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Expanding access to coverage Parity in substance use treatment coverage means that cov-
The ACA was designed to reduce uninsurance primarily by erage must be comparable with similar coverage for physical
allowing states to expand their Medicaid programs to people health conditions. For example, under parity, substance use
with incomes up to 138% of Federal Poverty Guidelines (FPG) services cannot have higher cost-sharing, such as higher
and by establishing health insurance marketplaces where co-pays; more-restrictive limitations, such as requirements
people with incomes between 139-400% of FPG could receive for pre-authorization not required for treatment of physical
financial assistance to purchase private health insurance. Since conditions; or limits on the number of services if they werent
Kentucky implemented these provisions in 2014, the number also applied to physical conditions. Additionally, the same 2000
of uninsured Kentuckians has dropped by about 320,000 Kentucky law requiring fully insured large employers to cover
peoplefrom 585,000 in 2012 to 265,000 in 2015.36 substance use treatment also requires that they offer those
benefits in parity with medical service coverage.43
Requiring coverage of substance use treatment
As part of the ACAs health insurance reforms, the ACA requires
that all individual-market and fully insured small-employer
health insurance cover 10 Essential Health Benefits (EHBs),
including mental health and substance use treatment.
3
Table 1: Substance use parity requirements have experienced a shift toward increased treatment of opioid
Coverage Coverage Parity use (heroin and non-heroin opioids) compared to other drugs.
Coverage Type Sub-type Requirement Requirement
Individual Market ACA ACA/MHPAEA Because the increase began a year before ACA implementation
Small ACA ACA/MHPAEA in 2014, this suggests there were probably other factors that
Fully insured ESI
Large KY KY & MHPAEA have contributed to increased treatment. For example, in 2012,
Self-insured employer Kentucky passed a law designed to reduce overprescribing and
Optional MHPAEA
(small or large)
Expansion ACA ACA/MHPAEA
misuse of prescription opioids by requiring providers to use the
Medicaid KASPER system, which may have driven some people to seek
Traditional Optional Optional
The table shows whether substance use coverage or parity is required or optional. If required, the table treatment because they lost access to prescription opioids.45
lists the source of the requirement.
ESI: Employer-Sponsored Insurance; ACA: Affordable Care Act.
However, because increases have continued into 2014 and
ACA/MPHAEA-Affordable Care Act, applying the 2008 Mental Health Parity and Addiction Equity Act. 2015, the ACAs policies to expand access to substance use
KY-Kentuckys 2000 HB268 substance use treatment coverage and parity law.
MHPAEA- 2008 federal Mental Health Parity and Addiction Equity Act treatment also likely played a role.
Access to substance use treatment in Kentucky Medicaid substance use treatment services
Since Kentucky expanded its Medicaid program under the ACA,
Since implementation of the ACA, Kentucky has experienced
the program has covered an increasing number of Kentuckians.
increases in multiple measures of substance use treatment,
By the second quarter of 2016, more than 493,000 Kentuckians
including inpatient admissions for substance use treatment,
were enrolled in the Commonwealths Medicaid expansion.46
substance use treatment services covered by Medicaid, and
Enrollment in the Commonwealths traditional Medicaid pro-
dispensing of the medication buprenorphine, which is used
gram has also increased about 22% from 2014 to 142,500
to treat opioid substance use disorders. There are multiple
non-elderly adults in 2016.
factors that may contribute to these changes in substance use
treatment, including increases in the prevalence of prescrip- Along with the increases in enrollment and coverage of sub-
tion opioid and heroin use, and increases in state funding for stance use treatment services, Kentuckys Medicaid program
substance use treatment.44 However, by reducing the number has paid for an increasing number of substance use services.
of uninsured Kentuckians by more than 300,000 and setting Between the first quarter of 2014 and the second quarter of
new requirements that another 300,000 Kentuckians health 2016, alcohol and drug use treatment services grew by more
insurance cover substance use treatment in parity with physical than 700% for Medicaid expansion beneficiaries, from about
health, the ACA likely has played a role in increased substance 1,500 to more than 11,000 (Figure 10). Substance use treatment
use treatment. services also grew for non-elderly adults enrolled in traditional
Medicaid, increasing by more than 300% in the same time
Inpatient substance use treatment admissions period, from nearly 1,300 to more than 4,000 services.
In the past decade, the number of inpatient substance use
treatment admissions in Kentucky has dropped by nearly Prior research suggests that many of those enrolled in
33%, from a high of more than 24,500 in 2006 to a low of Kentuckys Medicaid expansion were uninsured before 2014,
about 16,500 in 2012 (Figure 8). These data include admis- so many of these substance use treatment services were likely
sions at substance use treatment centers that receive public provided to people with limited access before implementation
funding from the Commonwealth. This drop coincided with of the ACA.47 Additionally, because coverage of substance use
statistically significant increases in overdose death rates in the treatment was limited before 2014, many of the services pro-
state, suggesting it was driven by gaps in access rather than a vided through traditional Medicaid since then may have gone
decline in need for treatment. Since 2012, however, inpatient untreated earlier.
admissions for substance use treatment have risen to about
19,000, an increase of nearly 15%. Unlike Kentucky, most Medication therapy
neighboring states have experienced continued declines in Treatment for substance use disorders differs based on the
inpatient substance use admissions since 2012, with the excep- types of substances used. For opioid use, research supports a
tions of Tennessee and West Virginia. In addition to changes combination of treatments that employs both behavioral thera-
in the number of treatment admissions, these data also show pies, such as counseling, and medication-assisted treatment.48,49
changing trends in the types of substances that Kentuckians
seeking treatment are using. In 2005, opioids were the primary The U.S. Food and Drug Administration has approved three
substance for slightly more than one in 10 Kentucky inpatient medications for use treating opioid use disorders:
admissions (2.0% heroin and 9.6% other opioids) (Figure 9). Methadone is an opioid that can be used to reduce with-
Ten years later, opioids accounted for nearly half of inpatient drawal symptoms and cravings, but it does not typically
treatment admissions in Kentucky (25.6% heroin and 19.6% produce the same euphoria as other opioids. It is only avail-
other opioids). Similar to Kentucky, all of its neighboring states able through specially licensed treatment programs.50
4
Similar to methadone, buprenorphine also is an opioid Conclusion
that can be used to reduce withdrawal symptoms and While increases in drug overdose deaths have recently brought
cravings. Additionally, it does not typically produce the national attention to the issue of opioid use, data show that
same euphoria as other opioids, especially when combined Kentucky was one of the earliest and hardest-hit states in this
with the medication naloxone.51,52 Unlike methadone, it can epidemic. The Commonwealth and its neighboring states have
be prescribed by health care providers outside of special some of the highest rates of opioid painkiller prescriptions in
treatment programs. the country, potentially leading to the misuse of these drugs.
Naltrexone is a non-opioid that works differently than While data show that use of the most commonly prescribed
methadone and buprenorphine. Instead of reducing with- opioid painkiller (hydrocodone) is declining, the state has
drawal, Naltrexone is used to prevent relapse by blocking experienced a recent increase in deaths related to heroin.
the euphoria and causing withdrawal symptoms if a person
takes opioids.53 The ACA was designed to improve access to substance use
treatment in three ways: First, the laws expansion of Medicaid
In one common formulation, known by the brand name eligibility and financial assistance for people to purchase
Suboxone, buprenorphine is combined with the medica- private health coverage are designed to reduce uninsurance.
tion naloxone, which also is used to reverse the toxic effects Second, the law makes substance use treatment an essential
of opioid overdoses. With this combination, Suboxone is health benefit that most insurance plans must cover. Third, the
designed to both reduce the symptoms of withdrawal and law requires health insurance to cover substance use treatment
prevent the feelings of euphoria typically caused by opioids. comparably to treatment for physical health conditions.
Kentucky reports data from the KASPER system on the number Early evidence suggests that the law has played a role in
of doses of buprenorphine dispensed each quarter. Since the expanding access to substance use treatment in Kentucky.
first quarter of 2013, the number of buprenorphine doses Since implementation of the ACA, the Commonwealths
dispensed has increased 73%, from approximately 2 million Medicaid program has provided increasing numbers of sub-
to 3.5 million (Figure 11). Because buprenorphine use was stance use treatment services, and the state has continued to
already increasing in 2013, before implementation of the ACA see increases in inpatient admissions and utilization of certain
in Kentucky, there are likely other factors that have played a medications for treating substance use disorders. However,
role. For example, compared to methadone, buprenorphine while research suggests that access to evidence-based sub-
was only recently approved by the FDA for opioid dependence stance use treatment can play an important role in recovery
treatment and may be replacing methadone treatment in for individuals with substance use disorders, the ACAs focus
some circumstances.54 However, when examined alongside on expanding and improving treatment are not designed as
other data, such as the increases in substance use treatment a complete solution to the long-term rise in opioid-related
services in Medicaid, which covers buprenorphine, these data problems in Kentucky. Substance use is a complex issue, and
suggest that increased coverage of substance use treatment it will be important to consider multiple facets of the problem,
likely plays a role. including potential drivers of prescription opioid use, such as
the prevalence of injuries and disability, and an emphasis on
medication management of pain; and limitations on access
to treatment for substance use, such as shortages of qualified
health professionals and availability of treatment services
in high-need regions. It will be important to consider other
policy options for addressing the rise of opioid use in the
Commonwealth, such as ways to reduce the initiation of pre-
scription painkiller misuse, in addition to ensuring access to
treatment.
5
Substance Use Policy Timeline
2007-2009
Launch of KASPER House Bill 268 Funding for eKASPER Senate Bill 14 Mental Health Parity and
In 1998, Kentucky became In 2000, Kentucky passed a In 2003, the Kentucky General In 2004, the Kentucky Addiction Equity Act
one of the first states to launch law requiring fully-insured Assembly appropriated fund- legislature passed a bill that This 2008 federal law required
a prescription drug monitoring large employers to cover ing to improve the KASPER expanded the ability to share large employers (50+ employ-
program, the Kentucky All substance use treatment in system and allow it to KASPER data with organi- ees) both fully-insured and
Schedule Prescription Elect- parity with physical health, produce real-time reports. zations including law self-insured that offered
ronic Reporting (KASPER) but it did not apply to fully- enforcement entities health insurance with substance
system. The system was insured small employers or and Medicaid. use treatment benefits to cover
created to monitor the use self-insured employers of substance use similarly to
of controlled substances, any size. physical health conditions.
including prescription
opioid painkillers. 2007 - 2009
The Great Recession
Officially from December 2007 to June
2009, the Great Recession was a time
of high job loss and unemployment
that resulted in rising poverty across
the U.S.
Affordable Care Act Passage CDC Declares Prescription House Bill 1 Kentucky Expands Medicaid Senate Bill 192
The 2010 Patient Protection Painkiller Overdose Epidemic In 2012, Kentucky legislat- Program and Adds Substance In 2015, the Kentucky General
and Affordable Care Act (ACA) In 2011, the U.S. Centers for ors passed a bill requiring Use Benefits to Traditional Assembly passed a bill that
made numerous reforms to Disease Control and Prevent- providers to use the KASPER Medicaid Effect funded substance use treat-
the U.S. health insurance ion (CDC) declared an epidem- system when prescribing In 2014, Kentucky implment- ment programs and authorized
market, including allowing ic due to the large increases controlled substances, ed the ACAs option to expand expanded use of naloxone,
states to expand their Medicaid in overdoses compared to the with the goal of reducing its Medicaid program, which drug that treats opioid
programs to non-elderly prior decade. overprescribing and the included substance use treat- overdoses.
childless adults, and requiring misuse of prescription ment coverage for newly
individual market and small- drugs, including opioids. eligible Kentuckians, and it
employer plans to cover also added substance use
substance use treatment. treatment coverage to the
Commowealths traditional
Medicaid program.
6
SUBSTANCE USE IN KENTUCKY
DRUG OVERDOSES
Figure 1: Drug Overdose Deaths Per 100,000 People, Kentucky and U.S., 2000-2014 Figure 3: Kentucky Drug Overdose Deaths
Kentucky
by Drug Type, 2011-2014
30
United States 24.4 Heroin
25 Prescription Opioids
Other Drugs
4.1%
20
14.8
15 6.2
43.1%
10 6.0 2011
5 52.7%
0
12.5%
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
41.9%
Figure 2: Drug Overdose Deaths Per 100,000 People, Kentucky and Neighboring States, 2014 2012
U.S. 45.6%
OH 14.8 *
IL IN 23.7 20.4%
13.2 * 17.8 * 36.5%
WV
33.9 * VA 2013
MO KY 11.8 *
17.6 * 24.4 43.1%
21.5%
TN 31.7%
19.4 *
AR
Kentucky
Neighboring states 2014
12.0 * United States
46.8%
* Statistically significant difference from KY at 95% level.
FL 10
AK
Up to 75 5
75-99
HI 100+ 0
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2
2013 2014 2015 2016
PREVALENCE OF SUBSTANCE USE
Figure 6: Abuse of or Dependence on Illicit Drugs Figure 7: Percentage of Adult Kentuckians Who Knew Someone With Problems
by Age, Kentucky and U.S., 2013/2014 From Heroin and Prescription Drugs, 2015
Kentucky United States
HEROIN Northern
Kentucky
Overall Kentucky rate: 12.6%
All 2.7% 7.9% in Western Kentucky
9.8% in Eastern Kentucky
Greater
Louisville
Ages Greater
16.7% in Greater Louisville Lexington
(12+) 2.6% 13.8% in Greater Lexington
34.9% in Northern Kentucky
Eastern
Western Kentucky
Kentucky
Ages
2.9%
12-17
3.5%*
PRESCRIPTION DRUGS Northern
Kentucky
Overall Kentucky rate: 24.7%
Ages
6.6%* 16.3% in Western Kentucky Greater
Louisville
18-25 24.6% in Greater Lexington
7.0%*
Greater
26.9% in Greater Louisville Lexington
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
0
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2
Figure 9: Kentucky Substance Abuse Treatment Inpatient Admissions 2014 2015 2016
by Drug Type, 2005 and 2015 ACA Expansion Income-based Traditional Medicaid
5.3% 3.5%
Figure 11: Number of Buprenorphine Doses Dispensed in Kentucky,
5.8% 9.7% 2013 Q1-2016 Q2
4.0 3.5M
5.4%
17.1% 3.5
12.8% 3.0
2.5 2.0M
Millions
2.0
Other 18.7%
1.5
Amphetamines
23.3% 1.0
Cocaine
0.5
Marijuana
0
Alcohol Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2
2013 2014 2015 2016
Other Opiates 19.6%
Heroin 41.5%
Sources: See page 11 for figures' source notes.
25.6%
9.6% Opioids
2.0%
2005 2015
References
1 U.S. Centers for Disease Control and Prevention. Prescription Painkiller Overdoses at Epidemic Levels. CDC Newsroom. 2011. Available at: https://www.cdc.gov/
media/releases/2011/p1101_flu_pain_killer_overdose.html
2 U.S. Centers for Disease Control and Prevention. Drug Overdose Deaths in the United States Hit Record Numbers in 2014. 2016. Available at: https://www.cdc.
gov/media/releases/2011/p1101_flu_pain_killer_overdose.html
3 U.S. Centers for Disease Control and Prevention, National Center for Health Statistics. Drug Poisoning Mortality: United States, 1999-2014. 2016. Available at:
https://blogs.cdc.gov/nchs-data-visualization/drug-poisoning-mortality/
4 Tilley, J., & Ingram, V. 2015 Overdose Fatality Report. 2015. Available at: http://odcp.ky.gov/Documents/2015%20KY%20ODCP%20Overdose%20Fatality%20
Report%20Final.pdf
5 Kentucky Cabinet for Health and Family Services. Kentucky All Schedule Prescription Electronic Reporting (KASPER). 2006. Available at: http://chfs.ky.gov/nr/
rdonlyres/7057e43d-e1fd-4552-a902-2793f9b226fc/0/kaspersummaryreportversion2.pdf
6 Richardson, K., & Sebastian, T. Gov. Beshear Signs Landmark Anti-Heroin Bill. 2015. Available at: http://kentucky.gov/Pages/Activity-Stream.
aspx?viewMode=ViewDetailInNewPage&eventID=%7B3B6958E7-F44D-4293-A774-F3670DF3DF24%7D&activityType=PressRelease
7 Richardson, K., & Sebastian, T. Gov. Beshear Announces Plan for Funds to Curb Heroin Use. 2015. Available at: http://kentucky.gov/Pages/Activity-Stream.
aspx?viewMode=ViewDetailInNewPage&eventID=%7B93FE2AF1-C542-4DC3-B8BB-329AC333BB53%7D&activityType=PressRelease
8 Substance Abuse and Mental Health Services Administration. Behavioral Health Barometer: Kentucky, 2015. 2015. Available at: http://www.samhsa.gov/data/
sites/default/files/2015_Kentucky_BHBarometer.pdf
9 Heroin and many prescription painkillers are part of a family of drugs commonly called opioids or opiates. Experts sometimes distinguish between those
opiates that are naturally derived from the opium poppy plant, such as morphine, and opioids that are created synthetically, such as oxycodone and fentanyl.
In this report, we use the term opioid as a general term referring to both naturally derived and synthetic versions.
10 U.S. Centers for Disease Control and Prevention, National Center for Health Statistics. Drug Poisoning Mortality: United States, 1999-2014. 2016. Available at:
https://blogs.cdc.gov/nchs-data-visualization/drug-poisoning-mortality/
11 Tilley, J. & Ingram, V. 2015 Combined Annual Report: Kentucky Office of Drug Control Policy and Kentucky Agency for Substance Abuse Policy. 2016. Available
at: http://odcp.ky.gov/Documents/2015%20Final%20combined%20annual%20report.pdf
12 Canfield, M., Keller, C., Frydrych, L., Ashrafioun, L., Purdy, C., & Blondell, R. Prescription Opioid Use Among Patients Seeking Treatment for Opioid Dependence.
Journal of Addiction Medicine. 2010; 5(1):86. Available at: https://www.ncbi.nlm.nih.gov/pubmed/20543897
13 Muhuri, P., Gfroerer, J. & Davies, C. Associations of Nonmedical Pain Reliever Use and Initiation of Heroin Use in the United States. SAMHSA Center for Behavioral
Health Statistics and Quality Data Review. 2013. Available at: http://www.samhsa.gov/data/sites/default/files/DR006/DR006/nonmedical-pain-reliever-use-2013.
htm#endnote2
14 Cicero, T., & Ellis, M. Abuse-Deterrent Formulations and the Prescription Opioid Abuse Epidemic in the United States: Lessons Learned from OxyContin. Journal
of the American Medical Association Psychiatry. 2015;72(5): 424-30. Available at: https://www.ncbi.nlm.nih.gov/pubmed/25760692
15 Huecker, M. & Shoff, H. The Law of Unintended Consequences: Illicit for Licit Narcotic Substitution. The Western Journal of Emergency Medicine. 2014; 15(4):
561-563. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4100869/#b14-wjem-15-561
16 Cicero, T., Ellis, M., & Harney, J. Shifting Patterns of Prescription Opioid and Heroin Abuse in the United States. The New England Journal of Medicine. 2015;
373(18): 1789-1790. Available at: http://www.nejm.org/doi/pdf/10.1056/NEJMc1505541
17 Keyes, K., Cerda, M., Brady, J., Havens, J., & Galea, S. Understanding the Rural-Urban Differences in Nonmedical Prescription Opioid Use and Abuse in the United
States. The American Journal of Public Health. 2014; 104(2): e52-e59. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3935688/#bib68
18 Canfield, M., Keller, C., Frydrych, L., Ashrafioun, L., Purdy, C., & Blondell, R. Prescription Opioid Use Among Patients Seeking Treatment for
Opioid Dependence. Journal of Addiction Medicine. 2010; 5(1):86. Available at: https://www.ncbi.nlm.nih.gov/pubmed/20543897
19 Leukefeld, C., Walker, R., Havens, J., Leedham, C., & Tolbert, V. What Does the Community Say: Key Informant Perceptions of Rural Prescription
Drug Use. Journal of Drug Issues. 2007;37(3): 503-524. Available at: http://jod.sagepub.com/content/37/3/503.short
20 Keyes, K., Cerda, M., Brady, J., Havens, J., & Galea, S. Understanding the Rural-Urban Differences in Nonmedical Prescription Opioid Use and Abuse in the United
States. The American Journal of Public Health. 2014; 104(2): e52-e59. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3935688/#bib68
21 Leff, M., Stallones, L., Keefe, T., Rosenblatt, R., & Reeds, M. Comparison of Urban And Rural Non-Fatal Injury: The Results of a Statewide Survey.
Injury Prevention. 2003; 9(4): 332-337. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1731041/
22 Hoffman, P., Meier, B., & Council, J. A Comparison of Chronic Pain between an Urban and Rural Population. Journal of Community Health Nursing. 2002; 19(4):
213-224. Available at: https://www.jstor.org/stable/3427701?seq=8#page_scan_tab_contents
23 In addition to opioid painkillers, the KASPER system tracks other controlled substances prescribed by health care providers, including stimulants, such as Ritalin
and Adderall; benzodiazepines, such as Xanax and Valium; and opioids used to treat substance use, such as methadone and buprenorphine.
24 Kentucky Cabinet for Health and Family Services. KASPER Trend and Threshold Analysis Reports. 2016. Available at: http://www.chfs.ky.gov/os/oig/
kaspertrendreports
9
25 Kentucky Cabinet for Health and Family Services. KASPER Trend and Threshold Analysis Reports. 2016. Available at:
http://www.chfs.ky.gov/os/oig/kaspertrendreports
27 Substance Abuse and Mental Health Services Administration. 2011-2012 National Survey on Drug Use and Health National Maps of Prevalence Estimates, by
State. 2012. Available at: http://archive.samhsa.gov/data/NSDUH/2k12State/Maps/NSDUHsaeMaps2012.htm
28 U.S. Department of Justice, Drug Enforcement Administration. Drugs of Abuse. 2015. Available at: https://www.dea.gov/pr/multimedia-library/publications/
drug_of_abuse.pdf
29 State Health Access Data Assistance Center. Study of the Impact of the ACA Implementation in Kentucky: Quarterly Snapshot: April-June 2016. 2016. Available
at: https://www.healthy-ky.org/res/images/resources/Quarterly-Snapshot-6-FINAL.pdf
30 Tilley, J., & Ingram, V. 2015 Overdose Fatality Report. 2015. Available at: http://odcp.ky.gov/Documents/2015%20KY%20ODCP%20Overdose%20Fatality%20
Report%20Final.pdf
31 U.S. Centers for Disease Control and Prevention, National Center for Health Statistics. Drug Poisoning Mortality: United States, 1999-2014. 2016. Available at:
https://blogs.cdc.gov/nchs-data-visualization/drug-poisoning-mortality/
34 The Henry J. Kaiser Family Foundation. Market Share and Enrollment of Largest Three Insurers Individual Market. 2012. Available at: http://kff.org/other/
state-indicator/market-share-and-enrollment-of-largest-three-insurers-individual-market/?currentTimeframe=2&sortModel=%7B%22colId%22:%22Loca-
tion%22,%22sort%22:%22asc%22%7D
35 The Henry J. Kaiser Family Foundation Market Share and Enrollment of Largest Three Insurers - Small Group Market. 2014. Available at: http://kff.org/other/
state-indicator/market-share-and-enrollment-of-largest-three-insurers-small-group-market/?currentTimeframe=0
37 Kentucky General Assembly. Acts of the General Assembly. 2000. Available at: http://www.lrc.ky.gov/statrev/tables/00rs/actsmas.pdf
38 Letter from Commissioner Lisa Lee to Medicaid Providers. March 20, 2015. Available at: http://chfs.ky.gov/NR/rdonlyres/0090158B-A487-4032-87F0-92762FB-
FEEB7/0/ProvLtrPolicyClarification032015.pdf
39 Letter from Commissioner Lisa Lee to Medicaid Providers. March 20, 2015. Available at: http://chfs.ky.gov/NR/rdonlyres/0090158B-A487-4032-87F0-92762FB-
FEEB7/0/ProvLtrPolicyClarification032015.pdf
40 Substance Abuse and Mental Health Services Administration. Medicaid Coverage and Financing of Medications to Treat Alcohol and Opioid Use Disorders.
2014. Available at: http://store.samhsa.gov/shin/content/SMA14-4854/SMA14-4854.pdf
41 Beronio, K., Po, R., Skopec, L., & Glied, S. Affordable Care Act Will Expand Mental Health and Substance Use Disorder Benefits and Parity Protections for 62 Million
Americans. U.S. Department of Health and Human Services, Assistant Secretary for Planning and Evaluation. 2013. Available at: https://aspe.hhs.gov/sites/
default/files/pdf/76591/rb_mental.pdf
42 Morton, J. & Aleman, P. Trends in employer-provided mental health and substance abuse benefits. Monthly Labor Reivew. 2005; 128: 25-35. Available at:
http://www.bls.gov/opub/mlr/2005/04/art3full.pdf
43 Kentucky General Assembly. Acts of the General Assembly. 2000. Available at: http://www.lrc.ky.gov/statrev/tables/00rs/actsmas.pdf
44 Kentucky Office of Drug Control Policy. 2016 Legislative Initiatives. 2016. Available at: http://odcp.ky.gov/Pages/Legislative-Initiatives.aspx
45 Freeman, P., Goodin, A., Troske, S., Talbert, J. Kentucky House Bill 1 Impact Evaluation. 2015. Available at: http://www.chfs.ky.gov/NR/rdonlyres/8D6E-
BE65-D16A-448E-80FF-30BED11EBDEA/0/KentuckyHB1ImpactStudyReport03262015.pdf
46 SHADAC analysis of Kentucky Medicaid data obtained through the Cabinet for Health and Family Services.
47 State Health Access Data Assistance Center. Annual Report: Study of the Impact of the ACA Implementation in Kentucky. 2016. Available at:
https://www.healthy-ky.org/res/images/resources/FINAL-FULL-Annual-Report-2.29-1-.pdf
48 National Institute on Drug Abuse. Principles of Drug Addiction Treatment: A Research-Based Guide. 2012. Available at: https://d14rmgtrwzf5a.cloudfront.net/
sites/default/files/podat_1.pdf
49 Substance Abuse and Mental Health Services Administration. Medication-Assisted Treatment For Opioid Addiction in Opioid Treatment Programs. 2014.
Available at: http://store.samhsa.gov/shin/content//SMA12-4214/SMA12-4214.pdf
50 Mann, C., Frieden, T., Hyde, P., Volkow, N., & Koob, G. Information Bulletin: Medication Assisted Treatment for Substance Use Disorders. 2014. Available at:
https://www.medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-07-11-2014.pdf
51 Whelan, P., & Remski, K. Buprenorphine vs Methadone Treatment: A Review of Evidence in Both Developed and Developing Worlds. Journal of Neurosciences in
Rural Practice. 2012; 3(1): 45-50. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3271614/
10
52 Mann, C., Frieden, T., Hyde, P., Volkow, N., & Koob, G. Information Bulletin: Medication Assisted Treatment for Substance Use Disorders. 2014. Available at:
https://www.medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-07-11-2014.pdf
53 Mann, C., Frieden, T., Hyde, P., Volkow, N., & Koob, G. Information Bulletin: Medication Assisted Treatment for Substance Use Disorders. 2014. Available at:
https://www.medicaid.gov/Federal-Policy-Guidance/Downloads/CIB-07-11-2014.pdf
54 Whelan, P., & Remski, K. Buprenorphine vs Methadone Treatment: A Review of Evidence in Both Developed and Developing Worlds. Journal of Neurosciences in
Rural Practice. 2012; 3(1): 45-50. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3271614/
Figures 1 and 2: U.S. Centers for Disease Control and Prevention, National Center for Health Statistics Drug Poisoning Mortality dataset.
Accessible at: https://blogs.cdc.gov/nchs-data-visualization/drug-poisoning-mortality/
Figure 3: Kentucky Justice and Public Safety Cabinet report of Office of Vital Statistics death certificate files.
Accessible at: http://odcp.ky.gov/Documents/2015%20Final%20combined%20annual%20report.pdf
Figure 4: U.S. Centers for Disease Control and Prevention analysis of IMS National Prescription Audit, 2012.
Accessible at: http://www.cdc.gov/vitalsigns/opioid-prescribing/infographic.html
Figure 5 and 11: Kentucky All Schedule Prescription Electronic Reporting (KASPER) Quarterly Trend Reports.
Accessible at: http://www.chfs.ky.gov/os/oig/kaspertrendreports
Figures 8 and 9: Substance Abuse and Mental Health Services Administration, Treatment Episode Data Set.
Accessible at: http://www.samhsa.gov/data/sites/default/files/2014_Treatment_Episode_Data_Set_State_Admissions_9_15_16.pdfand https://wwwdasis.
samhsa.gov/webt/tedsweb/tab_year.choose_year_web_table?t_state=KY
Figure 10: SHADAC analysis of data provided by the Kentucky Cabinet for Health and Family Services.
Figure 11: Kentucky All Schedule Prescription Electronic Reporting (KASPER) Quarterly Trend Reports.
Accessible at: http://www.chfs.ky.gov/os/oig/kaspertrendreports
11