Poor access to medication for opioid use a problem of scale

Limited access to medications for opioid use disorder in community-based settings could be an issue of scale, contend a group of researchers in JAMA Network Open.

Indeed, in the 20 states with the highest occurrence of substance use disorder (SUD), particularly opioid use disorder, only about a third of the community outpatient mental health facilities even offer MOUD. Half of certified community behavioral health clinics (CCBHCs), a specified type of outpatient mental health facility required to treat co-occurring mental health and SUD cases, offer MOUD.

These findings could suggest issues scaling MOUD access, with key institutional barriers limiting certain facilities that treat SUD from offering the medications that could aid in therapy.

This is amidst the backdrop of a growing SUD and opioid use disorder problem in the country. According to the CDC, there were more than 107,000 drug overdose deaths in the U.S. in 2022, with over 81,000 of them being attributable to any kind of opioid.

MOUD is considered the gold standard in treating opioid use disorder. The treatment uses a combination of buprenorphine, methadone and naltrexone to rebalance brain circuits affected by addiction, healing the brain while the individual works toward recovery.

Patient access to MOUD is infamously poor, with 2022 numbers showing that nearly 90% of patients with opioid use disorder lack access to the treatment.

Community-based mental health facilities have emerged as key sites of OUD and mental healthcare, with researchers stressing their potential for improving MOUD access.

However, according to this latest assessment of 450 community-based mental health facilities in 20 of the states with the most pressing SUD problems, access is limited. Only about a third of all facilities included in the assessment offered access to MOUD. Of the facilities that did offer access to MOUD, 84% offered buprenorphine and 70% offered naltrexone. Far fewer (14%) offered access to naltrexone.

Notably, only about half of CCBHCs offered access to MOUD. CCBHCs are required to offer streamlined mental and behavioral healthcare services, including treatment for SUD, although the researchers pointed out that they are not required to offer MOUD. Still, this finding was surprising to the researchers and indicates a high reliance on referral and potentially systemic barriers to offering MOUD.

Of the facilities that don't offer MOUD, 87% refer patients somewhere else to receive the treatment, and 38% are able to refer patients to another facility within the same organization. Even when patients are referred out for MAT, 60% of them still get SUD-related counseling within the referring facility.

The researchers said these findings further suggest institutional barriers that keep some facilities from prescribing MOUD drugs.

"That more than one-third of [mental health treatment facilities] not offering MOUD refer patients for MOUD to a facility within the same organization suggests the existence of different models of MOUD provision within organizations that may not have the capacity to provide MOUD at all sites. Specifically, this finding could reflect that some of the MHTFs are unable to support a MOUD prescriber," the researchers explained.

Key barriers limiting MOUD prescribing might include insufficient institutional support, lack of access to psychosocial services, the stigma associated with treating SUD and lack of training or experience in prescribing MOUD. Further research will help identify specific issues and guide improvements.

Policymakers have already worked to eliminate some of the roadblocks clinics face in delivering MOUD.

Section 1262 of the Consolidated Appropriations Act, 2023, removed the federal requirement that clinicians submit a Notice of Intent (the X waiver) to prescribe certain medications, including those included in MOUD. This was done to increase the clinical workforce authorized to administer MOUD.

Still, demand for MOUD outpaces access significantly, in part because of workforce issues. Identifying challenges within clinics will help healthcare leaders scale efforts to improve access to opioid treatment.

Sara Heath has been covering news related to patient engagement and health equity since 2015.