By Barbara Goodheart, ELS
With opioid overdoses now killing more people than traffic accidents or HIV infection—more than 45,000 lives were lost to overdoses in 2017—you’d think that most people with opioid use disorder (OUD) could easily access treatment. But that’s not the case. Only a minority receive any substance use treatment, such as counseling or inpatient treatment; even fewer receive medication treatment (MT).
With an eye to better understanding MT dynamics, and in hopes of helping policy makers “identify and close critical gaps in the opioid treatment infrastructure,” a team headed by Ramin Mojtabai, MD, MPH, PhD, at Baltimore’s Johns Hopkins Bloomberg School of Public Health, examined data from the National Survey of Substance Abuse Treatment Services. Study results covered 2007 through 2016, and were published in the January issue of Health Affairs.
Study Results
Medication Use
Buprenorphine and XR Naltrexone Use Is Up; Methadone Lags
The percentage of facilities offering any MT increased from 20% in 2007 to about 36% in 2016; in the latter year only 256 facilities (6.1%) carried all three medications; almost two-thirds provided none.
As the Table below shows, driving the increase in treatment availability were buprenorphine and extended-release (XR) naltrexone. Virtually left behind: methadone—up less than one percentage point over the nine-year period. Yet methadone is “the only medication requiring a federally certified opioid treatment program,” the authors noted; and “methadone may be more effective in retaining patients in treatment and may be especially beneficial for patients with prior treatment failure.”
Medication Availability at OUD Facilities, 2007-2016
| Buprenorphine | XR Naltrexone | Methadone | |
|---|---|---|---|
| Increase in % of facilities offering each medication type | 14.9 to 25.4 | 9.6 to 20.7 | 9.4 to 10.3 |
| Facilities offering each medication type among 4,218 offering any of these medications in 2016 (%) | 2,968 (70.4) | 2,429 (57.6) | 1,208 (28.7) |
Factors Influencing Patient Access
Limits on Availability of Medication
In 2016, only 256 facilities (6.1%) offered all three MT medications; almost two-thirds provided none. Because each medication has pros and cons, the authors view the limited availability of all three at one facility as a “barrier to the optimal use of MT.”
Some likely benefits of full availability: some patients do better with the “structured treatment and accountability offered by methadone maintenance programs, while others may perceive treatment at a methadone clinic as stigmatizing or find the required daily travel overly burdensome.” As for naltrexone, some patients aren’t able or willing to complete naltrexone’s mandatory induction period.
Facility Location
States most likely to offer MT in their facilities were New York and Vermont; least likely were Hawaii, Arkansas, and Idaho. Offering MT was more common in:
- Department of Veterans Affairs facilities, compared to private for-profit facilities
- Facilities located in or operated by a hospital
- Facilities with residential and inpatient services, compared to those without these services
- Large facilities
- Facilities accepting health insurance, especially those accepting Medicaid in states that had expanded Medicaid eligibility
- Facilities in states that accepted Medicare, private insurance, and self-payment or cash
- Facilities in states with higher opioid death rates
- Facilities in states whose Medicaid plans offered more comprehensive coverage of MT
These findings, noted the authors, “highlight the persistent unmet need for MT nationally and the role of expansion of health insurance in the dissemination of these treatments.”
Type of Funding
Medicaid expansion has made MT available to more people, such as those treated in facilities that accept Medicaid. This is especially true in expansion states, where coverage under Medicaid is broader. Still, as the authors point out, many people don’t have easy access to facilities accepting Medicaid.
The Bottom Line
Financing has shifted from state and local general revenues to Medicaid and private insurance—thus, more money has gone into treatment in general medical settings, with prescription medications. This has dimmed the outlook for methadone, given the federal requirement for treatment programs.
Noting the typically slow pace of “changes in policy, financing of care, and insurance coverage,” the authors expressed concern that these changes “might not be extensive enough to meet the present urgent need for the expansion of MT.” They suggest governments may be able “to leverage block grants and other local funding mechanisms to promote more expeditious implementation of MT in substance use treatment facilities.”
What’s Ahead?
Addiction Treatment Forum contacted Tami L. Mark, PhD, MBA, senior director, Behavioral Health Financing, at RTI International. Dr. Mark, an internationally known expert on behavioral health care financing and delivery, agreed with Dr. Mojtabai and colleagues about the need for better access.
“Dr. Mojtabai and his colleagues should be commended for providing data on access to MAT [medication-assisted treatment] in specialty addiction treatment programs,” she said. “The trend is moving in the right direction but we still have a ways to go to improve access to these life-saving medications. A critical next step is to give consumers easy to access and understand information on which providers offer MAT and other aspects of high quality addiction treatment, such as use of effective behavioral therapies for substance use disorders for which there are no medication-based treatments.”
In reply to Dr. Mark’s comments, Dr. Mojtabai agreed that provision of such information to consumers is a critical step, adding that it “should be accompanied by provisions at the federal and local level to increase availability of these treatments, improving patient access through expansion of public insurance and greater integration of these treatments in general health and specialty mental health services.”
(A grant from the National Institute on Drug Abuse supported the authors in this work.)
Reference
Mojtabai R, Mauro C, Wall MM, Barry CL, Olfson M. Medication treatment for opioid use disorders in substance use treatment facilities. Health Affairs. 2019;38(1):14-23. doi:10.1377/hlthaff.2018.05162.
For Additional Reading
Mark TL, Yee T, Levit KR, Camacho-Cook J, Cutler E, Carroll CD. Insurance financing increased for mental health conditions but not for substance use disorders, 1986-2014. Health Affairs. 2016;35(6):958-965. doi:10.1377/hlthaff.2016.0002.
“Where Multiple Modes Of Medication-Assisted Treatment Are Available.” Health Affairs Blog, January 9, 2018. doi:10.1377/hblog20180104.835958.