Substance Use Disorders (SUD) and Opioid Use Disorders (OUD) can present in primary care and specialty settings. Molina’s goal is to encourage and support providers in prevention, screening and intervention efforts at all levels of care regardless of specialty. Dependence and addiction can stand alone, but there can also be a relationship between mental health and/or chronic pain related opioid therapy. Molina continues to align with nationally recognized clinical guidelines to ensure access and appropriate interventions are available to manage SUDs and OUDs, as well as co-occurring conditions.
A pattern of substance use (alcohol or other drugs) may lead to clinical impairment affecting your patient’s overall health and well-being. During your evaluation of your patient, you may discover a further need to assess the frequency of use, drug of choice (prescribed or non-prescribed) due to presenting factors, including: a developed tolerance leading to more use over time; persistent inability to cut down or stop use; a strong desire or urge to use substances resulting in failure to fulfill major role obligations at work, school or home.
Molina Healthcare recommends the use of the CAGE-AID to screen for alcohol and other drug abuse & dependence. You can obtain a copy of the CAGE-AID, as well as background and metrics directly on the SAMHSA website.
The CAGE-AID questionnaire is used to test for alcohol and other drug abuse and dependence in adults .
The tool is not diagnostic, but is indicative of the existence of an alcohol or other drug problem.
Each item on the CAGE-AID are scored 0 or 1. A total score of 2 or greater is considered clinically significant, which then should lead the physician to ask more specific questions about frequency and quantity CAGE is derived from the four questions of the tool:
|When thinking about drug use, include illegal drug use and the use of prescription drug use other than prescribed.||YES||NO|
|1. Have you felt you should cut down or stop drinking or using drugs?|
|2. Has anyone annoyed you or gotten on your nerves by telling you to cut down or stop drinking or using drugs?|
|3. Have you felt guilty or bad about how much you drink or use drugs?|
|4. Have you been waking up wanting to have an alcoholic drink or use drugs? (eye-opening)|
|TOTAL 'YES' SCORE|
|SCORING||Regard one or more positive responses to the CAGE-AID as a positive screen.|
ICD 10 codes capture current symptoms, severity, and onset
Opioid Dependence with Withdrawal: F11.23
Opioid Dependence with Opioid-Induced Mood Disorder: F11.24
Providers are responsible for coordinating care and providing or referring members to appropriate treatment. Treatment benefits vary for each member, so providers are encouraged to check member’s benefit structure prior to referring.
There are FDA-approved medication based therapies to treat opioid dependence, such as Buprenorphine and Naltrexone. MAT services may be covered for the member; however, providers are encouraged to verify coverage.
Psychotherapy, Intensive Outpatient Programs, or Partial Hospitalization Programs may be covered for the member. Providers are encouraged to verify benefit coverage and refer to an in-network provider or program as clinically appropriate.
RTC may be a covered benefit for members with more intensive needs and who meet medical necessity for these services. Please verify coverage and request an in-network program.
The Center for Disease and Control Prevention (CDC) established Guidelines for Prescribing Opioids for Chronic Pain. Molina Healthcare aligns with these guidelines, which are intended to improve communication between providers and patients about risks and benefits of opioid therapy, as well as provide support to providers in reducing associated risks and improving the safety and effectiveness of pain. Visit the CDC’s Guidelines for Prescribing Opioids for Chronic Pain to access the complete list, which includes:
48 year old male presents with tolerance - use has increased from 12 12-oz beers daily to 18-20 12- oz beers daily. Has tried but states he's unable to stop use despite work and marriage problems due to alcohol dependence. Missing work 3-4 days/month. Late to work several times/week. Increase in intensity of arguments with wife, whom is threatening to divorce.
Assessment and Diagnosis: Patient is aware of risks of continuing use especially given A-fib and Coumadin medication therapy (F10.20, Alcohol Dependence, Uncomplicated).
Plan: Referred patient to AA meetings or other 12-step support program. Patient will consider.
**For specific Risk Adjustable codes related to Substance Use Disorders, contact
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