Medications for Opioid Use Disorder Save Lives (2019) / Chapter Skim
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5 Barriers to Broader Use of Medications to Treat Opioid Use Disorder
5 Barriers to Broader Use of Medications to Treat Opioid Use Disorder
Pages 109-136
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5 Barriers to Broader Use of Medications to Treat Opioid Use Disorder Confronting the major barriers to the use of medications to treat opioid use disorder is critical to addressing the opioid crisis.
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From page 110... ...
. The barriers preventing broader access to life-saving medications for OUD include stigma, inadequate professional education and training related to the evidence base for using medication, and challenges in connecting indi iduals v with medication-based treatment due to delivery system fragmentation, regulatory and legal barriers, barriers related to public and private health insurance coverage, and reimbursement and payment policies that do not incentivize the provision of high-value care for OUD.
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, which generally finds personal experience with mental illness to be associated with less negative attitudes. Higher levels of stigma were also associated with greater support among the public for more punitive policy responses to the opioid epidemic (e.g., arresting and prosecuting people who obtain multiple prescriptions from different doctors)
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. A 2017 national public opinion study revealed low rates of awareness among the public about the evidence base for medications to treat OUD; Blendon and Benson found that half of U.S.
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, Changing the Language of Addiction, and a 2017 version of the Associated Press Stylebook recommending more careful attention to language by reporters covering news stories about the opioid epidemic (Aliferis, 2017)
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and are now slightly lower than the rates for buprenorphine. To put diversion of OUD medications in context, it is worth noting that these rates are lower than the diversion rates for other prescribed medications.
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. Integrating addiction treatment into mainstream health systems could expand treatment capacity and improve providers' education about addiction medicine (Merrill, 2002)
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Separate addiction treatment delivery settings and care financing streams are reinforced by regulatory and legal requirements that impose further barriers on accessing medication-based treatment for OUD. The existence of distinct treatment systems and financing mechanisms for SUDs has created sizable barriers to providing integrated services, particularly for people who have OUD and co-occurring medical or mental health conditions.
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From page 117... ...
For example, as was noted in Chapter 4, major barriers to OUD medication uptake and continuation are driven by the high rates of OUD within criminal justice settings, the lack of availability of medication-based treatment during incarceration, and the absence of strong connections with outpatient treatment in community settings offering medications upon release from incarceration (Fox et al., 2015)
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From page 118... ...
Furthermore, research is needed on how best to integrate care for justice-involved individuals with OUD and other health care needs who are moving into community-based treatment settings. LEGAL AND REGULATORY BARRIERS Legal and regulatory barriers prevent broad access to medication-based treatment for OUD within the mainstream of the medical care system.
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. For example, a randomized controlled trial comparing office-based care versus OTP care for people who are stabilized on methadone treatment found physician offices to be a feasible and effective setting for maintenance treatment (Fiellin et al., 2001)
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. Additional barriers to buprenorphine prescription reported by waivered primary care physicians include a lack of institutional support, mental health support, and psychosocial support (Hutchinson et al., 2014)
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. In contrast to the literature examining why providers do or do not obtain and use the DATA waiver to treat OUD, no evidence base supports the waiver process itself.
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At the same time, the special privacy protection contributes to the traditional separation of addiction treatment from the rest of medical care. Consequently, a patient's primary care, inpatient, mental health, and SUD treatment provider may not be aware of the patient's status in treatment for OUD, unless the patient chooses to disclose that status; this can complicate the patient's overall medical treatment regimen and discourage continuity of treatment for OUD when a patient transitions from one care location to another.
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. Among publicly funded addiction treatment organizations, reliance on Medicaid reimbursement has been positively associated with offering medications for OUD (Knudsen et al., 2010)
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. In addition, new approaches being instituted in some state Medicaid programs through section 1115 waivers including work requirements, increased costsharing and deductibles, and other consumer-oriented approaches such as health savings accounts that put enrollee coverage at risk for failure to make payments could pose barriers to access and continuation on medication for OUD (Somers et al., 2018)
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The Mental Health Parity and Addiction Equity Act of 2008 preserves the MHPA protections and adds significant new protections, such as extending the parity requirements to SUDs. Evidence suggests that as a result of this law, the treatment rate for SUDs increased by 9 percent in all specialty treatment facilities and by 15 percent in facilities accepting private insurance (Wen et al., 2013)
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However, some evidence suggests that the addiction treatment sector is not keeping pace with the rest of the health care field in adopting new value-based payment systems (McDowell et al., 2018; Stuart et al., 2017)
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• nadequate education of the professionals responsible I for working with people with OUD, including treatment providers and law enforcement and other criminal jus tice personnel. • urrent regulations around methadone and uprenorphine, C b such as waiver policies, patient limits, restrictions on settings where medications are available, and other pol icies that are not supported by evidence or employed for other medical disorders.
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2014. Termination of Medicaid policies and implications for the Affordable Care Act.
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2011. The evidence doesn't justify steps by state medicaid programs to restrict opioid addiction treatment with buprenorphine.
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2018. Postincarceration fatal overdoses after implementing medications for addiction treatment in a statewide correctional system.
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2010. Facilitating factors and barriers to the use of medications in publicly funded addiction treatment organizations.
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2015. Implementing buprenorphine in addiction treatment: Payer and provider perspec tives in Ohio.
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2018. Changes in buprenorphine naloxone and opioid pain reliever prescriptions after the Affordable Care Act Medicaid expansion.
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2008. Use of b uprenorphine for addiction treatment: Perspectives of addiction specialists and general psychiatrists.
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2017. Medications for addiction treatment: Changing language to improve care.
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