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Changing the Way Opioid Addiction Treatment Is Delivered Could Reduce Death and Suffering

Stephanie Robtoy, who suffered from addiction to prescription opioids for a decade, with her daughter in St. Albans, Vermont.

Stephanie Robtoy, who suffered from addiction to prescription opioids for a decade, with her daughter in St. Albans, Vt. Vermont is one of the states striving to increase availability of tightly regulated medications for opioid addiction. Photo: John Tlumacki/Boston Globe via Getty Images

Stephanie Robtoy, who suffered from addiction to prescription opioids for a decade, with her daughter in St. Albans, Vt. Vermont is one of the states striving to increase availability of tightly regulated medications for opioid addiction. Photo: John Tlumacki/Boston Globe via Getty Images

Authors
  • Jesse Baumgartner
    Jesse C. Baumgartner

    Senior Research Associate, Health Care Coverage and Access & Tracking Health System Performance, The Commonwealth Fund

  • Celli Horstman Headshot
    Celli Horstman

    Senior Research Associate, Delivery System Reform, The Commonwealth Fund

Authors
  • Jesse Baumgartner
    Jesse C. Baumgartner

    Senior Research Associate, Health Care Coverage and Access & Tracking Health System Performance, The Commonwealth Fund

  • Celli Horstman Headshot
    Celli Horstman

    Senior Research Associate, Delivery System Reform, The Commonwealth Fund

Opioids are involved in nearly 75 percent of overdose deaths in the United States, which claim more than 100,000 lives per year.

But even though opioid addiction can be treated with several effective medications, only 10 percent to 15 percent of U.S. residents with opioid use disorder receive them.

What accounts for this deadly treatment deficit? In this post, we discuss how government regulation and inadequate treatment capacity can limit patients’ access to lifesaving care and what policymakers could do to help.

Stringent Regulations Limit the Availability of Opioid Addiction Medications

Methadone and buprenorphine are the two main prescribed medications for opioid use disorder (MOUD) and are usually taken daily for extended periods alongside counseling services. Decades of evidence show they mitigate withdrawal symptoms and cravings, decrease opioid use, and greatly lower overdose mortality risk.

Because they are designated as controlled substances, both are closely regulated by the Drug Enforcement Administration (DEA) and other federal agencies to prevent misuse, more so than other drugs. This limits who can prescribe and administer them to patients, and in what settings.

Methadone, which is used by nearly half of people on opioid addiction medication, is the more tightly regulated of these two medications.

Patients may only be prescribed and receive methadone doses at federally authorized opioid treatment programs (OTPs). It cannot be accessed from office-based providers or pharmacies, unlike in the United Kingdom, Canada, and Australia. Under U.S. regulations, patients at first must travel to OTP facilities daily to receive doses; over time, they may be given limited doses for at-home administration. States also may have regulations governing the establishment of new OTPs and additional rules regulating providers.

Buprenorphine can be prescribed by office-based providers, including primary care doctors, nurse practitioners, and physician assistants, and dispensed at pharmacies. Providers have historically had to complete additional training and receive a DEA waiver to prescribe the drug to a limited number of patients (30–100 for nonphysicians, 30–275 for physicians). Federal regulations require in-person office visits to initiate treatment, and some states have regulations that deter nurse practitioners and physician assistants from prescribing, such as requiring them to have physician supervision.

During COVID-19, the federal government showed flexibility by allowing OTPs to provide more take-home methadone doses, allowing buprenorphine treatment initiation via telehealth, and removing buprenorphine waiver training requirements for providers treating 30 or fewer patients.

Data indicate that methadone take-home flexibilities have not been associated with worse outcomes or significant misuse, and telehealth services have been associated with improved medication retention and lower overdose risk. Some of these provisions are temporary and could sunset or change after the COVID-19 public health emergency ends.

Treatment Capacity Is Inadequate but Can Be Improved Through Integrated Care

These regulations have helped create a disjointed drug treatment system with inadequate capacity to meet patient needs.

Confining methadone access to OTPs has severely limited its availability. Many patients must travel significant distances daily to an insufficient number of clinics. Nearly all states had fewer than three OTPs per 10,000 estimated residents with opioid use disorder in 2020; Wyoming had none. Indiana, which had less than one per 10,000 residents with opioid use disorder, prohibited the establishment of new OTPs from 2008 until 2015. West Virginia, which had just nine programs for its estimated 54,000 residents with opioid use disorder, has had a moratorium since 2007.

Although buprenorphine can be prescribed by a wider range of providers and is more accessible than methadone, a 2018 analysis showed that 40 percent of counties, particularly rural counties, had no waivered providers. Another study showed that less than 10 percent of primary care providers are waivered. In addition, many waivered providers prescribe buprenorphine to far fewer patients than their licensing allows, for reasons including provider discomfort, lack of training, administrative burden, and low insurance reimbursement.

To navigate these challenges, some states have brought together office-based providers and addiction-care facilities under a single care model to increase access points for patients and allow them to seek treatment in the health care settings they visit regularly.

Vermont has developed a “hub-and-spoke” model that integrates OTPs and primary care. This has resulted in an increase in prescribing providers and treated patients. Higher-need patients begin treatment at OTP hubs, which offer high-intensity specialized treatment, including methadone. Patients can eventually transition into spokes, which are outpatient facilities recruited by the state/hubs (including primary care practices). There, a full care team led by waivered providers can prescribe ongoing buprenorphine doses (but not methadone) and help maintain treatment plans for patients while also consulting with hub specialists. Washington State and California have implemented similar programs.

Looking Forward

As overdose deaths continue to rise, it is critical that we improve access to treatment and rethink how we deliver it.

Regulatory flexibilities allowed by the federal government during the pandemic have yielded encouraging results. These temporary changes to loosen methadone and buprenorphine treatment rules can be made permanent.

But faster progress will require bolder policy changes that better integrate addiction treatment within the traditional health care system.

Vermont’s hub-and-spoke model shows how states can foster collaboration between specialty and primary care to expand access and ensure addiction treatment continuity for patients, without changing existing regulations. These efforts can be amplified by improving provider education and raising reimbursement rates.

At the same time, the U.S. can follow international precedent and change regulatory guidance to ensure that methadone — one of the most effective treatments — can be accessed through office-based locations and providers.

By prioritizing integration and rethinking decades-old regulation, health systems and policymakers can expand treatment capacity and improve how and where lifesaving care is delivered.

Publication Details

Date

Contact

Jesse C. Baumgartner, Senior Research Associate, Health Care Coverage and Access & Tracking Health System Performance, The Commonwealth Fund

[email protected]

Citation

Jesse Baumgartner and Celli Horstman, “Changing the Way Opioid Addiction Treatment Is Delivered Could Reduce Death and Suffering,” To the Point (blog), Commonwealth Fund, Oct. 24, 2022. https://doi.org/10.26099/jx0y-vd50