Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
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.
110 MEDICATIONS FOR OPIOID USE DISORDER SAVE LIVES Despite the strong evidence for the effectiveness of medications in reduc- ing morbidity and mortality, increasing treatment retention, and improving Â well-being for individuals with opioid use disorder (OUD), numerous bar- riers prevent broader access to medication-based treatment. According to 2019 estimates, less than 35 percent of adults with OUD had received treatment for opioid use in the past year (Jones and McCance-Katz, 2019), and no national data sources are currently available to precisely estimate the share of those patients who are being treated with one of the three U.S. Food and Drug Administration (FDA)-approved medications. Furthermore, national estimates indicate that there is usually a gap of several years be- tween the onset of OUD and entering treatment. The delay between disease onset and initial treatment receipt has been estimated to be, on average, in the range of 4 to 7 years (Blanco et al., 2013; Wang et al., 2005). The bar- riers preventing broader access to life-saving medications for OUD include stigma, inadequate professional education and training related to the evi- dence base for using medication, and challenges in connecting indiÂ 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. A critical unanswered question is which interventions or policy changes would be most likely to drive real system-level changes to increase access and use of medication- based treatment for people with OUD? STIGMA There are high levels of stigma toward individuals with OUD and to- ward medications to treat OUD both among the general public and among professionals in key sectors that commonly interact with individuals with OUD. This stigma poses significant barriers to the uptake of medication- based treatment. According to Link and Phelan (2001, p. 377), âstigma exists when elements of labeling, stereotyping, separation, status loss and discrimination occur together in a power situation that allows them.â While some definitions of stigma do not include discrimination, in this report, we conceptualize stigma based on Link and Phelanâs reasoning that the term stigma cannot hold the meaning we commonly assign to it when the con- cept of discrimination is not included. According to Link and Phelan (2001, p. 371), people are stigmatized when âthe fact that they are labeled, set apart and linked to undesirable characteristics leads them to experience sta- tus loss and discrimination,â thereby affecting their life prospects including income, education, housing status, and well-being. National public opinion data indicate that negative attitudes toward individuals with prescription OUD exceed those reported for other medical conditions, including mental
BARRIERS TO BROADER USE OF MEDICATIONS TO TREAT OUD 111 illness (Barry et al., 2014). More than three-quarters of respondents in a 2016 national survey reported viewing individuals with OUD as to blame for their substance use, and nearly three-quarters of respondents charac- terized people with OUD as lacking self-discipline (Kennedy-Hendricks et al., 2017). Two-thirds of respondents were unwilling to have a person with a drug use disorder marry into their family, and a majority endorsed discriminatory measures, such as allowing employers to deny employment to a person with OUD (Kennedy-Hendricks et al., 2017). Individuals who had personal experience with OUDâfor example, having a family member or close friend with OUDâreported equally negative or more negative attiÂudes toward the disorder than the general public (Kennedy-Hendricks t et al., 2017). This is notable because it differs from research on stigma toward people with mental illness (Alexander and Link, 2003; Corrigan et al., 2012; Couture and Penn, 2003; McSween, 2002), 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) and lower support for public healthâoriented policy responses (e.g., expanding Medicaid insurance benefits to cover OUD treat- ment) (Kennedy-Hendricks et al., 2016b). Stigma toward people with OUD and toward people with substance use disorders (SUDs) more broadly is intertwined with persistent stigma (in- cluding labeling, stereotyping, status loss, and discrimination) that occurs on the basis of race and social class in the United States. Historically, U.S. drug policies have disproportionately targeted already marginalized groups (Morone, 1997; Singer and Page, 2014). For instance, early restrictions on opium were implemented during a period of heightened xenophobia toward Chinese immigrants (Morone, 1997). Studies have also focused attention on race-based stigma and discrimination directed toward African Americans as a profound legacy of the war on drugs (Capitanio and Herek, 1999; Kulesza et al., 2013; Minior et al., 2003; Semple et al., 2005). An analysis of a small sample of news media published between 2001 and 2011 found that white non-urban people with prescription OUDs were represented more sympathetically than non-white urban people with heroin use disorder (Netherland and Hansen, 2016). Substance use is often featured in media representations of economically disadvantaged populations (Bullock et al., 2001; Singer and Page, 2014). By tying populations that are already dis- enfranchised to substance use, these media representations may contribute to and reinforce negative attitudes among the public toward people with SUDs. Some evidence bears this out; an experimental study found that atti- tudes toward people with OUD were more positive among people random- ized to read a narrative about a woman with OUD of high socioeconomic
112 MEDICATIONS FOR OPIOID USE DISORDER SAVE LIVES status compared to those randomized to read about a woman with OUD of low socioeconomic status (Kennedy-Hendricks et al., 2016b). Furthermore, high rates of stigma have been documented within key professions that interact regularly with individuals with OUD. Stigmatizing attitudes among health professionals have been shown to be widespread, which has detrimental consequences for connecting persons with OUD to treatment (Brondani et al., 2017; DeFlavio et al., 2015; Livingston et al., 2018; van Boekel et al., 2013). One recent large-scale study assessing pri- mary care physiciansâ views indicated that the rates of stigmaâÂncluding i measures of blame for the condition and a desire for social distance from individuals with prescription OUDâwere as high as or higher than stigma rates among the general public (Kennedy-Hendricks et al., 2016a). StigmaÂ tizing attitudes toward people with OUD are also found among proÂ fessionals working in the public safety and criminal justice settings, the housing sector, and the child welfare system (Rich et al., 2005; Stringer and Baker, 2018; Wittman et al., 2017). Fewer studies have examined stigma directed specifically toward the medications to treat OUD, particularly the agonist medications metha- done and buprenorphine. Stigma toward the opioid agonists appears to be grounded in the misperception that these medications are substituting one drug for another (Volkow et al., 2014). 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. adults reported believing that there is no effective treatment for OUD (Blendon and Benson, 2018). Similarly, attitudinal surveys and qualitative data collected from professional groups indicate high levels both of misÂ information and of stigma about agonist medication for OUD among per- sonnel within drug courts (Matusow et al., 2013) and in the prison system (McKenzie et al., 2009; Nunn et al., 2009). Semi-structured interviews with individuals with OUD using methadone confirm that this group experiences high rates of stigma related to their medication use in interactions with the public and with health care professionals (Woo et al., 2017). Some limited evidence suggests that as clinicians gain experience treating patients with OUD with buprenorphine, they gain more positive perceptions about the role of medications in effective treatment (Thomas et al., 2008). A systematic review of studies examining the consequences of the high rates of stigma experienced by individuals who use drugs found consistent evidence that stigma has a detrimental effect on their psychological well- being (Kulesza et al., 2013). In turn, shame or self-stigma is characterized as the internalization of the social opprobrium from public stigmatization that leads to the association of negative stereotypes with addiction (Â atthews M et al., 2017). While it makes intuitive sense that self-stigma would reduce treatment seeking (Olsen and Sharfstein, 2014), more research is needed
BARRIERS TO BROADER USE OF MEDICATIONS TO TREAT OUD 113 to better understand how self-stigma and negative attitudes toward OUD medications among people with OUD may inhibit an individual from enter- ing treatment. In the context of stigma, increasing attention has focused on the role of language in reinforcing negative perceptions about OUD (McGinty et al., 2017). Terms such as âsubstance abuserâ have been shown in randomized experiments to increase stigma relative to person-centered terms like âper- son with a substance use disorderâ (Kelly and Westerhoff, 2010). Other research studies based on randomized experiments have confirmed that the use of certain terms can reinforce blame of individuals with OUD and drive up stigma rates (Ashford et al., 2018a,b). Conversely, Ashford and col- leagues found that use of the term âpharmacotherapyâ produced more posiÂ tive associations than the term âmedication-assisted treatmentâ (Â shford et A al., 2018b). This research has prompted stigma-reduction efforts focused Â on language (McGinty et al., 2017; Wakeman, 2017). Recent efforts have Â included the release of a memorandum on terminology from the White House Office of National Drug Control Policy (ONDCP, 2017), 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). It will be critical to build an evidence base for effectively confronting stigma associated with medications for OUD, particularly opioid agonists. A small but growing body of evidence is being used to identify and test the effectiveness of communications strategies targeting the general public and professionals in key sectors (e.g., health care, law enforcement, correc- tions) in an effort to reduce stigma and to encourage higher rates of entry into medication-based treatment. There has also been a growing interest in increasing awareness of the benefits of medication for OUD and in decreas- ing stigma through communications campaigns (McGinty et al., 2017). Approaches highlighting the effectiveness of medication-based treatment in helping patients sustain remission (McGinty et al., 2015) and approaches presenting sympathetic narratives (Bachhuber et al., 2015)âparticularly those that illuminate the barriers that people with OUD face in trying to ac- cess treatment (Kennedy-Hendricks et al., 2016b)âhave been shown to be effective in reducing stigma, but they need to be studied further. CONCERNS ABOUT DIVERSION OF MEDICATIONS FOR OUD Concerns about the misuse and diversion of medications for OUD also contribute to the insufficient numbers of providers willing to prescribe them. Evidence suggests that these concerns emanate from stigma and mis- understanding about the motivations for using diverted medication. A fear of patients engaging in the diversion of medication is cited by prescribers
114 MEDICATIONS FOR OPIOID USE DISORDER SAVE LIVES as a barrier to treating individuals with OUD (Lin et al., 2018; Netherland et al., 2009). One national survey of buprenorphine prescribers found that one-third of respondents viewed diversion as a significant or very significant concern; half reported that they would no longer be willing to see a patient suspected of diversion (Lin et al., 2018). But education can help. A survey of both buprenorphine-waivered and non-waivered physicians found that 26 percent of non-waivered physicians were concerned about diversion, compared with 10 percent of waivered physicians (Huhn and Dunn, 2017). Providersâ concerns about the diversion of medication are inconsis- tent with available data, particularly in the context of medications that are formulated with deterrent properties, such as buprenorphine/naloxone. The buprenorphine/naloxone formulation was developed as a deterrent to misuse because it blocks the rewarding effects of opioids and triggers withdrawal if injected. Rates of misuse of the buprenorphine/naloxone for- mulation are much lower than for the mono-buprenorphine formulation. The Research Abuse, Diversion and Addiction-Related Surveillance System, which tracks the rates of misuse and diversion of medications, found that past-month injection use of mono-buprenorphine was 45 percent, compared with 16 percent for the buprenorphine/naloxone formulation (Lofwall and Walsh, 2014). Due to the higher rates of misuse of the mono-Â uprenorphine, b the combination product is the most commonly prescribed formulation. Of the different formulations of buprenorphine/naloxone, rates of both misuse and diversion are lowest for the buprenorphine/Â aloxone film (Lavonas et n al., 2014). Methadone diversion rates in the United States have been declin- Â ing by 13 percent each year since 2011 (Jones et al., 2016) 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. For instance, prescribed antibiotics and allergy medications are diverted at rates of 25 and 21 per- cent, respectively (Caviness et al., 2013; Goldsworthy et al., 2008; Lofwall and Walsh, 2014). Importantly, the rates of both misuse and diversion decline as bu- prenorphine availability increases (Cicero et al., 2007; Lofwall and Walsh, 2014). The reasons reported for misuse or diversion include peer pressure, a desire to help a friend or family member or to make money, and a lack of access to buprenorphine treatment (Fox et al., 2015; Lofwall and Walsh, 2014). While some individuals with OUD report misusing buprenorphine to achieve intoxication, more report using it to relieve symptoms of with- drawal (Lavonas et al., 2014).
BARRIERS TO BROADER USE OF MEDICATIONS TO TREAT OUD 115 INADEQUATE PROFESSIONAL EDUCATION AND TRAINING Another barrier to the availability and use of medications to treat OUD is the lack of appropriate education and training among health care proÂ viders and personnel in law enforcement and the judicial system. Health Workforce Education and Training A broad range of professions typically provide treatment or related services for addiction in the United States, including physicians, physician assistants (PAs), nurses, and nurse practitioners (NPs); psychologists, social workers, and therapists; pharmacists; and addiction counselors. However, few among the broad range of providers who may treat patients with addicÂ ion are trained in or knowledgeable about evidence-based practices t in addiction prevention and treatment. . . . Compounding this problem is that the diversity in education and training among the different types of individuals providing addiction treatment results in inconsistent treatment approaches and care for patients with addiction. (CASA, 2012, p. 178) Because addiction treatment is typically separate from mainstream health systems (Frank and Glied, 2016), education about OUD is often neither required nor standardized for health care providers in the United States. The American Board of Medical Specialties only recognized addic- tion medicine as a subspecialty in 2015 (ABMS, 2016), and many schools and training programs have limited access to experts to develop and teach curricula. Consequently, providers often lack the education required to ad- dress numerous aspects of OUD assessment and treatment (Merrill, 2002). Even though treating addiction has similarities to treating other chronic conditions, health education curricula do not educate all providers about addiction (Merrill et al., 2002; Moran et al., 2017). Integrating addiction treatment into mainstream health systems could expand treatment capacity Â and improve providersâ education about addiction medicine (Merrill, 2002). It should be noted, however, that the sole reliance on workforce education and training is not an assurance that evidence-based interventions will be implemented into standard care (Patterson Silver Wolf, 2015; Patterson Silver Wolf et al., 2017). Law Enforcement and Judicial System Education and Training For patients with OUD, critical treatment decisions often occur in the law enforcement and judicial systems rather than in medical settings. However, no policies are in place to require that the people making these decisions have received any education about evidence-based OUD treat-
116 MEDICATIONS FOR OPIOID USE DISORDER SAVE LIVES ment. Education and training about OUD for court officers could in- crease the uptake of medications to treat OUD. Probation and parole officers also need to be trained on medications used to treat people with OUD. Many prison medical directors limit treatment to abstinence-only or detoxification-only modalities for people with OUD in their prisons. A Â survey of prison medical directors across the United States revealed that many were not familiar with the medical and social benefits of providing Â medications for OUDâÂ articularly buprenorphineâin correctional facili- p ties (Nunn et al., 2009). Implementing methadone treatment in correctional facilities can be logistically complicated and impeded by stigma toward the medication among management and staff; however, those challenges can and should be addressed, given the potential health and social benefits to be gained by providing the medication (McKenzie et al., 2009). SYSTEM FRAGMENTATION The delivery and financing of treatment for people with OUD is rarely integrated with care delivered in the broader medical care system. Separate addiction treatment delivery settings and care financing streams are rein- forced 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. For example, while primary care settings are an important venue for providing care for most chronic medical conditions, these settings have not historically been a prominent locale for addiction treatment. Similarly, the sources of payment for SUD treatments differ in impor- tant respects from the broader medical care system. Compared to the gen- eral medical treatment sector, a substantially larger share of the financing of SUD treatmentâincluding OUD treatmentâcomes from public sources. In 2014, for example, 69 percent of SUD treatment was paid via public sources, including Medicaid (21 percent), Medicare (6 percent), other fed- eral sources (12 percent), and other state and local sources (29 percent) (SAMHSA, 2016). Only 18 percent of financing for SUD treatment is paid via private insurance: 9 percent paid by consumers out of pocket and 4 percent paid through other private sources (SAMHSA, 2016). A lack of care integration and underfunding are legacies of the historical separation of drug treatment from the mainstream system, with what limited funding exists coming primarily from state and local funding grants rather than through insurance programs (Buck, 2011). Unlike insurance, these funding sources can lead to waitlists if funded slots are insufficient to meet treat- ment needs within a community.
BARRIERS TO BROADER USE OF MEDICATIONS TO TREAT OUD 117 In the United States, a large share of SUD treatment has been provided through a network of specialty addiction treatment facilities, but only 6.1 percent of these facilities offered all three FDA-approved medications in 2016 (Mojtabai et al., 2019). The share of facilities offering methadone barely changed over the past decade, from 9.4 percent of facilities offering methadone in 2007 to 10.3 percent in 2016. The reasons why some facili- ties offer medications and others do not is not well understood, although the rates of offering medications for OUD are higher in regions with height- ened past-year heroin use and overdose death rates. The provision of medications for OUD in treatment facilities varies substantially across the country. Among outpatient specialty SUD treat- ment facilities, the highest rates of offering medications for OUD are found in Rhode Island (76.1 percent), New York (73.7 percent), and Vermont (73.7 percent). The states with the lowest rates of offering medications include Idaho (16.8 percent), Arkansas (14.1 percent), and Hawaii (8.6 per- cent) (Mojtabai et al., 2019). Recent estimates indicate that only 23 percent of publicly funded facilities in the country offer medication-based treatment for OUD (Knudsen et al., 2010). Among those facilities, the likelihood of medication being adopted and offered was greater in programs endors- ing cognitive behavioral therapy than in programs emphasizing 12-step approaches (Knudsen et al., 2010). Publicly funded programs are also less likely to have a physician on staff to prescribe medications for OUD (Abraham et al., 2013). System fragmentation poses barriers beyond the health care sector that extend to other settings with high prevalence rates of OUD. 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 incar- ceration, and the absence of strong connections with outpatient treatment in community settings offering medications upon release from incarceration (Fox et al., 2015). The implementation of comprehensive medication-based treatment programs for OUD in correctional settings has been shown to be feasible and is associated with significant mortality declines (Green et al., 2018). To better address this fragmentation, research is needed on system integration models. For example, research could explore how office-based collaborative care approaches used to treat depression in primary care with specialty consultation, care management, and peer support might work in the context of medication-based OUD treatment. Future research could focus on patient-centered care approaches that measure the preferences of individuals with OUD, including their preferred attributes of treatment or settings for receiving treatment. For example, some research suggests a higher willingness to pay for SUD treatment in primary care settings than
118 MEDICATIONS FOR OPIOID USE DISORDER SAVE LIVES in specialty addiction treatment settings (Epstein et al., 2015). In a large national sample of individuals who met the diagnostic criteria for SUD but were not currently in treatment, only 24.6 percent reported being willing to enter drug treatment in specialty settings, compared with 37.2 per- cent for primary care (Barry et al., 2016a). Additionally, little is known about patient preferences for integrated delivery system approaches, such Â as provider co-location, which allow individuals to receive addiction care alongside primary care and chronic or infectious disease management for co-occurring conditions. 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. As noted previously, methadone is the most stringently regulated of the three FDA-approved medications. It can be dispensed only by opioid treatment programs (OTPs) that are certified by the Substance Abuse and Mental Health Services Administration (SAMHSA) and registered with the Drug Enforcement Administration (DEA). Buprenorphine can only be prescribed for OUD by providers after they receive training and specialized certifica- tion by the DEA. In contrast, extended-release naltrexone can be prescribed by any licensed health care provider. Legal and Regulatory Barriers for Methadone In providing methadone, OTPs have limited flexibility in tailoring treat- ment plans to the individual needs of patients. Regulations with little to no evidence baseâwhich vary by stateâoften restrict take-home medication privileges, require supervised medication consumption, and mandate the frequency of urine testing and counseling. Patients receiving care through an OTP are mandated to receive counseling as part of their treatment. However, studies of the effectiveness of this counseling have not demon- strated differences in treatment retention or opioid use among patients randomized to receive little or no interaction with clinic drug counselors as compared with those who received the federally mandated level of coun- seling (Gruber et al., 2008; Schwartz et al., 2006, 2012; Yancovitz et al., 1991). See Chapter 2 for a more detailed discussion of behavioral interven- tions in conjunction with medication. Most patients receiving methadone are required to visit treatment programs daily to receive their medications. For some patients, these rigid and time-consuming requirements can impede their ability to find and maintain employment and can affect their relation-
BARRIERS TO BROADER USE OF MEDICATIONS TO TREAT OUD 119 ships; these requirements may also discourage providers from opening new treatment programs (Harris and McElrath, 2012). As a strategy to increase access to evidence-based treatment, there has been increased attention on removing regulatory barriers to prescribing methadone in primary care. Methadone may be prescribed in primary care clinics and filled in commu- nity pharmacies in Australia, Canada, and Great Britain (Merrill, 2002). Pilot studies examining the use of methadone in primary care suggest that this care delivery model is feasible and can positively affect treatment access and retention (Fiellin et al., 2001; Merrill et al., 2005). For example, a ran- domized controlled trial comparing office-based care versus OTP care for people who are stabilized on methadone treatment found physician officesÂ to be a feasible and effective setting for maintenance treatment (Fiellin et al., 2001). Calls are increasing to allow methadone to be prescribed for OUD in a wider range of medical settings (Samet et al., 2018). Legal and Regulatory Barriers for Buprenorphine and Naltrexone Buprenorphine is less stringently regulated at the federal level than methadone, but federal regulations on certification and state regulations on the scope of practice result in limited provider capacity. The Drug Addic- tion Treatment Act (DATA) of 2000 allowed physicians who completed an 8-hour course to become waivered by the DEA to prescribe buprenorphine in office-based settings. Initially, federal requirements limited waivered providers to treating only 30 patients with OUD in their first year of cer- tification and 100 thereafter. The Comprehensive Addiction and Recovery Act (CARA) of 20161 increased the maximum number of patients that waivered physicians could treat concurrently to 275 for physicians who met certain criteria, but the eligibility requirements may be difï¬cult for rural physicians to meet. Federal guidelines also require providers to reduce the risk of diversion and to provide patients with reasonable access to comple- Â mentary services, such as counseling (CRS, 2018). Fifty-six percent of U.S. counties now have a physician with a DEA waiver, which is an increase from 47 percent in 2012 (Andrilla et al., 2018b). CARA also allowed NPs and PAs who complete 24 hours of training to treat up to 30 patients concurrently in the ï¬rst year, and 100 patients in subsequent years, for a Â 5-year time period. In 2018 the Substance UseâDisorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Â Act permanently allowed NPs and PAs to prescribe buprenorphine. The bill further aims to increase access to medications for OUD by allowing nurse anesthetists, nurse midwives, and clinical nurse specialists to prescribe 1â Public Law 114-198.
120 MEDICATIONS FOR OPIOID USE DISORDER SAVE LIVES Â uprenorphine for the next 5 years.2 Twenty-eight states prohibit NPs from b prescribing buprenorphine without oversight by a waivered M.D. Three states (Oklahoma, Tennessee, and Wyoming) prohibit any prescribing of buprenorphine by NPs, and Kentucky prohibits prescribing by PAs. The inclusion of NPs and PAs in the workforce that can prescribe medication-based treatment has modestly increased the provider supply Â across the country. Among urban counties, 45.9 percent have a waivered NP and 24.5 percent have a waivered PA. Among rural counties, 13.8 per- cent have a waivered NP and 4.6 percent have a waivered PA (Andrilla et al., 2018b). The increase in the number of waivered providers is also reï¬ected in the changes in the provider-to-population ratios since 2012. In urban counties, the number of waivered physicians per 100,000 popula- tion increased from 6.3 to 11.0; furthermore, adding NPs and PAs to this provider workforce raised the current urban provider-to-population ratio to 12.4 (Andrilla et al., 2018a,b). Despite this progress, most providers who are waivered to prescribe buprenorphine maintain patient panels well below the regulated patient limits. According to one estimate, fewer than 30 percent of buprenorphine- waivered physicians were actually prescribing the medication, and less than 50 percent of waivered physicians had elected to be listed on SAMHSAâs physician and treatment locator site (Moran et al., 2017). Most waivered providers treat a small number of patients: half of providers treat five or fewer patients with buprenorphine and one-third treat just a single patient (Moran et al., 2017). Even if all waivered providers were prescribing at capacity, the treatment coverage would still be inadequate to meet the need for treatment for OUD. Estimates suggest that just half of all people with OUD would receive treatment if all waivered providers were prescribing at capacity (Huhn and Dunn, 2017; Jones et al., 2015; Murphy et al., 2014; Rosenblatt et al., 2015). Reasons cited by waivered physicians for not prescribing buprenorphine Â at capacity include a lack of time for new patients, concern about diver- sion, and reimbursement concerns (Huhn and Dunn, 2017; Molfenter et al., 2015). Another survey reported that diversion concerns were com- mon, especially among rural physicians (Andrilla et al., 2017). Waivered physicians tend to have partners who are also waivered (Hutchinson et al., 2014). 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). Waivered providers have also reported that the DEAâs approach can be âthreatening,â and some buprenorphine-waivered providers feel that they 2â See House amendment to Senate amendment to House of Representatives bill H.R. 6. https://www.congress.gov/115/bills/hr6/BILLS-115hr6eah.pdf (accessed February 12, 2019).
BARRIERS TO BROADER USE OF MEDICATIONS TO TREAT OUD 121 are unfairly scrutinized by the DEA (Moran et al., 2017). More recent aggressive enforcement strategies by the DEA and several state attorneys generalâincluding increases in raiding, auditing, and launching criminal investigations of waivered providersâperpetuate the fear of such surveil- lance that has been articulated by waivered and non-waivered providers (Mendoza et al., 2016). When asked about their willingness to prescribe buprenorphine, non- waivered providers report that they are concerned about attracting people who use drugs to their practices as well as about encountering resistance from clinical practice partners (Andrilla et al., 2017). Other reasons for not prescribing cited by non-waivered providers include concerns about managing the volume of patient requests for buprenorphine and concerns about buprenorphine diversion (Huhn and Dunn, 2017). In a survey of non-waivered providers, respondents indicated a number of factors that could increase their willingness to begin prescribing buprenorphine, in- cluding being provided with information about local counseling resources, Â having access to an experienced prescriber for consultation, and receiving continuing medical education about OUD (Huhn and Dunn, 2017). In a Â nother survey of family physicians, the barriers to adopting buprenorphine treatment included the lack of adequately trained office staff, a lack of time, inadequate office space, regulatory requirements, a mistrust of people with addiction, the perception of people with addiction as a difficult population, and poor perceived efficacy of buprenorphine treatment (DeFlavio et al., 2015). 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. Buprenorphine management is less risky and com- plicated than many other treatments that do not require special certification (Wakeman and Barnett, 2018). To expand access to buprenorphine treat- ment, there have been calls to eliminate prescribing limits on the grounds that there is no evidence base for limiting access to this medication (Fiscella et al., 2018). Another concern that has been raised involves the need to develop best practices to enhance the certification processes for prescribing clinicians and to better ensure high-quality prescribing practices (Blum et al., 2016). Relative to methadone and buprenorphine, the legal barriers to access- ing naltrexone are low. Naltrexone can be provided in an office setting with few regulatory requirements. The most common barrier to wider access identified by providers of naltrexone is related to its high cost, about $1,200 per monthly dose (Alanis-Hirsch et al., 2016).
122 MEDICATIONS FOR OPIOID USE DISORDER SAVE LIVES Privacy Regulations Privacy regulations, particularly 42 Code of Federal Regulations (CFR) part 2 regulations, present a gap in knowledge in terms of policy impact on individual behavior, as it is unclear whether they act to promote or dis- courage treatment initiation and retention. The 42 CFR part 2 regulations stipulate that a program that receives any federal fundingâÂncluding fund- i ing through the Medicaid or Medicare programsâand âholds itself out as providing . . . treatmentâ of SUDs may not disclose that its patients have a SUD or are in treatment without explicit patient consent or a court order (SAMHSA, 2018). Given the history of stigma and discrimination, this reg- ulation protects the privacy of patients with SUDs, similar to statutes pro- Â tecting sensitive health conditions like HIV. The regulation creates a high bar for disclosure of treatment status to indiÂ iduals or organizations, which v have the power to sanction patients for engaging in evidence-based medi- cal treatment, such as the criminal justice system, governmental agencies such as Child Protective Services, and housing corporations. In this way, privacy protections may encourage patients to seek treatment at specialized Â centers. At the same time, the special privacy protection contributes to the traditional separation of addiction treatment from the rest of medical care. Consequently, a patientâs primary care, inpatient, mental health, and SUD Â treatment provider may not be aware of the patientâs status in treatment for OUD, unless the patient chooses to disclose that status; this can complicate the patientâs overall medical treatment regimen and discourage continuity of treatment for OUD when a patient transitions from one care location to another. Another knowledge gap concerns differences in medical and pharmacy records and how this impacts patient treatment selection. Extended-release naltrexone is generally covered under a medical benefit and administered in a providerâs office, so the level of privacy depends on whether the provider is subject to 42 CFR part 2. On the other hand, state and re- gional Prescription Drug Monitoring Programs (PDMPs) track records of controlled substances, so the vast majority of patients who are main- tained on buprenorphine have their treatment status disclosed without their Â c Â onsentâwhether or not their providerâs medical record is subject to the 42 CFR part 2 regulations. Because methadone for OUD is provided only at licensed specialty programs, 42 CFR part 2 regulations prohibit disclosure of dispensed medication to the PDMP. PUBLIC AND PRIVATE INSURANCE BARRIERS Regulations that govern public and private insurance coverage pose substantial barriers to patientsâ ability to access medication-based treatment
BARRIERS TO BROADER USE OF MEDICATIONS TO TREAT OUD 123 for OUD. Adjusting policies related to coverage and reimbursement has the potential to expand access to life-saving medications across the country and to make headway against the opioid epidemic. Medicaid Medicaid is the single most important source of insurance coverage for individuals with OUD. It is the largest health insurance program in the United States, covering more than 62 million Americans, including millions of the nationâs lowest-income individuals and families. Medicaid covers an estimated 4 in 10 non-elderly adults with OUD (Zur and Tolbert, 2018), and more than $9 billion was paid by Medicaid for the treatment of OUD in 2016 alone (Niederee and Lawless, 2018). Research suggests that Medicaid coverage can help individuals access medication-based treatment for OUD and facilitate treatment retention. States that expanded access to Medicaid under the Patient Protection and Affordable Care Act (ACA) have experienced increased use of buprenorphine treatment (Saloner et al., 2018; Sharp et al., 2018; Wen et al., 2017). One analysis found that Medicaid expansion states were associated with a 70 percent increase in buprenorphine prescriptions covered by Medicaid and a 50 percent increase in buprenorphine spending (Wen et al., 2017). Having stable Medicaid Â eligibility is also assoÂ iated with higher rates of retention on medication c for OUD (Deck et al., 2009). One study found a 50 percent lower risk of return to use among Medicaid enrollees treated with medication relative to other treatments, and longer treatment duration among Medicaid enrollees was associated with lower return to use rates (Clark et al., 2011). Among publicly funded addiction treatment organizations, reliance on Medicaid reimbursement has been positively associated with offering medications for OUD (Knudsen et al., 2010). Under one stateâs Medicaid program, enrollees treated with OUD medication had lower overall health care expenditures; coupled with reduced medical care costs, this offset the cost of medication- based treatment for OUD (Mohlman et al., 2016). Conversely, the elimina- tion of Medicaid coverage for active methadone patients under one stateâs Medicaid program led to negative outcomes for patients with OUD, includ- ing an increased inability to afford treatment, increased property crimes, greater frequency of medical care visits, and employment-related challenges (Fuller et al., 2006). Important gaps remain in Medicaid coverage for medications to treat OUD. One survey identified five states that excluded both buprenorphine and methadone from their Medicaid coverage policies (Burns et al., 2016); 14 states lack any facility that offers medication-based treatment and also accepts Medicaid coverage for OUD (Jones et al., 2018). Use manage- ment policies under Medicaid serve as additional barriers to medication
124 MEDICATIONS FOR OPIOID USE DISORDER SAVE LIVES access, including prior-authorization requirements, formulary restrictions, and restrictions on treatment duration and doses (Moran et al., 2017). In addition, new approaches being instituted in some state Medicaid programs through section 1115 waivers including work requirements, increased cost- sharing 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 medica- tion for OUD (Somers et al., 2018). Medicaid and Incarceration Importantly, Medicaid expansion under the ACA has created unprec- edented opportunities for addressing the low rates of insurance coverage among individuals with OUD who are returning to the community follow- ing incarceration. Medicaid expansion meaningfully affects justice-involved individuals, which is a group that consists disproportionally of low-income men who have historically been excluded from Medicaid coverage (Â uellar C and Cheema, 2012). Birnbaum and colleagues report that nearly all crimi- nal justiceâinvolved individuals are eligible for Medicaid in expansion states upon release (Birnbaum et al., 2014). By federal regulation, how- ever, Medicaid dollars cannot be used to cover health care provided while Â a person is incarcerated (Somers et al., 2014). Medicaid coverage must be terminated or suspended during periods of incarceration (Gates et al., 2014; Rosen et al., 2014). Typically, people on medication-based treatment for OUD who become incarcerated are rapidly tapered off medication, and people with OUD are rarely initiated on medication-based treatment while incarcerated. For people who are discontinued when incarcerated, being disconnected from care contributes to lost opportunities to more cost-effectively and humanely treat chronic diseases; it also perpetuates extremely high overdose mortality risk upon release. For an inmate leav- ing incarceration in states that terminate Medicaid benefits, re-enrolling in coverage can cause months-long delays that contribute to disruptions in the receipt of care. Such disruption has negative clinical impacts for patients with OUD. Some states are instituting policies to lower the barriers to Medicaid coverage for justice-involved individuals, including those with OUD (Bandara et al., 2015). Those policies include suspending rather than terminating Medicaid benefits during incarceration, allowing enrollment in Medicaid during incarceration, and presumptive eligibility policy options. Private Insurance Private insurance also offers important opportunities for expanding access to medications for OUD. Evidence suggests an association between
BARRIERS TO BROADER USE OF MEDICATIONS TO TREAT OUD 125 gaining private health insurance and accessing medication-based treatment for OUD. One study of individuals injecting drugs found that when partici- pants acquired private insurance, the likelihood that they would report a buprenorphine prescription and a regular source of medical care increased (Feder et al., 2018). However, until recently, private coverage for SUD treat- ment required higher cost sharing and special annual service caps relative to the insurance benefits for other medical conditions (Barry and Sindelar, 2007; Gabel et al., 2007). A number of recent policy changes have lowered barriers to receiving medication-based treatment for OUD paid for via insurance. The Mental Health Parity Act of 1996 (MHPA) mandated that large-group health plans cannot impose annual or lifetime dollar limits on mental health benefits that are less favorable than any such limits imposed on medical and surgi- cal benefits. 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). Federal parity also increased inpatient SUD admissions. Some evidence also suggests that the parity ensured by this law led to a decrease in the financial burden on families of paying for addiction treatment via commercial insurance (Azzone et al., 2011). Importantly, parity requirements and other insurance market changes extend private health insurance to more individuals with OUD. These include the âdepen- dent careâ provision, which allows children to be kept on their parentsâ insurance until the age of 26 years, as well as the ACA ban of the once common insurance industry practice of refusing to sell insurance policies to individuals with pre-existing disorders (Barry et al., 2016b; Humphreys and Frank, 2014). Nonetheless, barriers continue to prevent access to medication for OUD under private insurance. For example, a recent study of benefits in 2017 marketplace plans found that 14 percent of health plans did not cover any formulations of buprenorphine/naloxone. Despite the new patient pro- tections, plans were more likely to require prior authorization for covered office-based buprenorphine or naltrexone treatment than for short-acting opioid pain medications. Only 10.6 percent of plans covered implantable buprenorphine, while 26.1 percent covered injectable naltrexone (Huskamp et al., 2018). Reimbursement and Payment System Barriers Research indicates that altering reimbursement and payment incentives could lower the barriers to accessing medications for OUD. Reimbursement
126 MEDICATIONS FOR OPIOID USE DISORDER SAVE LIVES concernsâsome of which are specific to Medicaid (Quest et al., 2012)âare a commonly cited barrier to buprenorphine prescribing, particularly among waivered physicians (Barry et al., 2009). The predominant fee-for-service model of reimbursement for providers rewards quantity rather than care quality (Fodeman, 2017). Efforts are under way to address this by shifting to value-based payment systems through accountable care and payment reforms (e.g., global payment, bundled payment). Payment changes that drive health systems to provide high-value care could be instrumental in increasing OUD medication-based treatment rates. 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). A 2006 Institute of Medicine report made sweeping recommenda- tions to improve the quality of SUD care in the United States, but few of those recommendations have been implemented (IOM, 2006).Â The lack of performance metrics for measuring the uptake of OUD medication poses additional barriers to progress (Thomas et al., 2011). An important area in which SUD care is lagging behind the rest of the medical care sector is the development, evaluation, and implementation of healthÂ quality measures aimed at increasing patientsâ access to medications and their continuation in evidence-based treatment for OUD; these measures include metrics that can be used in value-based payment systems (Pincus et al., 2016). For ex- ample, a performance metric for OUD medication could track and reward providers who are able to maintain a sizable share of their patient popula- tions in longer-term, medication-based treatment. Other types of payment incentives might also be consideredâfor example, requiring that substance use treatment facilities receiving federal block grant funding provide medi- cations for OUD as a condition of participation.
BARRIERS TO BROADER USE OF MEDICATIONS TO TREAT OUD 127 Conclusion 7: Confronting the major barriers to the use of medications to treat opioid use disorder is critical to addressing the opioid crisis. The major barriers to the use of medications for OUD include â¢â igh levels of misunderstanding and stigma toward H drug addiction, individuals with OUD, and the medica- tions to treat it. â¢ânadequate education of the professionals responsible I for working with people with OUD, including treatment providers and law enforcement and other criminal jus- tice personnel. â¢â urrent regulations around methadone and Â 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. â¢â he fragmented system of care for people with OUD T and current financing and payment policies. REFERENCES ABMS (American Board of Medical Specialties). 2016. ABMS officially recognizes addiction medicine as a subspecialty. Press Release on March 14, 2016. https://www.abms.org/ news-events/abms-officially-recognizes-addiction-medicine-as-a-subspecialty (accessed Feburary 28, 2019). Abraham, A. J., H. K. Knudsen, T. Rieckmann, and P. M. Roman. 2013. Disparities in ac- cess to physicians and medications for the treatment of substance use disorders between publicly and privately funded treatment programs in the United States. Journal of Studies on Alcohol and Drugs 74(2):258â265.
128 MEDICATIONS FOR OPIOID USE DISORDER SAVE LIVES Alanis-Hirsch, K., R. Croff, J. H. Ford, K. Johnson, M. Chalk, L. Schmidt, and D. McCarty. 2016. Extended-release naltrexone: A qualitative analysis of barriers to routine use. Journal of Substance Abuse Treatment 62:68â73. Alexander, L., and B. G. Link. 2003. The impact of contact on stigmatizing attitudes toward people with mental illness. Journal of Mental Health 12(3):271â289. Aliferis, L. 2017. In stylebook, AP directs its reporters: Addiction is a disease. California Health Care Foundation, June 13. https://www.chcf.org/blog/in-stylebook-ap-directs-its- reporters-addiction-is-a-disease (accessed February 12, 2019). Andrilla, C. H. A., C. Coulthard, and E. H. Larson. 2017. Barriers rural physicians face pre- scribing buprenorphine for opioid use disorder. Annals of Family Medicine 15(4):359â362. Andrilla, C. H. A., C. Coulthard, and D. G. Patterson. 2018a. Prescribing practices of rural physicians waivered to prescribe buprenorphine. American Journal of Preventive Medi- cine 54(6S3):208â214. Andrilla, C. H. A., T. E. Moore, D. G. Patterson, and E. H. Larson. 2018b. Geographic dis- tribution of providers with a DEA waiver to prescribe buprenorphine for the treatment of opioid use disrder: A 5-year update. Journal of Rural Health 35(1):108â112. Ashford, R. D., A. M. Brown, and B. Curtis. 2018a. The language of substance use and recovery: Novel use of the go/no-go association task to measure implicit bias. Health Communication June 4:1â7. Ashford, R. D., A. M. Brown, and B. Curtis. 2018b. Substance use, recovery, and linguistics: The impact of word choice on explicit and implicit bias. Drug and Alcohol Dependence 189:131â138. Azzone, V., R. G. Frank, S. L. Normand, and M. A. Burnam. 2011. Effect of insurance parity on substance abuse treatment. Psychiatric Services 62(2):129â134. Bachhuber, M. A., E. E. McGinty, A. Kennedy-Hendricks, J. Niederdeppe, and C. L. Barry. 2015. Messaging to increase public support for naloxone distribution policies in the United States: Results from a randomized survey experiment. PLOS ONE 10(7):e0130050. Bandara, S. N., H. A. Huskamp, L. E. Riedel, E. E. McGinty, D. Webster, R.E. Toone, and C. L. Barry. 2015. Leveraging the Affordable Care Act to enroll justice-involved popula- tions in Medicaid: State and local efforts. Health Affairs (Millwood) 34(12):2044â2051. Barry, C. L., and J. L. Sindelar. 2007. Equity in private insurance coverage for substance abuse: A perspective on parity. Health Affairs (Millwood) 26(6):w706âw716. Barry, C. L., E. E. McGinty, B. A. Pescosolido, and H. H. Goldman. 2014. Stigma, discrimina- tion, treatment effectiveness, and policy: Public views about drug addiction and mental illness. Psychiatric Services 65(10):1269â1272. Barry, C. L., A. J. Epstein, D. A. Fiellin, L. Fraenkel, and S. H. Busch. 2016a. Estimating demand for primary care-based treatment for substance and alcohol use disorders. Â ddiction 111(8):1376â1384. A Barry, C. L., H. H. Goldman, and H. A. Huskamp. 2016b. Federal parity in the evolving mental health and addiction care landscape. Health Affairs (Millwood) 35(6):1009â1016. Barry, D. T., K. S. Irwin, E. S. Jones, W. C. Becker, J. M. Tetrault, L. E. Sullivan, H. Hansen, P. G. OâConnor, R. S. Schottenfeld, and D. A. Fiellin. 2009. Integrating buprenorphine treatment into office-based practice: A qualitative study. Journal of General Internal Medicine 24(2):218â225. Birnbaum, N., M. Lavoie, N. Redmond, C. Wildeman, and E. A. Wang. 2014. Termination of Medicaid policies and implications for the Affordable Care Act. American Journal of Public Health 104(8):e3âe4. Blanco, C., M. Iza, R. P. Schwartz, C. Rafful, S. Wang, and M. J. D. Olfson. 2013. Probability and predictors of treatment-seeking for prescription opioid use disorders: A national study. Drug and Alcohol Dependence 131(1â2):143â148.
BARRIERS TO BROADER USE OF MEDICATIONS TO TREAT OUD 129 Blendon, R. J., and J. M. Benson. 2018. The public and the opioid-abuse epidemic. New England Journal of Medicine 378(5):407â411. Blum, K., M. Gold, H. W. Clark, K. Dushaj, and R. D. Badgaiyan. 2016. Should the United States government repeal restrictions on buprenorphine/naloxone treatment? Substance Use & Misuse 51(12):1674â1679. Brondani, M. A., R. Alan, and L. Donnelly. 2017. Stigma of addiction and mental illness in healthcare: The case of patientsâ experiences in dental settings. PLOS ONE 12(5): e0177388. Buck, J. A. 2011. The looming expansion and transformation of public substance abuse treatment under the Affordable Care Act. Health Affairs. https://www.healthaffairs.org/ doi/10.1377/hlthaff.2011.0480 (accessed February 20, 2019). Bullock, H. E., K. F. Wyche, and W. R. Williams. 2001. Media images of the poor. Journal of Social Issues 57:229â246. Burns, R. M., R. L. Pacula, S. Bauhoff, A. J. Gordon, H. Hendrikson, D. L. Leslie, and B. D. Stein. 2016. Policies related to opioid agonist therapy for opioid use disorders: The evolu- tion of state policies from 2004â2013. Substance Abuse 37(1):63â69. Capitanio, J. P., and G. M. Herek. 1999. AIDS-related stigma and attitudes toward injectÂ ing drug users among black and white Americans. American Behavioral Scientist 42(7):1148â1161. CASA (Center on Addiction and Substance Abuse at Columbia University). 2012. Addiction medicine: Closing the gap between science and practice. New York. https://ia800406. us.archive.org/10/items/781862-casa-columbia-addiction-med/781862-casa-Âcolumbia- addiction-med.pdf (accessed Februrary 28, 2019). Caviness, C. M., B. J. Anderson, M. A. de Dios, M. Kurth, and M. Stein. 2013. Prescription medication exchange patterns among methadone maintenance patients. Drug and Alco- hol Dependence 127(1â3):232â238. Cicero, T. J., H. L. Surratt, and J. Inciardi. 2007. Use and misuse of buprenorphine in the management of opioid addiction. Journal of Opioid Management 3(6):302â308. Clark, R. E., M. Samnaliev, J. D. Baxter, and G. Y. Leung. 2011. The evidence doesnât justify steps by state medicaid programs to restrict opioid addiction treatment with Âbuprenorphine. Health Affairs 30(8):1425â1433. Corrigan, P. W., S. B. Morris, P. J. Michaels, J. D. Rafacz, and N. Rusch. 2012. Challeng- ing the public stigma of mental illness: A meta-analysis of outcome studies. Psychiatric Services 63(10):963â973. Couture, S. M., and D. L. Penn. 2003. Interpersonal contact and the stigma of mental illness: A review of the literature. Journal of Mental Health 12(3):291â305. CRS (Congressional Research Service). 2018. Buprenorphine and the opioid crisis: A primer for Congress. https://fas.org/sgp/crs/misc/R45279.pdf (accessed February 12, 2019). Cuellar, A. E., and J. Cheema. 2012. As roughly 700,000 prisoners are released annu- ally, about half will gain health coverage and care under federal laws. Health Affairs (ÂMillwood) 31(5):931â938. Deck, D., W. Wiitala, B. McFarland, K. Campbell, J. Mullooly, A. Krupski, and D. McCarty. 2009. Medicaid coverage, methadone maintenance, and felony arrests: Outcomes of o Â piate treatment in two states. Journal of Addictive Diseases 28(2):89â102. DeFlavio, J. R., S. A. Rolin, B. R. Nordstrom, and L. A. Kazal, Jr. 2015. Analysis of Â arriers b to adoption of buprenorphine maintenance therapy by family physicians. Rural and Remote Health 15:3019. Epstein, A. J., C. L. Barry, D. A. Fiellin, and S. H. Busch. 2015. Consumersâ valuation of pri- mary care-based treatment options for mental and substance use disorders. Psychiatric Services 66(8):772â774.
130 MEDICATIONS FOR OPIOID USE DISORDER SAVE LIVES Feder, K. A., Krawczyk, R. Mojtabai, R. M. Crum, G. Kirk, and S. H. Mehta. 2018. Health i Ânsurance coverage is associated with access to substance use treatment among indi- viduals with injection drug use: Evidence from a 12-year prospective study. Journal of Substance Abuse Treatment 96:75â81. Fiellin, D. A., P. G. OâConnor, M. Chawarski, J. P. Pakes, M. V. Pantalon, and R. S. S Â chottenfeld. 2001. Methadone maintenance in primary care: A randomized controlled trial. JAMA 286(14):1724â1731. Fiscella, K., S. E. Wakeman, and L. Beletsky. 2018. Buprenorphine deregulation and main- streaming treatment for opioid use disorder. JAMA Psychiatry, December 26 [Epub ahead of print]. Fodeman, J. D. 2017. The opioid epidemic and the role of reimbursement. Healthcare Trans- formation 2(1). March 1. https://www.liebertpub.com/doi/full/10.1089/heat.2017.29036. jdf (accessed February 12, 2019). Fox, A. D., J. Maradiaga, L. Weiss, J. Sanchez, J. L. Starrels, and C. O. Cunningham. 2015. Release from incarceration, relapse to opioid use, and the potential for buprenorphine maintenance treatment: A qualitative study of the perceptions of former inmates with opioid use disorder. Addiction Science & Clinical Practice 10(1):2. Frank, G., and A. Glied. 2006. Better but not well: Mental health policy in the United States since 1950. Baltimore, MD: Johns Hopkins University Press. Fuller, B. E., T. R. Rieckmann, D. J. McCarty, R. Ringor-Carty, and S. Kennard. 2006. Elimination of methadone benefits in the Oregon health plans and its effects on patients. Psychiatric Services 57(5):686â691. Gabel, J. R., H. Whitmore, J. D. Pickreign, K. R. Levit, R. M. Coffey, and R. Vandivort- Warren. 2007. Substance abuse benefits: Still limited after all these years. Health Affairs (Millwood) 26(4):w474âw482. Gates, A., S. Artiga, and R. Rudowitz. 2014. Health coverage and care for the adult crimi- nal justice-involved population. Kaiser Family Foundation. September 5. https://www. kff.org/uninsured/issue-brief/health-coverage-and-care-for-the-adult-criminal-justice- involved-population (accessed February 12, 2019). Goldsworthy, R. C., N. C. Schwartz, and C. B. Mayhorn. 2008. Beyond abuse and exposure: framing the impact of prescription-medication sharing. American Journal of Public Health 98(6):1115â1121. Green, T. C., J. Clarke, L. Brinkley-Rubinstein, B. D. L. Marshall, N. Alexander-Scott, R. Boss, and J. D. Rich. 2018. Postincarceration fatal overdoses after implementing medications for addiction treatment in a statewide correctional system. JAMA Psychiatry 75(4):405â407. Gruber, V. A., K. L. Delucchi, A. Kielstein, and S. L. Batki. 2008. A randomized trial of 6-month methadone maintenance with standard or minimal counseling versus 21-day methadone detoxification. Drug and Alcohol Dependence 94(1â3):199â206. Harris, J., and K. McElrath. 2012. Methadone as social control: Institutionalized stigma and the prospect of recovery. Qualitative Health Research 22(6):810â824. Huhn, A. S., and K. E. Dunn. 2017. Why arenât physicians prescribing more buprenorphine? Journal of Substance Abuse Treatment 78:1â7. Humphreys, K., and R. G. Frank. 2014. The Affordable Care Act will revolutionize care for substance use disorders in the United States. Addiction 109(12):1957â1958. Huskamp, H. A., L. E. Riedel, C. L. Barry, and A. B. Busch. 2018. Coverage of medication that treat opioid use disorder and opioids for pain management in marketplace plans, 2017. Medical Care 56(6):505â509. Hutchinson, E., M. Catlin, C. H. A. Andrilla, L.-M. Baldwin, and R. A. Rosenblatt. 2014. Barriers to primary care physicians prescribing buprenorphine. Annals of Family Medi- cine 12(2):128â133.
BARRIERS TO BROADER USE OF MEDICATIONS TO TREAT OUD 131 IOM (Institute of Medicine). 2006. Improving the quality of health care for mental and substance-use conditions. Washington, DC: The National Academies Press. Jones, A., B. Honermann, A. Sharp, and G. Millett. 2018. Where multiple modes of Â edication-assisted treatment are available. Health Affairs blog, January 9. https://www. m healthaffairs.org/do/10.1377/hblog20180104.835958/full (accessed February 12, 2019). Jones, C. M., and E. F. McCance-Katz. 2019. Co-occurring substance use and mental disorders among adults with opioid use disorder. Drug and Alcohol Dependence 197(1):78â82. doi: 10.1016/j.drugalcdep.2018.12.030. Jones, C. M., M. Campopiano, G. Baldwin, and E. McCance-Katz. 2015. National and state treatment need and capacity for opioid agonist medication-assisted treatment. American Journal of Public Health 105(8):e55âe63. Jones, C. M., G. T. Baldwin, T. Manocchio, J. O. White, and K. A. Mack. 2016. Trends in methadone distribution for pain treatment, methadone diversion, and overdose deathsâ United States, 2002â2014. U.S. Centers for Disease Control and Prevention. https://www. cdc.gov/mmwr/volumes/65/wr/mm6526a2.htm (accessed February 12, 2019). Kelly, J. F., and C. M. Westerhoff. 2010. Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms. Inter- national Journal of Drug Policy 21(3):202â207. Kennedy-Hendricks, A., S. H. Busch, E. E. McGinty, M. A. Bachhuber, J. Niederdeppe, S. E. Gollust, D. W. Webster, D. A. Fiellin, and C. L. Barry. 2016a. Primary care physi- ciansâ perspectives on the prescription opioid epidemic. Drug and Alcohol Dependence 165:61â70. Kennedy-Hendricks, A., E. E. McGinty, and C. L. Barry. 2016b. Effects of competing narra- tives on public perceptions of opioid pain reliever addiction during pregnancy. Journal of Health Politics, Policy, and Law 41(5):873â916. Kennedy-Hendricks, A., C. L. Barry, S. E. Gollust, M. E. Ensminger, M. S. Chisolm, and E. E. McGinty. 2017. Social stigma toward persons with prescription opioid use disorder:Â AssoÂiations with public support for punitive and public health-oriented policies. c Â sychiatric Services 68(5):462â469. P Knudsen, H. K., P. M. Roman, and C. B. Oser. 2010. Facilitating factors and barriers to the use of medications in publicly funded addiction treatment organizations. Journal of ÂAddiction Medicine 4(2):99â107. Kulesza, M., M. E. Larimer, and D. Rao. 2013. Substance use related stigma: What we know and the way forward. Journal of Addictive Behaviors, Therapy, & Rehabilitation 2(2):782. Lavonas, E. J., S. G. Severtson, E. M. Martinez, B. Bucher-Bartelson, M. C. Le Lait, J. L. Green, L. E. Murrelle, T. J. Cicero, S. P. Kurtz, A. Rosenblum, H. L. Surratt, and R. C. Dart. 2014. Abuse and diversion of buprenorphine sublingual tablets and film. Journal of Substance Abuse Treatment 47(1):27â34. Lin, L. A., M. R. Lofwall, S. L. Walsh, A. J. Gordon, and H. K. Knudsen. 2018. Perceptions and practices addressing diversion among U.S. buprenorphine prescribers. Drug and Alcohol Dependence 186:147â153. Link, B. G., and J. C. Phelan. 2001. Conceptualizing stigma. Annual Review of Sociology 27:363â385. Livingston, J. D., E. Adams, M. Jordan, Z. MacMillan, and R. Hering. 2018. Primary care physiciansâ views about prescribing methadone to treat opioid use disorder. Substance Use & Misuse 53(2):344â353. Lofwall, M. R., and S. L. Walsh. 2014. A review of buprenorphine diversion and misuse: The current evidence base and experiences from around the world. Journal of Addiction Medicine 8(5):315â326.
132 MEDICATIONS FOR OPIOID USE DISORDER SAVE LIVES Matthews, S., R. Dwyer, and A. Snoek. 2017. Stigma and self-stigma in addiction. Journal of Bioethical Inquiry 14(2):275â286. Matusow, H., S. L. Dickman, J. D. Rich, C. Fong, D. M. Dumont, C. Hardin, D. Marlowe, and A. Rosenblum. 2013. Medication assisted treatment in us drug courts: Results from a nationwide survey of availability, barriers, and attitudes. Journal of Substance Abuse Treatment 44(5):473â480. McDowell, M. J., A. B. Busch, A. P. Sen, E. A. Stuart, L. Riedel, C. L. Barry, and H. A. Huskamp. 2018. Participation in accountable care organizations among hospitals offering substance use disorder and mental health services. Psychiatric Services. https://ps.psychiatryonline. org/doi/abs/10.1176/appi.ps.201800248?rfr_dat=cr_pub%3Dpubmed&url_ver=Z39.88- 2003&rfr_id=ori%3Arid%3Acrossref.org&journalCode=ps (accessed February 18, 2019). McGinty, E. E., H. H. Goldman, B. Pescosolido, and C. L. Barry. 2015. Portraying mental illness and drug addiction as treatable health conditions: Effects of a randomized experi- ment on stigma and discrimination. Social Science & Medicine 126:73â85. McGinty, E., B. Pescosolido, A. Kennedy-Hendricks, and C. L. Barry. 2017. Communication strategies to counter stigma and improve mental illness and substance use disorder policy. Psychiatric Services 69(2):136â146. McKenzie, M., A. Nunn, N. D. Zaller, A. R. Bazazi, and J. D. Rich. 2009. Overcoming ob- stacles to implementing methadone maintenance therapy for prisoners: Implications for policy and practice. Journal of Opioid Management 5(4):219â227. McSween, J. L. 2002. The role of group interest, identity, and stigma in determining mental health policy preferences. Journal of Health Politics, Policy, and Law 27(5):773â800. Mendoza, S., A. S. Rivera-Cabrero, and H. Hansen. 2016. Shifting blame: Buprenorphine prescribers, addiction treatment, and prescription monitoring in middle-class America. Transcult Psychiatry 53(4):465â487. Merrill, J. O. 2002. Policy progress for physician treatment of opiate addiction. Journal of General Internal Medicine 17(5):361â368. Merrill, J. O., L. A. Rhodes, R. A. Deyo, G. A. Marlatt, and K. A. Bradley. 2002. Mutual mistrust in the medical care of drug users: The keys to the ânarcâ cabinet. Journal of General Internal Medicine 17(5):327â333. Merrill, J. O., T. R. Jackson, B. A. Schulman, A. J. Saxon, A. Awan, S. Kapitan, M. Carney,Â L. C. Brumback, and D. Donovan. 2005. Methadone medical maintenance in primary care: An implementation evaluation. Journal of General Internal Medicine 20(4):344â349. Minior, T., S. Galea, J. Stuber, J. Ahern, and D. Ompad. 2003. Racial differences in discrimi- nation experiences and responses among minority substance users. Ethnicity & Disease 13(4):521â527. Mohlman, M. K., B. Tanzman, K. Finison, M. Pinette, and C. Jones. 2016. Impact of medica- tion-assisted treatment for opioid addiction on medicaid expenditures and health services utilization rates in Vermont. Journal of Substance Abuse Treatment 67:9â14. Mojtabai, R., C. Mauro, M. M. Wall, C. L. Barry, and M. Olfson. 2019. Medication treatment for opioid use disorders in substance use treatment facilities. Health Affairs 38(1):14â23. Molfenter, T., C. Sherbeck, M. Zehner, A. Quanbeck, D. McCarty, J. S. Kim, and S. Starr. 2015. Implementing buprenorphine in addiction treatment: Payer and provider perspec- tives in Ohio. Substance Abuse Treatment, Prevention, and Policy 10:13. Moran, G. E., C. M. Snyder, R. F. Noftsinger, and J. K. Noda. 2017. Implementing medica- tion-assisted treatment for opioid use disorder in rural primary care: Environmental scan. Rockville, MD: Agency for Healthcare Research and Quality. Morone, J. A. 1997. Enemies of the people: The moral dimension to public health. Journal of Health Politics, Policy, and Law 22(4):993â1020.
BARRIERS TO BROADER USE OF MEDICATIONS TO TREAT OUD 133 Murphy, S. M., P. A. Fishman, S. McPherson, D. G. Dyck, and J. R. Roll. 2014. Determinants of buprenorphine treatment for opioid dependence. Journal of Substance Abuse Treat- ment 46(3):315â319. Netherland, J., and H. B. Hansen. 2016. The war on drugs that wasnât: Wasted whiteness, âdirty doctors,â and race in media coverage of prescription opioid misuse. Culture, Medicine, and Psychiatry 40(4):664â686. Netherland, J., M. Botsko, J. E. Egan, A. Saxon, C. Cunningham, R. Finkelstein, M. G Â ourevitch, J. A. Renner, L. Weiss, and D. Fiellin. 2009. Factors affecting willingness to provide buprenorphine treatment. Journal of Substance Abuse Treatment 36(3):244â251. Niederee, K., and J. Lawless. 2018. Hatch, Wyden seek feedback to improve Medicare, Â edicaid responses to opioid epidemic. U.S. Senate Committee on Finance. https://www. M finance.senate.gov/chairmans-news/hatch-wyden-seek-feedback-to-improve-medicare- medicaid-responses-to-opioid-epidemic (accessed February 12, 2019). Nunn, A., N. Zaller, S. Dickman, C. Trimbur, A. Nijhawan, and J. D. Rich. 2009. Methadone and buprenorphine prescribing and referral practices in U.S. prison systems: Results from a nationwide survey. Drug and Alcohol Dependence 105(1â2):83â88. Olsen, Y., and J. M. Sharfstein. 2014. Confronting the stigma of opioid use disorderâand its treatment. JAMA 311(14):1393â1394. ONDCP (Office of National Drug Control Policy). 2017. Changing the language of addiction. https://www.whitehouse.gov/sites/whitehouse.gov/files/images/Memo%20-%20Changing %20Federal%20Terminology%20Regrading%20Substance%20Use%20and%20 Substance%20Use%20Disorders.pdf (accessed February 12, 2019). Patterson Silver Wolf, D. A. 2015. Factors influencing the implementation of a brief alcohol screening and educational intervention in social settings not specializing in addiction services. Social Work in Health Care 54(4):345â364. Patterson Silver Wolf, D. A., C. van den Berk-Clark, S.-L. Williams, and C. N. Dulmus. 2017. Are therapists likely to use a new empirically supported treatment if required? Journal of Social Work 18(6):666â678. Pincus, H. A., S. H. Scholle, B. Spaeth-Rublee, K. A. Hepner, and J. Brown. 2016. Quality measures for mental health and substance use: Gaps, opportunities, and challenges. Health Affairs 35:1000â1008. Quest, T. L., J. O. Merrill, J. Roll, A. J. Saxon, and R. A. Rosenblatt. 2012. Buprenorphine therapy for opioid addiction in rural Washington: The experience of the early adopters. Journal on Opioid Management 8(1):29â38. Rich, J. D., A. E. Boutwell, D. C. Shield, R. G. Key, M. McKenzie, J. G. Clarke, and P. D. Friedmann. 2005. Attitudes and practices regarding the use of methadone in U.S. state and federal prisons. Journal of Urban Health 82(3):411â419. Rosen, D. L., D. M. Dumont, A. M. Cislo, B. W. Brockmann, A. Traver, and J. D. Rich. 2014. Medicaid policies and practices in U.S. state prison systems. American Journal of Public Health 104(3):418â420. Rosenblatt, R. A., C. H. Andrilla, M. Catlin, and E. H. Larson. 2015. Geographic and spe- cialty distribution of us physicians trained to treat opioid use disorder. Annals of Family Medicine 13(1):23â26. Saloner, B., J. Levin, H. Chang, C. Jones, and G. Alexander. 2018. Changes in buprenorphine- naloxone and opioid pain reliever prescriptions after the Affordable Care Act Medicaid expansion. JAMA Network Open 1(4):e181588. Samet, J. H., M. Botticelli, and M. Bharel. 2018. Methadone in primary careâOne small step for Congress, one giant leap for addiction treatment. New England Journal of Medicine 379(1):7â8.
134 MEDICATIONS FOR OPIOID USE DISORDER SAVE LIVES SAMHSA (Substance Abuse and Mental Health Services Administration). 2016. Behavioral health spending and use accounts 1986â2014. Rockville, MD: Substance Abuse and Mental Health Services Administration. https://store.samhsa.gov/system/files/sma16- 4975.pdf (accessed February 12, 2019). SAMHSA. 2018. 42 CFR part 2 confidentiality of substance use disorder patient records. Rockville, MD: Substance Abuse and Mental Health Services Administration. https:// www.samhsa.gov/health-information-technology/laws-regulations-guidelines (accessed Februrary 22, 2019). Schwartz, R. P., D. A. Highfield, J. H. Jaffe, J. V. Brady, C. B. Butler, C. O. Rouse, J. M. C Â allaman, K. E. OâGrady, and R. J. Battjes. 2006. A randomized controlled trial of i Ânterim methadone maintenance. Archives of General Psychiatry 63(1):102â109. Schwartz, R. P., S. M. Kelly, K. E. OâGrady, D. Gandhi, and J. H. Jaffe. 2012. Randomized trial of standard methadone treatment compared to initiating methadone without coun- seling: 12-month findings. Addiction 107(5):943â952. Semple, S. J., I. Grant, and T. L. Patterson. 2005. Utilization of drug treatment programs by methamphetamine users: The role of social stigma. American Journal of Addiction 14(4):367â380. Sharp, A., A. Jones, J. Sherwood, O. Kutsa, B. Honermann, and G. Millett. 2018. Impact of Medicaid expansion on access to opioid analgesic medications and medication-assisted treatment. American Journal of Public Health 108(5):642â648. Singer, M., and J. B. Page. 2014. The social value of drug addicts: Uses of the useless. Walnut Creek, CA: Left Coast Press, Inc. Somers, S. A., E. Nicolella, A. Hamblin, S. M. McMahon, C. Heiss, and B. W. Brockmann. Â 2014. Medicaid expansion: Considerations for states regarding newly eligible jail-Ânvolved i individuals. Health Affairs (Millwood) 33(3):455â461. Somers, B. D., C. E. Fry, R. J. Blendon, A. M. Epstein. 2018. New approaches in medicaid: Work requirements, health davings sccounts, snd health vare sccess. Health Affairs (Millwood) 37(7):1099â1108. Stringer, K. L., and E. H. Baker. 2018. Stigma as a barrier to substance abuse treatment among those with unmet need: An analysis of parenthood and marital status. Journal of Family Issues 39(1):3â27. Stuart, E. A., C. L. Barry, J. M. Donohue, S. F. Greenfield, K. Duckworth, Z. Song, R. M Â echanic, E. M. Kouri, C. Ebnesajjad, M. E. Chernew, and H. A. Huskamp. 2017. E Â ffects of accountable care and payment reform on substance use disorder treatment: Evi- dence from the initial 3 years of the alternative quality contract. Addiction 112:124â133. Thomas, C. P., S. Reif, S. Haq, S. S. Wallack, A. Hoyt, and G. A. Ritter. 2008. Use of b Â uprenorphine for addiction treatment: Perspectives of addiction specialists and general psychiatrists. Psychiatric Services 59(8):909â916. Thomas, C. P., D. W. Garnick, C. M. Horgan, F. McCorry, A. Gmyrek, M. Chalk, D. G Â astfriend, S. G. Rinaldo, J. Albright, V. A. Capoccia, A. Harris, H. Harwood, P. G Â reenberg, T. L. Mark, H. Un, M. T. Oros, M. Stringer, and J. Thatcher. 2011. Advanc- ing performance measures for use of medications in substance abuse treatment. Journal of Substance Abuse Treatment 40:35â43. van Boekel, L. C., E. P. M. Brouwers, J. van Weeghel, and H. F. L. Garretsen. 2013. Stigma among health professionals towards patients with substance use disorders and its con- sequences for healthcare delivery: Systematic review. Drug and Alcohol Dependence 131:23â35. Volkow, N. D., T. R. Frieden, P. S. Hyde, and S. S. Cha. 2014. Medication-assisted t ÂherapiesâTackling the opioid-overdose epidemic. New England Journal of Medicine 370(22):2063â2066.
BARRIERS TO BROADER USE OF MEDICATIONS TO TREAT OUD 135 Wakeman, S. E. 2017. Medications for addiction treatment: Changing language to improve care. Journal of Addiction Medicine 11:1â2. Wakeman, S. E., and M. L. Barnett. 2018. Primary care and the opioid-overdose crisisâÂ Buprenorphine myths and realities. New England Journal of Medicine 379(1):1â4. Wang, P. S., P. Berglund, M. Olfson, H. A. Pincus, K. B. Wells, and R. C. Kessler. 2005. Failure and delay in initial treatment contact after first onset of mental disorders in the national comorbidity survey replication. Archives of General Psychiatry 62(6):603â613. Wen, H., J. R. Cummings, J. M. Hockenberry, L. M. Gaydos, and B. G. Druss. 2013. State parity laws and access to treatment for substance use disorder in the United States: I Âmplications for federal parity legislation. JAMA Psychiatry 70(12):1355â1362. Wen, H., J. M. Hockenberry, T. F. Borders, and B. G. Druss. 2017. Impact of Medicaid expan- sion on Medicaid-covered utilization of buprenorphine for opioid use disorder treatment. Medical Care 55(4):336â341. Wittman, F. D., D. L. Polcin, and D. Sheridan. 2017. The architecture of recovery: Two kinds of housing assistance for chronic homeless persons with substance use disorders. Drugs and Alcohol Today 17(3):157â167. Woo, J., A. Bhalerao, M. Bawor, M. Bhatt, B. Dennis, N. Mouravska, L. Zielinski, and Z. Â amaan. S 2017. âDonât judge a book by its coverâ: A qualitative study of methadone patientsâ experi- Â Â ences of stigma. Substance Abuse: Research and Treatment 11:PMC5398333. Yancovitz, S. R., D. C. Des Jarlais, N. P. Peyser, E. Drew, P. Friedmann, H. L. Trigg, and J. W. Robinson. 1991. A randomized trial of an interim methadone maintenance clinic. American Journal of Public Health 81(9):1185â1191. Zur, J., and J. Tolbert. 2018. The opioid epidemic and Medicaidâs role in facilitating access to treatment. Kaiser Family Foundation. April 11. https://www.kff.org/medicaid/issue- brief/the-opioid-epidemic-and-medicaids-role-in-facilitating-access-to-treatment (accessed February 21, 2019).