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Expanding access to MOUD: An interview with Dr. Cori Sheedy
December 4, 2020
Cori Sheedy, principal associate, division of health and environment
With the COVID-19 public health emergency exacerbating behavioral health needs and limiting some people’s access to evidence-based care, providers are concerned about a renewed growth in opioid use and misuse. We recently sat down with Dr. Cori Sheedy, a principal associate in the health and environment division, to discuss treatment for opioid use disorder (OUD) and access to medication for OUD (MOUD). For 20 years, Dr. Sheedy has been working in substance use treatment and recovery, health services, behavioral health policy, health care integration, and care transformation.
1. Access to treatment for opioid misuse is a major issue. What is the current status of access?
The opioid crisis continues to expand, and limited access to medications and behavioral therapies makes the situation worse. For people who want help, evidence-based approaches exist. Medication and behavioral therapies can help people reduce or stop their opioid use, lower the risk of infectious disease transmission, and reduce the chances of a fatal overdose.
People looking for help have a couple of options. They can seek out opioid treatment programs, where patients take medication under the supervision of staff and where they receive behavioral counseling and other services as part of a treatment plan. Another option is office-based opioid treatment, in which primary care physicians integrate medications into a patient’s general care.
Pregnant women with a substance use disorder (SUD) face a particularly risky situation. The recommended treatment is MOUD, which has ancillary benefits. Pregnant women using MOUD are more likely to adhere to prenatal care and substance use treatment programs. That can decrease the risk of infant death, pre-term birth, low birth weight, and other complications. Studies of pregnant women on MOUD who also receive counseling and support services have shown that they experience fewer obstetrical complications. Women in treatment are less likely to relapse, acquire HIV or another infectious disease, or overdose.
Opioid-exposed newborns, including those whose mothers are undergoing MOUD, may experience neonatal opioid withdrawal syndrome. But if the mothers have the OUD under control, they can develop a closer bond with the newborn in a calm environment, which can help alleviate the newborn’s symptoms.
2. What opportunities exist to expand access to treatment?
According to 2019 estimates, 35% of adults who needed or wanted OUD treatment received it in the previous year. Individuals may not receive treatment due to unavailability of treatment facilities, requirements associated with MOUD access, transportation limitations, stigma associated with accessing treatment, inadequate provider training, delivery system fragmentation, and regulatory and legal barriers.
The good news is that a number of federally funded initiatives expand access to OUD treatment. Medicare and Medicaid now can pay for these services. Also, due to the public health emergency, the government relaxed rules for how people access and obtain MOUD so that people don’t have to go into a doctor’s office to receive their medication daily but can get 7- or 14-day supplies. That lowers the risk of getting COVID-19. Demonstrations and models for states, communities, and providers are testing innovative payment approaches to expand access. These include several CMS-funded initiatives, including the Value in Treatment model, which is scheduled to go live in the spring. This model will test the impact of two different payment schemes: a per-beneficiary, per-month management fee and an incentive payment based on performance factors that include MOUD and patient engagement and retention.
3. What are some of the medications that work, how do they work, and what, if any, are the barriers to access?
Providers combine MOUD with counseling and behavioral therapies. Medications include buprenorphine, methadone, and naltrexone. While all three are effective, not all medications are appropriate for all patients. For instance, naltrexone requires patients to undergo a minimum 7- to 10-day detoxification before initiation. That won’t work for patients who need to begin treatment immediately. The medications are safe to use for months, years, or even a lifetime, like for any chronic disease.
4. What impact does insurance coverage have on access?
Insurance makes access to treatment easier by covering inpatient and outpatient treatment services, including medication and behavioral therapies, and rehabilitation services. States have used Medicaid waivers and other authorizations to expand treatment options. Because of the large number of Medicaid enrollees with OUD and the breadth of treatment services that Medicaid covers, Medicaid finances a substantial proportion of SUD treatment. Medicare also funds MOUD through the Support for Patients and Communities Act, which added a Medicare benefit category for treating OUD and expanded coverage of opioid treatment facilities and other specialized providers as of January 1, 2020.
5. Are there geographic or racial equity issues associated with access to MOUD?
There are tremendous inequity issues. Buprenorphine treatment is concentrated among white persons and those with private insurance or who self insure. Even though OUD rates are similar for Blacks and whites (3.5% for Blacks, 4.7% for whites), one study found that 35 white patients received a buprenorphine prescription for every patient of another race or ethnicity who received one. Compared with white patients, Black patients had 77% lower odds of having an office visit that included a buprenorphine prescription.
Facilities that provide all three forms of MOUD are clustered in the Southwest and Northeast, while the rest of the country has virtually no access. When filtered further by MOUD facilities that accept Medicaid, access is even more limited. In Appalachia, a region heavily affected by the opioid epidemic, Kentucky and Tennessee have no facilities that provide all three forms of medications and accept Medicaid.
This limited access reflects a decaying rural mental health and substance misuse treatment infrastructure, administrative barriers against the most effective form of opioid misuse treatment, and a shortage of rural physicians who provide MOUD. Patients must travel farther to access services, and that can be an unsurmountable burden for many. Numerous studies have found that those who live closer to a health care facility have better health outcomes.
6. Has the stigma attached to substance misuse generally and opioid misuse in particular declined?
Stigma continues to be a rampant issue. Many different types of stigma impact OUD treatment: structural stigma, public stigma, internalized stigma/self stigma, and anticipated stigma. And you can’t separate discrimination from stigma. Decriminalization of drugs has been proposed as a tool in confronting the opioid overdose crisis and a strategy to protect human rights by reducing stigma and discrimination. We don’t yet know what the long-term effects will be.
But one thing that is critical and doesn’t require legislation is changing the language that we use. Language frames what the public thinks about substance use, dependence, treatment, and recovery, and it can affect how individuals think about themselves and the ability to recover. There are people on the front lines every day talking about their recovery, and without these trailblazers, we would be in a harder place than we are now. The addictionary provides advice on the language to use.
7. What kind of experience does Abt have in evaluating SUD treatment programs?
Substance use and misuse touches far too many individuals and families, undermining their health, economic wellbeing, and relationships. We evaluate programs to see what works and what doesn’t so that governments and healthcare providers can help people grapple with OUD. We currently have a variety of SUD- and opioid-related projects, including: