Barriers to Medication Assisted Treatment for Opioid Use Disorders

The opioid epidemic began in the 1990s after pharmaceutical companies falsely claimed that opioid medications were not addictive, and has devastated the lives of millions in the United States [1]. Over 48,000 deaths were attributed to synthetic opioid overdose between June 2019 to 2020 alone [1]. These devastating outcomes have garnered much attention, and the government and scientific and medical communities have been searching for solutions. The current treatment for opioid use disorders includes residential or outpatient therapy and medication-assisted treatment, in which methadone, buprenorphine, or naltrexone are administered by physicians to treat cravings and withdrawal effects of illegal opioids [2]. While research demonstrates that medication-assisted treatment is highly effective in treating opioid use disorders, accessing these treatments proves to be difficult for certain populations [2]. A variety of factors including race, income, and location pose barriers to treatment and prove to be major determining factors in which patients with opioid use disorders receive care. These disparities are problematic, as they leave many patients without access to effective and life-saving interventions. Acknowledging these disparities and their sources is valuable as they may provide guidance for future intervention programs to increase access to medication assisted treatment and contribute to ending this devastating epidemic.

A wide range of disparities exist when analyzing the demographics of individuals with opioid use disorders receiving treatments. Racial disparities have been identified in which black, native-Hawaiian, Pacific-Islander, and Asian individuals are far less likely to receive treatment for opioid use disorders [3]. Furthermore, research conducted by the University of Michigan and the Veterans Affairs Ann Arbor Healthcare System have found that black patients were 77% less likely to receive a buprenorphine prescription at a visit to a physician than white patients [4]. Additionally, location contributes to the accessibility of medication assisted treatment; patients living in rural communities are less likely to obtain treatment than patients in urban communities [5]. While it is recognized that medication assisted treatment is effective in treating opioid use disorders, access to these treatments is glaringly unequal; wide racial disparities and access issues prevent patients in need from receiving potentially life-saving care.

Income levels and the practice of cash-only clinics also contribute to race-related disparities that prevent access to treatment. On average, the racial groups found to be less likely to receive medication-assisted treatment are also reported to have lower incomes than white families [6]. From 2014 to 2015, it was found that 40% of buprenorphine treatment was paid for out of pocket [4]. These out of pocket payments can be attributed to the practice of cash-only clinics. 19 to 47% of buprenorphine treatment providers run cash-only clinics which do not accept any insurance, instead requiring out-of-pocket payments [7]. This practice makes income levels a crucial factor in determining which patients can receive treatment, as costs can vary between around $5,000 to $80,000 [8]. Given the fact that many people of color are likely to have lower incomes combined with the realities of cash-only clinics, the economic burden that treatment can incur on patients of color with opioid use disorder may make access to treatment difficult, or even impossible.

The distribution of physicians authorized to provide medication assisted treatment is a major factor in widening location-based disparities, and creates the disproportionality between the amounts of patients receiving treatment in rural and urban areas. The total number of physicians authorized to provide medication-assisted treatment is very low considering the widespread devastation of the opioid epidemic, with less than 4% of physicians being authorized to provide buprenorphine treatments [9]. However, this small amount seems to be concentrated in urban areas, as 72% of rural counties were found to lack even a single physician with authorization to provide buprenorphine treatment [9]. Without access to physicians to provide treatment, patients with opioid use disorders in rural areas would need to travel to receive treatment which is both inconvenient and costly [10], causing effective treatment to be virtually unattainable.

There are clear race and location-based disparities in access to medication assisted treatment for opioid use disorders. Many people of color and rural communities lack access due to racial income inequalities, the common cash-based practices for treatment, and the disproportionate distribution of physicians authorized to administer medication-assisted treatment throughout the country. In order to bring an end to the opioid epidemic, these barriers and disparities must be addressed, so that treatment can be practical and accessible for all patients in need.

References:

1. Assistant Secretary of Public Affairs (ASPA). (2021, October 27). What is the U.S. opioid epidemic? HHS.gov.https://www.hhs.gov/opioids/about-the-epidemic/index.html.

2. Substance Abuse and Mental health Services Administration. (2018). Medications for Opioid Use Disorder: For Healthcare and Addiction Professionals, Policymakers, Patients, and Families (Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2018. (Treatment Improvement Protocol (TIP) Series, No. 63.) Part 1, Introduction to Medications for Opioid Use Disorder Treatment. Available from: https://www.ncbi.nlm.nih.gov/books/NBK535270/

3. Wu, L.-T., Zhu, H., & Swartz, M. S. (2016). Treatment utilization among persons with opioid use disorder in the United States. Drug and Alcohol Dependence, 169, 117–127. https://doi.org/10.1016/j.drugalcdep.2016.10.015

4. Robeznieks, A. (2019, November 4). Black patients less likely to get treatment for opioid-use disorder. American Medical Association. Retrieved November 14, 2021, from https://www.ama-assn.org/delivering-care/opioids/black-patients-less-likely-get-treatment-opioid-use-disorder.

5. Nguyen, T., Andraka-Christou, B., Simon, K., & Bradford, W. D. (2019). Comparison of rural vs urban direct-to-physician commercial promotion of medications for treating opioid use disorder. JAMA Network Open, 2(12). https://doi.org/10.1001/jamanetworkopen.2019.16520

6. Bhutta, N., Change, A. C., Dettling, L. J., & Hewitt, J. (2020). Disparities in wealth by race and ethnicity in the 2019 survey of Consumer Finances. The Fed - Disparities in Wealth by Race and Ethnicity in the 2019 Survey of Consumer Finances. Retrieved November 14, 2021, from https://www.federalreserve.gov/econres/notes/feds-notes/disparities-in-wealth-by-race-and-ethnicity-in-the-2019-survey-of-consumer-finances-20200928.htm.

7. Van Zee, A., & Fiellin, D. A. (2019). Proliferation of cash-only buprenorphine treatment clinics: A threat to the nation’s response to the opioid crisis. American Journal of Public Health, 109(3), 393–394. https://doi.org/10.2105/ajph.2018.304899

8. Perspectives in Medication Assisted Treatment: Economic Burden of Illness in Opioid Use Disorder (OUD) and Medication-Assisted Treatments. American Journal of Managed Care Perspectives, 8-11.https://www.ajmc.com/view/economic-burden-of-illness-in-opioid-use-disorder-oud-and-medication-assisted-treatments.

9. Haffajee, R. L., Bohnert, A. S. B., & Lagisetty, P. A. (2018). Policy pathways to address provider workforce barriers to buprenorphine treatment. American Journal of Preventive Medicine, 54(6). https://doi.org/10.1016/j.amepre.2017.12.022

10. Hancock, C., Mennenga, H., King, N., Andrilla, H., larson, E., & Schou, P. (2017). Treating the Rural Opioid Epidemic. National Rural Health Association Policy Brief, 1-13. https://www.ruralhealth.us/NRHA/media/Emerge_NRHA/Advocacy/Policy%20documents/Treating-the-Rural-Opioid-Epidemic_Feb-2017_NRHA-Policy-Paper.pdf.