Acupuncture: Safety [120]
The World Health Organization (WHO) reports that acupuncture can be considered inherently safe in the hands of well-trained practitioners; however without proper training, acupuncture can lead to serious, sometimes life-threatening complications (as in the case of organ puncture and hepatitis transmission). Large-scale clinical trials of over 2 million acupuncture treatments found only 8.6% adverse events in which less than 1% reported as serious.[3,10] All of the reported infections and 68% of the serious adverse events occurred in village clinics or rural hospitals in China where clinical skill disparities exist between rural and urban hospital acupuncturists because rural acupuncturists rarely receive formal education in acupuncture medical colleges.[10] In the United States, ACCAOM accredited curriculum includes indications and contraindications for acupuncture point selection (single and combination), anatomy and needle insertion depth, as well as evidence-based clean needle technique practice, as necessary to protect the public.
Increased cost of care from Opioid Epidemic.
In contrast to acupuncture’s safety record, deaths related to opioid misuse have reached epidemic levels, the financial impact of the epidemic is at crisis levels, and incurred expenses rise from general pharmacological-care side effects, medical errors, and failed surgical procedures. In fact, two Oklahoma citizens die daily from opioid overdose according to the Center for Disease Control: 725 deaths in 2015, 777 in 2014, and 790 in 2013 which 12 is an increase from 662 deaths in 2010, and 127 deaths in 1999.113 Oklahoma, has the highest prevalence of prescription painkiller abuse in the country and more overdose deaths involve hydrocodone than methamphetamines, heroin, and cocaine combined.113 The national epidemic is costing public and private insurers more than $72 billion annually.13 Additionally 30% of patients with chronic pain conditions also suffer from clinical depression, and nearly 50% of patients who suffer from both anxiety and depression disorders have a co-morbid pain diagnosis, which shows the compounding concerns of opioid use for pain.13 The impact of the epidemic is far reaching, including but not limited to families, incarcerated persons, children, and disabled. See Appendix C, D, F.
Emergency room misuse.
The percentage of emergency department (ED) visits associated with pharmaceutical misuse or abuse increased 114% between 2004 and 2011. Opioid overuse not only increases ED visits but leads to increased avoidable services and costs that may actually harm beneficiaries. In fact, Medicaid recipients have a higher rate of ED visits and hospitalization for poisoning by opioids and related narcotics than individuals with other forms of insurance or the uninsured.13
Acupuncture Regulation Impact
Accepted method of care. Acupuncture is a standardized, licensed and regulated health care profession1 that conducts technical, master’s, and doctoral level training in U.S. Department of Education recognized accredited institutions.2 A Licensed Acupuncturist (or comparable state designated title) provides safe, low cost, and comparatively effective health care services.3,4 Forty seven states and the District of Columbia have developed licensure laws and regulation for acupuncturists. Alabama, Oklahoma, and South Dakota are without acupuncturist regulations. See Appendix B.
Recognized as a distinct occupation.
In 2016, a recommendation to establish a new code for this distinct occupation in 2018, “29-1291 Acupuncturists,” was made by the Bureau of Labor and Statistics (BLS) Standard Occupational Classification Policy Committee (SOCPC).1 Projected growth of the profession through 2024 is greater than average (13%), with 17,700 new job positions predicted.8 Since 2009, “Acupuncturists” have been recognized by the Bureau of Labor and Statistics’ O-Net Online as an emerging profession and assigned a Standard Occupational Code (SOC) of 29-1199.01 under “Health Diagnosing and Treating Practitioners, All Others.”7,8
Congressional Support.
The National Institutes of Health (NIH) affirms the validity and promise of acupuncture by the 1997 NIH Consensus Conference, concluding that there is sufficient evidence to expand its use into conventional medicine, encouraging further studies of its physiology, and urging broader public access through insurance companies, federal and state health insurance programs, including Medicare and Medicaid, and other third party payers.67 For twenty years thereafter, rigorous scientific investigation of acupuncture continues through the NIH National Center for Complementary and Integrative Medicine.68
Acupuncture efficacy.
An expanding body of evidence confirms that acupuncture stimulates the body’s natural healing abilities, promoting physical and emotional well-being.15,18 Through evidence review in 2003, the World Health Organization determined that acupuncture is an effective treatment for 28 named conditions and 79 potential conditions.78 See Appendix A.
Utilization.[120]
Acupuncture utilization is rapidly increasing in the United States. Nearly 100 primary and specialty physician practice guidelines recommend acupuncture as a non-pharmacological approach to patient care. An integral component of the “collaborative
model of care”, thousands of licensed acupuncturists are independently practicing acupuncture in hundreds of clinics, hospitals, universities, military and veterans’ care facilities. An increasing number of insurance companies are reimbursing for acupuncture, Medicaid in some states covers acupuncture for specific conditions, and the military has long utilized acupuncture for conditions from PTSD to brain injury. 61 See Appendix C, D, E, F.
Acupuncture for pain and mental health.[120]
Effective as a non-pharmacological approach to pain management and compounded by a holistic approach to comorbidity care, tens of thousands of licensed acupuncturists effectively treat patients with acute and chronic pain across the nation while now thousands of hospitals and clinics employ acupuncturists to improve outcomes and reduce costs. Acupuncture has recently been found to be as effective as counseling, and both more effective than usual care, for reducing symptoms of depression, a common co-morbid condition found in patients managing chronic pain.50 See Appendix D, E, F.
The opioid epidemic & auricular (ear) acupuncture.
To improve behavioral health program retention, reduce withdrawal symptoms, enhance recovery outcomes, and decrease costs, a standardized auricular (ear) acupuncture protocol has gained favor throughout the nation for use as an adjunctive treatment by a variety of health care and criminal justice workers within a variety of comprehensive programs.28,32,33,36,39,92,94 The National Acupuncture Detoxification Association (NADA) has trained over 25,00029 professionals to use the NADA 5-point auricular acupuncture protocol to treat individuals of all ages recovering from substance use disorder, trauma, and other behavioral health issues.28 Over 628 licensed addiction treatment facilities utilize NADA30 and inclusion within comprehensive criminal justice programs has reduced inmate expense and re-incarceration rates for two decades.33,36,37,39,40,42,103 See Appendix D.
Emergency department savings.
Expanding acupuncture utilization in the ED provides a non-pharmacological option to citizens, reduces drug-seeking behavior, and can reduce costs. A clinically relevant “real-world” 2016 study published in the Journal of Emergency Medicine, finds acupuncture to be more effective than intravenous morphine in the ED, when individualized patient-centered plans are administered by licensed acupuncturists.55 Newly available preliminary statistical outcomes are available from Rhode Island’s state Medicaid Section 1115 Demonstration, a pilot designed to cut costs by reducing member emergency room visits; members with chronic pain receive acupuncture and other complementary services within a comprehensive pain management plan. Outcomes are demonstrating that on average per year, these members have: decreased ER visits by 61%, reduced opioid prescriptions by 86%, lowered prescription totals by 63%, and reduced annual costs per member by 27%. 90,92-94
Other cost benefits.
Overall savings resulting from acupuncture inclusion include decreased requirements for surgical procedures, shorter in-patient hospital stays, reduction in pharmacologic prescriptions, reduction of days lost at work, and reduction of necessary medical review appointments. See Appendix C, D, E, F.
Call for Inclusive Collaborative Action
Abusers of opioids have been found to have total health care costs eight times that of non-abusers, placing a significant economic and resource burden on providers and health systems. Dr. Shellie Keast, from the University of Oklahoma’s College of Pharmacy, which supports SoonerCare pharmacy operations, believes that the Medicaid agency is ideally positioned to leverage collaborative efforts with other state agencies in the development of documents and best practice guidelines for intrastate work.13 Appendix F. Oklahoma’s plan in 2012, Reducing Prescription Drug Abuse in Oklahoma, calls for lowering the states’ unintentional overdose deaths by 15% will aim for “action to ensure the proper and appropriate use of opioids to treat pain and improve patient’s quality of life while reducing the risk of abuse and diversion… through various partnerships…is imperative.”113 Governor Fallin emphasizes: “Immediate action must be taken in order to reverse this rapidly growing epidemic, which has become one of the most serious public health and safety threats to our state… a broad-based coordination between law enforcement, prevention and treatment providers, the Oklahoma Legislature, community organizations, tribes, and health care is required… It is unacceptable for any Oklahoman to lose their life to this preventable problem.”113
Appendix A: Physiological Effects of Acupuncture Attention through research has been focused upon the following modern theories to explore acupuncture’s effects upon the body:
· Stimulation of the hypothalamus and pituitary gland
· Change in secretion of neurotransmitters and neurohormones
· Conduction of electromagnetic signals
· Activation of the body’s natural opioid secretion system
Most recently, twenty first century state-of-the-art technological advances allow observation of physiological effects of acupuncture. For example-
· fMRI scans detect reduction in pain sensation within the brain after acupuncture.19
· Ultrasound Color Doppler Imaging detects increased blood flow of peripheral, mesenteric, and retrobulbar arteries.20
· PET-CT study concludes acupuncture induces different levels of cerebral glucose metabolism in pain-related brain regions.21
· Demonstrated autonomic nerve function control and modulation of neurotransmitters in related brain regions are observed.22
· Blood panels measure immune system regulatory function, increased humoral/cellular immunity, and NK cell activity.23
· Synchrontron radiation based Dark Field Image method finds accumulation of miro-vessels in acupoints.24
· fMRI scans detect bilateral activation of insula and adjacent operculum; correlation to increased saliva production.25
· Synchrontron x-ray fluorescence analysis detects concentrations of Ca, Fe, Cu and Zn in and around acupuncture points.26
· Acupuncture’s role in triggering the release of adenosine, a neuromodulator with anti-nociceptive properties, is confirmed.14
· Tonometery, electrocardiogram, phtoplethysmogram, ultrasonography, and cardiographyconfirm acupuncture effects upon peripheral pulse amplitudes, wave, blood flow velocity, and sympathetic nerve activity.27
A 2013 study of acupuncture effect upon central autonomic regulation concludes: “Acupuncture has clinical efficacy on various autonomic nerve-related disorders, such as cardiovascular diseases, epilepsy, anxiety and nervousness, circadian rhythm disorders, polycystic ovary syndrome (PCOS) and subfertility. An increasing number of studies have demonstrated that acupuncture can control autonomic nerve system (ANS) functions including blood pressure, pupil size, skin conductance, skin temperature, muscle sympathetic nerve activities, heart rate and/or pulse rate, and heart rate variability. Emerging evidence indicates that acupuncture treatment not only activates distinct brain regions in different kinds of diseases caused by imbalance between the sympathetic and parasympathetic activities, but also modulates adaptive neurotransmitter in related brain regions to alleviate autonomic response.”22
Appendix B: State Licensure and Regulation The National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) has provided more than 21,000 certificates for acupuncturists applying for licensure in 46 states and the District of Columbia since 1982.6 NCCAOM Diplomates have passed a set of certification examinations which assure that the knowledge, skills, and abilities necessary for safe and effective entry-level practice of acupuncture have been demonstrated. The NCCAOM is the only national organization in the United States whose certification programs are accredited for the purpose of qualifying candidates for state licensure status. The Institute for Credentialing Excellence (ICE)’s National Commission on Certifying Agencies (NCCA) recognizes the NCCAOM national certification programs in Acupuncture, Chinese Herbology, and Oriental Medicine as having achieved national accreditation by meeting the NCCA’s 21 standards.6 When providing services in health system and hospital facilities within the 45 regulated states, licensed acupuncturists are credentialed as “Licensed Independent Practitioners” (L.I.P.) to be in compliance with The Joint Commission quality assurance standard for healthcare system accreditation.5 The Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM) is recognized by the U.S. Department of Education as the accreditor for Acupuncture and Oriental Medicine (AOM) educational programs in the United States. ACAOM accredited institutions and programs are shaped by a rigorous peer review process. Over sixty institutions throughout the country have achieved the standards of educational excellence by meeting ACAOM’s accreditation requirements.2 The Oklahoma Board of Private Vocational Schools (OBPV) provides licensure and oversight of two acupuncture training schools.9 The existing grass-roots acupuncture education network may contribute to bridge-building collaborations necessary for acupuncturist workforce expansion within the fabric of Oklahoma’s existing infrastructures. Collaboration in the development of innovative tiered apprenticeship programs for life-long career advancement are in alignment with current workforce expansion plans. In addition, to accommodate evolving health care industry workforce requirements, stakeholders are exploring practice scope expansion solutions, such as competency based certifications. Oklahoma appears to be postured for incubating hybrid models that bridge life-long learners from beginner to entry-level and master clinician to doctoral research.
Appendix C: Acupuncture Utilization Examples Forty-seven states regulate the practice of acupuncture and over sixty colleges host accredited acupuncture programs. Hundreds of hospitals and health systems throughout the nation utilize licensed acupuncturist services. Some leading hospitals currently employing licensed acupuncturists include but are not limited to: Massachusetts General, Ohio’s UH MacDonald Women’s Hospital, Stanford Hospitals, Seattle Children’s Hospital, Los Angeles’ Cedar Sinai, Athen’s Regional Medical Center, Lutheran’s Medical Center, NYU Rusk, Beth Israel Medical Center, Columbia Presbyterian Medical Center, Long Island Jewish Medical Center, Mount Sinai Medical Center, Memorial Sloan-Kettering Cancer Center, Gouverneur Healthcare, University of Wisconsin Hospital and Clinics, Mercy Hospital Chicago, Children’s Memorial Hospital Chicago, Chanadaigua VA Medical Center, University Medical Center of AZ, Arizona Center for Integrative Medicine, Midwestern Regional Medical Center, Cancer Treatment Centers of America, University of Colorado Medical Center, University of New Mexico Hospitals, Cleveland Clinic for Integrative Medicine, Beth Israel Medical Center (Continuum Center for Health and Healing), and Duke University Medical Center, George Washington University Hospital, Greenwich Hospital Integrative Medicine Program. Research Hospitals that offer licensed acupuncturists services include but are not limited to: John Hopkins, Ronald Regan Hospital – UCLA, Cleveland Clinic, San Francisco Medical Center, University of California, Hospital of the University of Pennsylvania, Barnes Jewish St. Louis, and Henry Ford Hospital Detroit. An ever growing number of insurance plans throughout the nation include acupuncture as a member benefit102 and acupuncture meets, at minimum, five of the Essential Health Benefit (EHB) criteria and service categories of care: ambulatory patient services, maternity/infertility, mental health and substance use disorders services, rehabilitative services, preventative wellness, and chronic disease management. As a result of acupuncture being designated as an EHB, nearly 54 million Americans in six states (California,69 Alaska,70 Maryland,71 Massachusetts,97 New Mexico,72 Washington73) and four territories (American Samoa,74 Guam,75 North Mariana Island,76 Virgin Islands77) gained access to acupuncturists’ services in 2014. As of 2017, eight states provide acupuncture coverage through Medicaid (California,79 Maryland,86-88,99 Massachusetts,97 Minnesota,80 New Mexico,81 Ohio,82,83 Oregon84,85 and Rhode Island89,91); New Jersey’s Medicaid plan covers acupuncture anesthesia during surgery;108 and several states, such as Vermont,96 implement temporary innovative Medicaid pilot programs to examine outcomes and savings.90-93 Various programs within the United States Department of Defense medical community have long utilized acupuncturists’ services and provide introductory training for physicians.56 Acupuncturist services are recognized as important and “extremely effective” treatments for non-opioid pain management;57 post-traumatic stress disorder and resilience care;58 mild traumatic brain injury and related insomnia and headaches;59 traumatic brain injuries and psychological disorders,60 and for Gulf War Illness,62 in facilities across the country (e.g., Camp Pendleton, Ft. Hood, Ft. Bliss, Ft. Carson, Walter Reed Army Medical Center). Additionally, the military has provided these services to military families for stress management and post-traumatic stress disorder.61 The United States Department of Veterans Affairs has integrated acupuncture into a number of facilities while expanding outreach into the community; of 125 Veterans Affairs facilities, 58 offered acupuncture services to patients in 2011.34 The 2014 Veteran Choice Program provides acupuncture as a standalone procedure, or within a comprehensive plan, for treating veterans experiencing service-connected low back pain, PTSD, and more. The U.S. Health and Human Services’ Substance Abuse and Mental Health Services Administration identifies acupuncture as a complementary treatment for detoxification in comprehensive addiction treatment programs.31 A 2014 report for the National Association for Medicaid Directors recommends acupuncture as one part of a holistic approach to treating patients suffering from pain and co-morbidities such as substance use disorder (SUD) and behavioral health issues.13 The National Congress of American Indians issued resolution #SD-15-027 in 2015 requesting inclusion of licensed acupuncturist services within Indian Health Services and tribal health facilities. 16 To remove barriers to licensed acupuncturist services, equitable inclusion and expansion of coverage within all payer programs, including state and federally funded programs, is import to industry stakeholders for public health improvement.13,16,17,65,66
Appendix D: NADA and Substance Use Disorder – Utilization, Research & Cost-Saving Information Throughout the United States, comprehensive treatment settings utilizing the NADA protocol are multiple including but not limited to inpatient, outpatient, addiction treatment programs, mental health facilities, jails, prisons, criminal justice and parole, drug-court, prison psychiatric units, street outreach, homeless shelters, half-way houses, harm reduction, natural disaster emergency relief, HMOs, active-duty military programs, and veterans healthcare programs.28,29,33-37,39,64 Although studies now confirm high risk groups have poorer completion rates than non-risk groups, the high risk groups are proving more likely to complete treatment when participating in NADA treatment.32 NADA is used in the acute and chronic phases of substance use treatment and is increasingly integrated into dual diagnosis settings to help patients with substance use disorders with concurrent behavioral health conditions, psychiatric symptoms,32 and other comorbidities, including personality disorders.35 Report benefits from NADA include improvement in depression, anxiety, anger, sleep disturbances, impaired concentration, fatigue, and body aches/headaches as well as reduction in withdrawal symptoms and cravings.28,32,35-39 Referrals for comprehensive programs utilizing NADA typically include a variety of agencies, such as probation and parole, Drug-Court, Department of Social Services, Department of Motor Vehicles, Recovering Professionals Program, employee assistance program, and physician offices, to name a few.32,28,39 U.S. Health and Human Services’ Substance Abuse and Mental Health Services Administration (SAMHSA) identifies acupuncture as a complementary treatment for detoxification recognizing that it can be included as part of a comprehensive treatment program for addictions;31and, multiple studies support the adjunctive use of NADA for the treatment of nicotine, heroin, alcohol, and cocaine addiction.28,32,35-39 628 licensed addiction treatment programs30 included acupuncture as a therapeutic tool in 2012. Twenty-two states encourage utilization of the NADA protocol through regulation.28 A 2016 study of NADA within a substance abuse treatment program demonstrates long term savings to the state in NADA control group upon discharge: increased employment by 71% of those previously unemployed vs 35% in the control group, and long term abstinence from alcohol, drugs, and tobacco use.32 A study outcome produced expenditures in a non-NADA control group totaling $17,890.00 while NADA control group costs were $15,580.00, equating to a savings of $2,310.00 per patient,37 a savings of 1 million dollars to the state for every 433 participants. Prison and jail inmates are seven times more likely than individuals in the general population to have a SUD.13 Inmates medicated for violent behavior experienced improved behavior ratings and required fewer psycholeptic drugs than controls when receiving NADA three times weekly.36 A model comprehensive homeless and criminal justice incarceration diversion program in Oregon reports 11% recidivism, saving the state $25,000/year for every rehabilitated person.42 A Sacramento Drug Court Cost Study of a model program demonstrates cost-benefit through comprehensive programming with a 17% recidivism rate after two years for graduates compared to 67% in the non-participation control group, and a saving of $6,605 per graduate; ten year program lifetime savings is calculated as more than $20 million.64
Incorporating NADA treatment into Oklahoma’s existing drug-court diversion and rehabilitation programs may further reduce prison populations and drive down crime rates; for example, reducing Oklahoma drug court graduates’ re-incarceration rates by 50% could save the state 2 million dollars for every 100 additional rehabilitated persons. “The average annual cost of incarceration in the Oklahoma Department of Corrections is $19,000 per person, compared with the average annual per person cost for drug court participation of $5,000. Drug court graduate re-incarceration rates of 23.5% when compared with rates of those whom successfully complete standard probation, 38.2%, and released inmates, 54.3%, are further proof that Oklahoma Drug Courts work.”100 Oklahoma’s existing drug-court program has expanded to 73 of the 77 counties,100 increasing rural and underserved population
access throughout the state. However, Oklahoma incarcerates “a greater portion of its population than any state but one, and a greater portion of its women than anyone”118 and the building of three new prisons is being considered. Pregnant women and neonates are one of “three populations with unique risk in the context of the opioid epidemic.”65 NADA has proven to be safe during pregnancy.41 Although specific acupuncture points on the body are contraindicated during pregnancy, NADA has consistently proven safe and effective throughout term and post-partum. For more than 25 years, NADA was incorporated into the Maternal Substance Abuse Services Program, inspiring programming world-wide while continuing the legacy of the innovative award winning Lincoln Recovery Center39 pregnancy program, an award granted to the center in 1991 by the American Hospital Association.28 Between 2000 and 2009, the rate of newborns diagnosed with neonatal abstinence syndrome (NAS) and dependent on narcotics nearly tripled and the number of mothers using or dependent upon drugs more than quadrupled, while costs associated with treating these infants increased by 35%. Medicaid was the primary payer for over 75% of these births.13 New studies on NADA efficacy suggest savings in neonatal intensive care units from shorter hospital stays and decreased withdrawal symptoms resulting in reduced costly interventions.44,45 The CDC reports that over $170 billion dollars annually is spent on treating diseases caused by smoking; 16 million Americans are currently living with a disease caused by smoking. When used in combination with educational programming, auricular acupuncture protocols (including NADA) have demonstrated marked effect upon reducing nicotine withdrawal symptoms and long-term measurable outcomes are comparable to that of pharmacological approaches at greatly reduced cost.109
Appendix E: Acupuncture, Chronic Pain Efficacy, and Cost-Saving Information 30% of patients with chronic pain conditions also suffer from clinical depression, and nearly 50% of patients who suffer from both anxiety and depression disorders have a comorbid pain diagnosis.13 A study published by the NIH in 2017 documents that “evidence on acupuncture compared with usual care and counseling compared with usual care shows that both treatments are associated with a statistically significant reduction in symptoms of depression in the short to medium term, with no reported serious adverse events related to treatment. Acupuncture is cost-effective compared with counseling or usual care alone, although the ranking of counseling and acupuncture depends on the relative costs of delivering these interventions.” 107 A 2017 study finds that acupuncture rewires the primary somatosensory cortex in patients experiencing carpel tunnel syndrome.18 The research supports previous findings recommending the use of acupuncture as a viable first-line long-term cost-effective approach, prior to consideration of costly surgical procedures. Over one-third of patients avoided surgery (arthroplasty of the knee) when acupuncture was added to the standard treatment protocol – generating a savings of $9,000 per patient.49 When incorporated into pre-surgical care, acupuncture has been found to reduce the amount of post-operative morphine consumption; post-operative pain is a strong predictor of subsequent chronic pain.46 Acupuncture is routinely used to reduce pain in cancer patients, as well as alleviate chemotherapy induced nausea and vomiting.46,51-54 Cancer Treatment Centers of American (CTCA) employs acupuncturists in its five nationwide hospitals, providing acupuncture in an integrative setting.51 Dana Farber Cancer Institute at Harvard University has developed evidence-based acupuncture protocols to provide clinically relevant solutions for clinicians and cancer patients with pain, including: postoperative cancer pain, postoperative nausea and vomiting, postsurgical gastroparesis syndrome, opioid-induced constipation, opioid-induced pruritus, chemotherapy-induced neuropathy, aromatase inhibitor-associated joint pain, and neck dissection-related pain and dysfunction.52-54 The National Cancer Institutes comprehensive cancer database (PDQ) statement on acupuncture indicates usage in a wide range of conditions: hot fashes, xerostomia (dry mouth), neuropathy, and cancer related-fatigue & pain management. A 2008 military study documents how replacing pharmacotherapy with acupuncture care for symptoms of pain can generate a $4,000 savings per patient to the Department of Defense – additional savings of $10,000-$18,000 per patient occur when procedures such as spinal fusion and laminectomy are successfully avoided.47
Appendix F: Medicaid and Acupuncture The 2014 Medicaid report articulates: “In addition to the financial implications of prescription drug abuse and overdose, chronic and severe social implications reverberate through Medicaid and social service programs as well in the areas of homelessness, domestic violence, unemployment, foster care, and others that can burden states for years in service and care needs.”13 “Medicaid is the largest health care safety net program and is responsible for the health care of 73 million Americans, including those with the most complex health care needs. The program covers 50 percent of all U.S. births, promotes children’s achievement of developmental milestones and school readiness and, enables adults to maintain good health in support of work readiness and job retention, and furthers the values, dignity, safety and integration of individuals who require long-term services and supports. States and the federal government jointly finance and operate Medicaid, making an effective federal-state partnership critical to success of the program.”114 “Because rates of prescription drug misuse and overdose are elevated in individuals that have co-occurring mental illness and/or have a history of substance abuse, access to and effective coordination of care is essential… Inclusion of other clinical and support specialists on the treatment team could also be considered and may be amenable to payer support, including case management and promotion of non-pharmacologic therapies such as acupuncture, massage, and health/wellness classes. Together these ancillary providers may help in shifting the focus away from prescribing opioids as a primary or exclusive means of pain relief… By incorporating recommendations across the six strategies, states can reasonably expect to bring about a reduction in prescription drug abuse and overdose, resulting in an overall reduction in healthcare expenses and an improvement in the health outcomes of Medicaid beneficiaries.”13 A Medicaid report in March 2017 articulates that “Medicaid must also be given statutory certainty around its ability to support holistic initiatives addressing the social determinants of health, which may cross federal programmatic and funding silos. These types of initiatives represent the next horizon for health care transformation, and with federal support, states may lead the way.”114 The Oklahoma Health Care Authority is a state government agency responsible for administering the Oklahoma’s Medicaid program known as “SoonerCare.”112 In 2015, approximately 17% of Oklahoma enrollees were categorized as disabled, aged, or blind; 61% of enrollees were children and more than half of children in Oklahoma were enrolled; average monthly enrollment was 820,000; and total Medicaid spending was $5.1 billion (including funding of $3.1 billion from federal government).111 The agency’s mission is to “responsibly purchase state and federally-funded health care in the most efficient and comprehensive manner possible; to analyze and recommend strategies for optimizing the accessibility and quality of health care; and, to cultivate relationships to improve the health outcomes of Oklahomans.”112 As of 2017, eight states provide acupuncture coverage through Medicaid (California,79 Maryland,86-88,99 Massachusetts,97 Minnesota,80 New Mexico,81 Ohio,82-83 Oregon84-85 and Rhode Island89,91); New Jersey’s Medicaid plan covers acupuncture anesthesia during surgery;108 and several states, such as Vermont,96 implement temporary innovative Medicaid pilot programs to examine outcomes and savings.90-93 Oklahoma appears to be poised to lead, saving lives by qualifying for supplemental Medicaid funding through 1115 demonstration pilots.90 Expanding upon current successful programming, replicable demonstrations utilizing licensed acupuncturists, with clearly-defined baseline measures, goals, and evaluation criteria in targeted sub-populations groups, have clear potential to propel Oklahoma into the lead for innovative emerging community-based collaborative approaches addressing the unique challenges that must be overcome to successfully combat the nation-wide opioid epidemic.
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