Kentucky Medicaid Is Funding the Wrong Things: Why Abstinence-Based Recovery Deserves Equal—and Serious—Investment
- lucasbennett17
- Jan 13
- 5 min read
By Lucas Bennett
Kentucky continues to rank among the states hardest hit by the opioid epidemic, yet despite years of aggressive spending, overdose deaths and relapse rates remain unacceptably high. In response, state Medicaid policy has increasingly prioritized Medication-Assisted Treatment (MAT)—primarily buprenorphine (Suboxone), methadone, and long-acting injectable buprenorphine (Sublocade). These approaches are routinely described as “evidence-based,” often to the exclusion of other recovery pathways. But evidence-based does not mean evidence-complete.
If the goal of public policy is long-term recovery, independence, and restored functioning, then Kentucky must critically examine whether Medicaid is funding what works best—or simply what bills best.
The Scope of Medicaid Spending on Opioid Treatment
Kentucky Medicaid expenditures total approximately $18–19 billion annually, with substance use disorder treatment representing a growing and prioritized share of spending (Kentucky Cabinet for Health and Family Services [CHFS], 2024). Public data indicate that tens of thousands of Kentuckians receive opioid-related treatment each year, largely through Medicaid-funded programs (CHFS, 2024).
Using conservative assumptions and publicly available pricing benchmarks, a three-year comparison of treatment models shows a stark difference in cost:
Abstinence-based recovery (no MAT): approximately $5,000 per person over three years
MAT (all forms combined): approximately $20,000–$30,000 per person over three years
When applied to an estimated 54,000 Kentuckians receiving opioid treatment, this results in:
Abstinence-based recovery: ~$270 million over three years
MAT-dominant recovery: ~$1.1–$1.6 billion over three years
These estimates hold support services constant—including assessments, counseling, monitoring, and follow-up. The cost difference is driven primarily by pharmacy expenditures and duration of treatment, not by differences in psychosocial care intensity.
Pharmacy Costs: The Primary Cost Driver in MAT
Medication-Assisted Treatment (MAT) is frequently treated as a single category, yet its cost profile varies substantially by medication. Generic sublingual buprenorphine/naloxone products are priced using the National Average Drug Acquisition Cost (NADAC) methodology, with publicly available CMS data showing per-film costs typically ranging from $3–$5, translating to approximately $250–$300 per month at common maintenance doses (Centers for Medicare & Medicaid Services [CMS], 2024).
Methadone, while less expensive than injectable buprenorphine, is reimbursed through ongoing bundled opioid treatment program (OTP) payments that include medication, counseling, and routine monitoring, making it a continuous and often indefinite Medicaid expenditure (Substance Abuse and Mental Health Services Administration [SAMHSA], 2021). Extended-release injectable buprenorphine (Sublocade) significantly alters the cost landscape, with a manufacturer-reported Wholesale Acquisition Cost (WAC) of approximately $2,200 per monthly injection—exceeding $26,000 annually before rebates—and even after mandatory Medicaid rebates under the Medicaid Drug Rebate Program, net per-patient costs remain in the mid–five-figure range (Indivior Inc., 2025; CMS, 2024). Importantly, the use of long-acting injectable formulations does not eliminate the need for counseling, monitoring, or follow-up services, rendering these pharmacy costs additive rather than substitutive.
Retention vs. Recovery: A Critical Distinction
MAT is frequently defended on the basis of treatment retention, which is often used as a proxy for success. However, retention is not synonymous with recovery.
A landmark randomized controlled trial found that over 90% of patients relapsed within months after discontinuing buprenorphine, even following extended treatment durations (Weiss et al., 2011). Additional studies summarized by SAMHSA report relapse rates exceeding 80% after medication cessation, regardless of treatment length (SAMHSA, 2021).
This raises a critical policy question:
If discontinuation of medication results in near-universal relapse, is Medicaid funding recovery—or permanent pharmacologic management?
By contrast, abstinence-based recovery explicitly aims for complete independence from treatment systems, with long-term support provided through mutual-aid organizations rather than ongoing clinical billing.
Abstinence-Based Recovery: Evidence, Not Ideology
Abstinence-based recovery is often portrayed as outdated or unscientific, despite substantial evidence supporting its effectiveness and efficiency.
A comprehensive Cochrane Review found that Alcoholics Anonymous (AA) and Twelve-Step Facilitation (TSF) programs produced equal or higher rates of continuous abstinence compared to cognitive behavioral therapy and motivational enhancement therapy, while being significantly more cost-effective (Kelly, Humphreys, & Ferri, 2020).
Programs like A Vision For You’s Surrender Program are built around this evidence. Rather than creating costly parallel systems, they rely on structured referral to and active engagement with existing, free recovery resources such as AA and other peer-led mutual-support programs. These models emphasize connection, accountability, sponsorship, and consistent participation—resources that already exist in nearly every community and require no taxpayer funding.
The effectiveness of AA is especially notable because it operates entirely outside public financing. For decades, it has supported millions of people worldwide through peer support and community accountability, demonstrating scalability without public expenditure (Alcoholics Anonymous World Services, 2023).
While relapse occurs in all recovery models, abstinence-based approaches emphasize personal responsibility, recommitment, and sobriety as the expected outcome—not indefinite clinical or pharmaceutical maintenance. By aligning individuals with free, self-sustaining recovery communities, these models reduce long-term system reliance, lower costs, and—most importantly—help people build lives that no longer depend on treatment to function.
Structural Incentives: Why Medicaid Favors MAT
Kentucky Medicaid does not prohibit abstinence-based care. However, its reimbursement structure strongly favors MAT:
Pharmacy claims are predictable and recurring (CMS, 2024)
Long-acting injectables generate high, stable revenue streams (Indivior Inc., 2025)
Abstinence-based programs face length-of-stay limits and underfunded follow-up care (CHFS, 2024)
As a result, providers are structurally incentivized to expand medication-centered treatment pipelines rather than time-limited recovery pathways.
This is not a failure of clinicians—it is a failure of policy design.
A Balanced Path Forward
MAT has a legitimate role, particularly in acute stabilization and overdose prevention (SAMHSA, 2021). However, it should function as a bridge—not a destination.
Kentucky should:
Establish funding parity for abstinence-based recovery pathways
Reward time-limited treatment models that lead to independence
Invest in peer-led recovery infrastructure
Measure success by long-term sobriety and functional recovery, not indefinite retention
Call to Action
To Kentucky legislators: Reform Medicaid incentives so that recovery—not dependency—is the endpoint
To the recovery community: We need multiple pathways—but we must stop pretending that all pathways are funded, measured, or valued equally.
Kentucky does not have a treatment shortage it has a recovery investment problem.
Works Cited
Alcoholics Anonymous World Services. (2023). Information on AA membership and effectiveness. https://www.aa.org
Centers for Medicare & Medicaid Services. (2024). National Average Drug Acquisition Cost (NADAC) database. https://www.medicaid.gov/medicaid/nadac
Indivior Inc. (2025). Sublocade prescribing information and wholesale acquisition cost disclosures. https://www.sublocade.com
Kelly, J. F., Humphreys, K., & Ferri, M. (2020). Alcoholics Anonymous and other 12-step programs for alcohol use disorder. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD012880.pub2
Kentucky Cabinet for Health and Family Services. (2024). Kentucky Medicaid budget and enrollment reports. https://chfs.ky.gov/agencies/dms
Substance Abuse and Mental Health Services Administration. (2021). TIP 63: Medications for Opioid Use Disorder. https://store.samhsa.gov/product/TIP-63/SMA18-5063FULLDOC
Weiss, R. D., et al. (2011). Adjunctive counseling during buprenorphine-naloxone treatment. Archives of General Psychiatry, 68(12), 1238–1246. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/1107417
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