Appalachia is an area long known for beautiful scenery, coal mining, and devastating poverty. And now the area around central Appalachia has 
become the epicenter of the opioid epidemic.
Four Appalachian states—Tennessee, Kentucky, North Carolina, and West Virginia—have been especially hard-hit in the epidemic. A team from Vanderbilt University in Nashville launched a study to investigate possible barriers to treatment in women with opioid use disorder (OUD). A report of their findings, summarized below, was published online June 27 in Substance Abuse.
The Study
Between April and May of 2017, the Vanderbilt team conducted a phone survey of opioid agonist treatment (OAT) providers, opioid treatment programs (OTPs), and providers of buprenorphine outpatient services, in the four Appalachian states.
They wanted to learn if insurance and pregnancy status had become barriers to treatment for women in states especially hard-hit by the opioid epidemic.
Primary outcomes – providers’ acceptance of insurance and providers’ treatment of pregnant women
Secondary outcome – patient wait time
Exposures – type of insurance, and pregnancy status
Results
It became clear to the team that some women seeking treatment were coming up against barriers—even stigma. Some barriers varied by location; others by type of payment; still others by type of treatment: methadone or buprenorphine. Two groups were especially affected: pregnant women, and women who wanted to pay using insurance instead of cash.
- Medicaid acceptance ranged from 83% in West Virginia to only 14% in Tennessee.
- Every OTP surveyed, and most buprenorphine providers (89%), accepted cash payments.
- Costs related to treatment varied considerably: Treatment intake cost $20 to $175; methadone treatment, $49 to $160 weekly; buprenorphine treatment, $35 to $245 weekly.
- About half the OTPs accepted pregnant women who had Medicaid or private insurance; slightly more than half the buprenorphine providers did.
Otherwise, comparing OTPs and buprenorphine providers, OTPs treated pregnant patients more favorably, as the table below shows.
| Opioid Treatment Programs | Buprenophine Providers | |
|---|---|---|
| Accept new patients | 97% | 83% |
| Accept pregnant patients | 90% | 53% |
| Treat pregnant patients | 91% | 75% |
| Wait times for treatment (nonpregnant patients) | 1 day | 7 days |
| Wait times for treatment (pregnant patients) | 0 days | 3.5 days |
Conclusions
Even though the area was disproportionately impacted by the opioid epidemic, many OTPs and buprenorphine providers didn’t accept any insurance, and buprenorphine providers treated a smaller percentage of women who were pregnant.
The research team had noted earlier the effectiveness of opioid agonist therapies in OUD, especially for pregnant women, and had emphasized that “improving access to OAT is an urgent public policy goal.”
On viewing the results of their survey, the Vanderbilt research team had two suggestions to help bring this about.
First, enhance access to treatment by prioritizing improvements in provider training. For example, obstetricians could be trained to become buprenorphine prescribers. Second, improve providers’ acceptance of insurance by raising reimbursement rates.
The study was funded by a grant from the National Institute on Drug Abuse, National Institutes of Health.
Under the NIDA grant, Stephan Patrick, MD, and his team at Vanderbilt created an infographic summarizing the study results. To download the infographic go to: https://www.vumc.org/health-policy/files/health-policy/public_files/OTPinfographic_Final%5B2%5D.pdf.
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Reference
Patrick SW, Buntin MB, Martin PR, et al. Barriers to accessing treatment for pregnant women with opioid use disorder in Appalachian states. Subst Abus. 2018;Jun 27:1-18. PMID:29949454. doi:10.1080/08897077.2018.1488336 [Epub ahead of print].
