility with other prescriptions. If an issue is found, a review of 

the enrollee’s care, prescriber’s practice or pharmacy practice can occur, along with limits 

placed on a prescription being filled until the issue is resolved. The retrospective DUR is a 

review process occurring after the drug has been dispensed. It may include a review of 

individual patient profiles for follow-up and intervention. It may also involve a review of the 

aggregate claims data to identify patterns in prescribing whether it be underutilization or 

overutilization, from which the Medicaid agency or its designee can make recommendations 

for future prescribing. There is no established stepped approach to therapy with any of the 

pharmaceuticals discussed here. The pharmacotherapy must be matched to the needs of the 

individual at the time of the assessment.

• Patient Review and Restriction Programs: If a Medicaid agency finds that a beneficiary has 

utilized Medicaid services at a frequency or amount that may not be medically necessary, as 

determined in accordance with utilization guidelines established by the State, the agency may 

restrict that beneficiary for a reasonable period of time to obtain Medicaid services from 

designated providers only. Some States have implemented Patient Review and Restriction 

programs (PRRs) to address possible patient overuse of physician services and prescription 

drugs. Medicaid programs may only impose restrictions if they give patients notice and an 

opportunity for a hearing, ensure that restricted patients still have reasonable access to 

Medicaid services, and exempt emergency services from the restriction.

State-Based Initiatives

MAT can be an effective strategy for addressing the needs of individuals who have a SUD. 

Policies regarding MAT and implementation practices that combine these medications with 

supportive counseling vary considerably across states. Many states are experimenting with 

 33 Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Rockville (MD): Substance 

Abuse and Mental Health Services Administration (US); 2005. Treatment Improvement Protocol (TIP) Series, No. 

43. http://www.ncbi.nlm.nih.gov/books/NBK64164/
Informational Bulletin – Page 9

different strategies to encourage the implementation and availability of MAT. States that have 

implemented strong evidence-based MAT programs tend to support financing and care 

provisions structures that provide pharmacological, medical, counseling and other supports 

within an integrated physical health and behavioral health system. The examples below 

highlight select state-based efforts to implement MAT.

Vermont

In Vermont, MAT for opioid addiction was implemented for methadone and buprenorphine in 

2002. Vermont incentivized implementation of buprenorphine by funding online training for 

physicians to obtain the additional DEA registration (also known as the “X-number”) to 

prescribe buprenorphine and other technical assistance to physicians. To improve the 

coordination of care for individuals struggling with opioid addiction issues and to facilitate MAT 

use, Vermont has developed a proposal for a health home model, called the Hub and Spoke 

model. 

The Hub and Spoke model consists of two levels of care, with the patients’ needs determining 

the appropriate level. Individuals with complex addictions and co-occurring substance abuse and 

mental health conditions will receive care through a Hub, or specialty treatment center 

responsible for coordinating care across the health and substance abuse treatment systems of 

care. Less clinically complex patients who require MAT but not methadone will receive 

treatment within the Spoke system. A Spoke is an integrated care system comprised of a 

prescribing physician and collaborating health and addictions professionals who provide 

assistance with obtaining a medical home, monitor adherence to treatment, coordinate access to 

recovery supports, and provide counseling, contingency management, and case management 

services. This model is incorporated in Vermont’s 1115 Waiver program and in their proposed 

2703 health home program. Additional information on Vermont’s MAT approach can be found 

here and here.

Rhode Island

In Rhode Island, the state received approval for their 2703 person-centered health home 

provision focused on opioid dependent Medicaid beneficiaries who are currently receiving or 

who meet criteria for MAT. Working with opioid treatment providers (OTPs) as the health home 

providers allows for heightened contact between medical and clinical professionals who have ongoing therapeutic relationships with patients. This will enable providers to use existing and 

enhanced resources to improve the health of patients and decrease inadequate/ineffective medical 

care. Each individual is assigned to a team, which may be specialized to their specific healthcare 

needs. Patients have an assigned nurse and case manager to monitor their healthcare needs; assist 

with referral, scheduling, and transportation to medical and other appointments; develop a health 

plan; provide health promotion and wellness activities; facilitate transitions between levels of 

care; support recovery needs; and identify and provide resources that support wellness and 

recovery. The Rhode Island health home model aims to provide a mechanism to support 

stronger, formalized relationships between OTPs and community healthcare providers. 

Additional information on Rhode Island’s MAT approach can be found here.
Informational Bulletin – Page 10

Texas

Since February of 2011, qualified physicians and Chemical Dependency Treatment Facilities are 

able to bill the Texas Medicaid and Healthcare Partnership for MAT. Texas legislation clearly 

articulated that medication should be available to manage withdrawal/intoxication from all 

classes of abusable drugs. To this end, the state has established procedure codes and modifiers 

that provide guidance to MAT providers. Additional information regarding Texas’ approach to 

covering MAT in Medicaid can be found here and here. 

Ohio

In July of 2012, the Ohio Medicaid program began to cover MAT as a component of its 

Medicaid program. Similar to Texas, Ohio’s Medicaid program allows certain facilities and 

qualified practitioners to provide MAT. In addition, the Ohio Department of Mental Health and 

Addiction Services developed protocols for MAT going beyond use of methadone, with specific 

standards of practice for buprenorphine and buprenorphine/naloxone products. Additional 

information regarding Ohio’s coverage of MAT can be found here and here.

Resources

Opioid Treatment Program Directory

http://dpt2.samhsa.gov/treatment/directory.aspx

Medication-Assisted Treatment For Opioid Addiction in Opioid Treatment Programs Inservice 

Training

Provides a training program for substance abuse treatment counselors and other clinicians on 

medication-assisted treatment for opioid addiction. Covers basic principles, best practices, 

history, and regulation. Includes scripted modules and handouts.

http://store.samhsa.gov/product/Medication-Assisted-Treatment-for-Opioid-Addiction-in-OpioidTreatment-Programs/SMA09-4341

Opioid Overdose Prevention Toolkit

Equips communities and local governments with material to develop policies and practices to 

help prevent opioid-related overdoses and deaths. Addresses issues for first responders, treatment 

providers, and those recovering from opioid overdose.

http://store.samhsa.gov/product/SMA13-4742?WT.mc_id=EB_20130828_SMA13-4742

TAP 30: Buprenorphine: A Guide for Nurses

Gives nurses information about buprenorphine for medication-assisted treatment of addiction to 

opioids and guidelines for working with physicians to provide office-based screening, 

assessment, supervised withdrawal (detoxification), and maintenance treatment. 
Informational Bulletin – Page 11

http://store.samhsa.gov/product/TAP-30-Buprenorphine-A-Guide-for-Nurses/SMA09-4376

TIP 40: Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction

Practice guidelines help physicians make decisions about using buprenorphine to treat opioid 

addiction. Includes information on patient assessment; protocols for opioid withdrawal; and the 

treatment of pregnant women, teens, and polysubstance users.

http://store.samhsa.gov/product/TIP-40-Clinical-Guidelines-for-the-Use-of-Buprenorphine-in-theTreatment-of-Opioid-Addiction/SMA07-3939

TIP 43: Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs

Gives a detailed description of medication-assisted treatment for addiction to opioids, including 

comprehensive maintenance treatment, detoxification, and medically supervised withdrawal. 

Discusses screening, assessment, and administrative and ethical issues.

http://store.samhsa.gov/product/TIP-43-Medication-Assisted-Treatment-for-Opioid-Addiction-in-OpioidTreatment-Programs/SMA12-4214

TIP 49: Incorporating Alcohol Pharmacotherapies Into Medical Practice

Provides clinical practice guidelines for using four medications in the medication-assisted 

treatment of alcoholism and alcohol abuse: acamprosate, disulfiram, oral naltrexone, and 

extended-release injectable naltrexone. Also discusses patient management.

http://store.samhsa.gov/product/TIP-49-Incorporating-Alcohol-Pharmacotherapies-Into-MedicalPractice/SMA13-4380

General Principles for the Use of Pharmacological Agents to Treat Individuals with CoOccurring Mental and Substance Use Disorders

Offers general principles to assist in the planning, delivery, and evaluation of pharmacologic 

approaches to support the recovery of individuals with co-occurring disorders. Covers 

engagement, screening, assessment, treatment planning, and continuity of care.

http://store.samhsa.gov/product/General-Principles-for-the-Use-of-Pharmacological-Agents-to-TreatIndividuals-with-Co-Occurring-Mental-and-Substance-Use-Disorders/SMA12-

4689?WT.ac=EB_20120607_SMA12-4689

Principles of Drug Addiction Treatment: A Research-based Guide (3rd Edition)

Presents research-based principles of addiction treatment for a variety of drugs, including 

nicotine, alcohol, and illicit and prescription drugs, that can inform drug treatment programs and 

services.

http://www.drugabuse.gov/publications/principles-drug-addiction-treatment
Informational Bulletin – Page 12

Principles of Adolescent Substance Use Disorders: A Research-Based Guide

Presents research-based principles of adolescent SUD treatment; covers treatment for a variety of 

drugs including, illicit and prescription drugs, alcohol, and tobacco; presents settings and 

evidence-based approaches unique to treating adolescents.

http://www.drugabuse.gov/publications/principles-adolescent-substance-use-disorder-treatment-researchbased-guide