'A long way to go': Nearly 90% of people with opioid use disorder do not receive medication
The majority of people with opioid use disorder in the United States are not receiving life-saving medication due to multiple barriers to access, according to a study published in the International Journal of Drug Policy.
Even though the use of medication for opioid use disorder (MOUD) has more than doubled over the last 10 years, researchers found that, as of 2019, 86.6% of people with OUD did not receive medication like methadone, buprenorphine and extended-release naltrexone, which have been shown to reduce the risk for overdose by more than 50%. This means the treatment increase has not kept pace with OUD and skyrocketing overdose mortality rates — which have largely been driven by fentanyl, a synthetic opioid that is up to 50 times stronger than heroin, according to a press release related to the study.
Study coauthor Noa Krawczyk, PhD, an assistant professor at the Center for Opioid Epidemiology and Policy in the department of population health at NYU Langone, told Healio that more must be done “to expand MOUD to people in need.”
“We know how to do this, but there needs to be greater political will among policymakers, the medical community and the substance use treatment community more broadly to break from long-held stigmatizing perspectives on substance use and instead adopt a pragmatic, humane and evidence-based approach to treating OUD and preventing overdose,” Krawczyk said.
Krawczyk and colleagues conducted a study to assess the gap between opioid overuse prevalence and the use of MOUD at the national and state levels from 2010 to 2019. Although “the gaps in access to MOUD are well known,” Krawczyk told Healio this study is the first that attempts to “quantify this gap using real world national data on treatment utilization and assess how this gap has changed over time.”
The researchers used a public database to track MOUD dispensing by licensed methadone clinics and a private database of pharmacy claims to track prescriptions that were filled for MOUD. They then were able to calculate the difference in the rates of people who received MOUD from 2018 to 2019 and those who received it from 2010 to 2019.
Overall, Krawczyk and colleagues found a 105.6% increase in MOUD rates across the U.S. from 2010 to 2019, and a nearly 5% increase from 2018 to 2019. However, while past-year OUD affected 7,631,804 individuals in the U.S. in 2019, only 1,023,959 individuals received MOUD the same year.
MOUD rates were highest in Vermont — 1,342.6 per 100,000 people — and lowest in South Dakota — 66.1 per 100,000 people.
Treatment rates increased in all 50 states between 2018 and 2019, but Washington, D.C., saw a 9.2% decrease. Washington, D.C., is also one of the regions with the largest gap between OUD prevalence and MOUD receipt at 95.1%, according to the researchers.
The other states with the largest gaps in care were North Dakota at 96.1% and Iowa at 97.3%. The smallest gaps existed in Connecticut, Maryland and Rhode Island at 53.9%, 58.1% and 58.6%, respectively.
“Even in states with the smallest treatment gaps, at least 50 percent of people who could benefit from medications for opioid use disorder are still not receiving them,” Magdalena Cerdá, DrPH, professor and director of the Center for Opioid Epidemiology and Policy at NYU Langone Health, said in the release.
Krawczyk told Healio that the treatment gaps can be partially explained by the “multiple regulatory, training and stigma barriers that prevent primary care physicians from prescribing MOUD.” She added that “many primary care physicians do not receive any training on addiction, and so they feel uncomfortable or unfamiliar with how to treat patients with MOUD,” and they are “currently not allowed to prescribe methadone for OUD in the U.S.”
“Unlike in other countries like Canada, Australia and the U.K. where methadone can be prescribed and picked up at a pharmacy, in the U.S., methadone for OUD can only be dispensed at licensed opioid treatment programs and by a board-certified addiction medicine specialist (not just any physician),” Krawczyk said.
Although PCPs cannot prescribe methadone, they can prescribe buprenorphine as long as they have a special “X waiver” from the Drug Enforcement Administration, “which acts as a hurdle and deterrent from providing buprenorphine,” Krawczyk said.
“Regulatory hurdles like requiring a special waiver make physicians think prescribing buprenorphine is more complex than it actually is, or feel that they do not have the resources to support individuals with OUD, despite the reality that buprenorphine is a quite straightforward medication and just taking the medication is highly effective at reducing overdose risk,” she said.
Another major factor is stigma from both patients and providers.
“There is a lot of stigma against individuals with OUD in medical settings. Many providers prefer not to treat patients with OUD because they do not want to serve this patient population or may falsely believe treating OUD patients may be disruptive to their practices,” Krawczyk said. “On the patient side, many also have stigma against MOUD, largely influenced by the false narrative that MOUD is replacing one drug for another. Regulatory hurdles and lack of training contribute to this stigma as many just do not understand how and why MOUD works.”
There are many efforts to address the barriers, Krawczyk said, including two bills that were recently introduced in Congress: the Opioid Treatment Access Act, which attempts to expand methadone dispensing to pharmacies, and the Mainstreaming Addiction Treatment Act, which would eliminate the buprenorphine X waiver.
These bills would not solve everything, but “given the emergency state of the overdose epidemic, it is essential to pass legislation to facilitate access to these MOUD,” Krawczyk said.
Another critical strategy is requiring every substance use treatment program to provide MOUD. As it stands today, about 70% of residential treatment facilities do not offer MOUD “and falsely believe behavioral interventions should be prioritized,” Krawczyk said.
“We need to make MOUD more fitting to the needs of patients with OUD by having treatment programs and providers adopt harm reduction principles and move away from being only focused on abstinence and punitive measures to address substance use,” she said.
In all, the researchers concluded that, though improving initial access to MOUD is a good first step, “our research and health systems have a long way to go in addressing the needs of people with OUD to support retention in treatment and services to effectively reduce overdose and improve long-term health and well-being.”
References:
- Almost 90 percent of people with opioid use disorder not receiving life-saving medication, new study finds. https://www.prnewswire.com/news-releases/almost-90-percent-of-people-with-opioid-use-disorder-not-receiving-life-saving-medication-new-study-finds-301599870.html. Published Aug. 4, 2022. Accessed Aug. 4, 2022.
- Krawczyk N, et al. Int J Drug Policy. 2022;doi:10.1016/j.drugpo.2022.103786.
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The drug crisis has continued to accelerate during the COVID-19 pandemic, widening the unmet needs of patients and access to treatment options. This study provides insights on the need to provide equitable access to preventive care, education and awareness to the ongoing impact of opioid use disorder and the need for further treatment for patients suffering with this condition.
Adjunct assistant professor, John’s Hopkins School of Medicine
Member, Healio Primary Care Peer Perspective Board
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