“There is hope,” reads the statement above the online bio for Richard Soper, MD, a specialist in addiction medicine and addiction psychiatry, but he admits to feeling pessimistic at times given the persistence of ineffective, punitive responses to the opioid epidemic.

Across his decades as a health care leader—as a clinician and in his previous service on the American Society of Addiction Medicine’s (ASAM) board of directors and as ASAM representative on the AMA Opioid Task Force—Dr. Soper has seen and felt progress in medical and policy circles toward understanding and treating substance-use disorder as a chronic condition like asthma, diabetes or hypertension.

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But today, he said, that forward movement sometimes seems elusive given payment and regulatory barriers that interfere with patients’ access to evidence-based care amid an epidemic that kills hundreds of Americans each day.

“Bottom line: The pendulum is swinging back,” said Dr. Soper. “It’s swinging back to judging substance use as a character flaw, not a medical disorder.”

Prior authorization tightens grip

Dr. Soper, addiction medicine chief at the Center for Behavioral Wellness in Nashville, says he’s seeing a tightening up of prior-authorization policies, a return to fail-first requirements, pharmacies refusing to fill prescriptions and law enforcement acting as gatekeepers deciding who gets access to clinical treatment.

“People want treatment; they are literally dying because they can’t get treatment,” he said. “It’s frustrating. It’s fatiguing.”

Other factors shaping Dr. Soper’s attitude include sharp increases in the cost of lifesaving drugs such as naloxone and buprenorphine, an increase in administrative burdens, and Medicaid’s 16-bed size limit on inpatient treatment centers. (As part of his declaration of a public health emergency related to the opioid crisis, President Donald Trump announced that he would grant waivers to states requesting relief from the 16-bed limit.)

Dr. Soper finds insurance plans that fail to cover non-opioid alternatives for pain treatment are particularly challenging for him and his patients.

“It’s not that there are a lack of alternatives; there’s a lack of reimbursement for alternatives,” he said. “It just befuddles me that we allow insurance companies to say, ‘We know physical therapy helps. We’re just not going to pay for it.’”