A group of researchers recently conducted a telltale survey: posing as heroin users with opioid use disorder (OUD), they called clinics to schedule an appointment for a buprenorphine prescription, claiming to be either Medicaid patients or uninsured.
The research team placed 1,092 calls to buprenorphine prescribers in areas with high rates of opioid deaths — Massachusetts, Maryland, New Hampshire, Ohio, West Virginia, and Washington, D.C.
About half (46%) of the “secret shoppers” who said they were on Medicaid and 38% who said they were uninsured were unable to get an appointment. Only 27% of Medicaid and 41% of uninsured contacts were offered an appointment with the possibility of buprenorphine prescription at the first visit.
The
study, published in the
Annals of Internal Medicine in June, illustrates how difficult it can be to get OUD treatment. “We were surprised to find roadblocks at every step of the process of getting buprenorphine, from finding a clinic with any prescribed, to finding one that will take public insurance,” senior author Michael Barnett, MD, of Harvard T.H. Chan School of Public Health in Boston, said in a statement.
While improving OUD treatment is a national priority, barriers remain high. Prior authorization requirements and treatment restrictions
disrupt and delay access to OUD therapy, experts said during a Medicaid and CHIP Payment Access Commission (MACPAC) meeting earlier this year.
Another hurdle is stigma, for both patients and providers. And patient stigma raises
privacy questions: making patients’ drug addiction treatment records more easily available is “a very thorny issue,” observed Peter Kaufman, MD, of Bethesda, Maryland, at the American Medical Association meeting earlier this month. “You’d definitely want to know what drugs the patient is on at any time, but on the other hand, you don’t want people with a substance abuse problem to have any inhibition … to get substance abuse treatment … I challenge you to come up with a good solution for that.”
In other countries, opioid overuse is handled much differently, noted Charles Reznikoff, MD, of the University of Minnesota in Minneapolis, at the American College of Physicians annual meeting in April.
In the U.S., only
specially certified prescribers can provide buprenorphine, a key component of medication-assisted treatment (MAT). But in 1995, France began allowing
any doctor to prescribe buprenorphine for OUD. “Now the majority of patients [there] with OUD are receiving buprenorphine from their primary care physicians,” Reznikoff explained. These changes led to a 10-fold increase in buprenorphine prescribing in France “and the overdose death rate dropped by 80%,” he added, noting that half of all people with OUD in France are on addiction medications, compared with 15% in the U.S.
Of all the specialty treatment facilities in the U.S., only 36% provide any type of FDA-approved medications for opioid use disorder, Rep. Elijah Cummings (D-Md.), pointed out at a House Committee on Oversight and Reform
hearing last week. Citing a National Academies of Sciences, Engineering, and Medicine
report, he said the opioid problem was not being addressed adequately because evidence-based medications were “not being deployed to maximum impact.”
Overall efforts to stem the opioid epidemic have been “woefully inadequate,” Cummings continued, pointing to the Trump administration’s 2-year delay in issuing a
formal National Drug Control Strategy. He also criticized its goal of reducing overdose deaths by “only 15%” over 5 years.
The Comprehensive Addiction Resources Emergency (
CARE) Act, reintroduced this year by Cummings and Sen. Elizabeth Warren (D-Mass.), could help build a “robust treatment infrastructure,” increase MAT, and support “wrap-around” services, he suggested. The bill, which provides $100 billion over 10 years, is modeled on the Ryan White Comprehensive AIDS Resources Emergency Act that helped curb the HIV/AIDS epidemic.
More solutions may come from a new study by the Helping to End Addiction Long-Term (HEAL) initiative that aims to
cut opioid overdose deaths by 40% in select Kentucky, Ohio, New York, and Massachusetts communities within 3 years.
HEAL awarded grants to academic institutions in the four states; each will partner with at least 15 communities to assess the effect of integrating evidence-based prevention, treatment, and recovery interventions in primary care, behavioral health, justice, and other settings.
“We’ve been doing it in isolation, but we’ve never done something as ambitious as this” with an integrated effort, said Nora Volkow, MD, director of the National Institute on Drug Abuse. “The communities themselves are going to be the laboratory that is going to allow us to learn how to address the crisis.”
In the meantime, the FDA is working to
expand naloxone access by making it easier for companies to make over-the-counter versions of the opioid overdose treatment. In April, the
agency approved the first generic version of naloxone nasal spray to halt or reverse suspected opioid overdose. And scientists continue to test new ways to curb addiction: a preliminary study this year showed cannabidiol may have the potential to
diminish cravings and anxiety in people with heroin use disorder.
