Addressing opioid use disorder: The role in pharmacotherapy barriers

Ghadyan Salem Alshamari; Hamad Dafalh Alrakhimy

doi:10.53730/ijhs.v1nS1.15216

Authors

Ghadyan Salem Alshamari KSA, National Guard Health Affairs
Hamad Dafalh Alrakhimy KSA, National Guard Health Affairs

Keywords:

opioid use disorder, pharmacotherapy barriers, medicaid coverage, regulatory constraints, geographic disparities

Abstract

Background: The opioid epidemic in the United States has escalated significantly since the early 2000s, leading to a dramatic increase in opioid-related fatalities and the spread of infectious diseases among users. Despite the availability of three FDA-approved medications for opioid use disorder (OUD), access remains severely limited due to various barriers. Aim: This paper aims to analyze the pharmacotherapy barriers affecting the treatment of OUD and propose strategies for addressing these challenges to enhance access to care. Methods: A comprehensive review of recent peer-reviewed literature was conducted to identify financial, regulatory, geographic, and attitudinal barriers influencing the delivery of pharmacotherapy for OUD. The analysis involved examining Medicaid coverage, the impact of federal regulations, and the distribution of treatment programs across urban and rural settings. Results: Findings indicate significant financial obstacles, including inadequate Medicaid coverage and pre-authorization requirements, which hinder access to treatment. Regulatory constraints, such as limits on prescribing waivers for buprenorphine, further exacerbate these issues. Geographic disparities were also noted, with rural areas lacking sufficient treatment options and healthcare providers. The study emphasizes the urgent need for policy reforms to reduce these barriers and improve treatment accessibility.

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References

Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United States: a retrospective analysis of the past 50 years. JAMA Psychiatry. 2014;71(7):821–6. doi:10.1001/jamapsychiatry.2014.366. DOI: https://doi.org/10.1001/jamapsychiatry.2014.366

Maxwell J. The pain reliever and heroin epidemic in the united states: shifting winds in the perfect storm. J Addict Dis. 2015;34:127–40. DOI: https://doi.org/10.1080/10550887.2015.1059667

Rudd RA, Aleshire N, Zibbell JE, Gladden RM. Increases in drug and opioid overdose deaths—United States, 2000–2014. MMWR Morb Mortal Wkly Rep. 2016;64(50–51):1378–82. doi:10.15585/mmwr.mm6450a3. DOI: https://doi.org/10.15585/mmwr.mm6450a3

Zibbell JE, Hart-Malloy R, Barry J, Fan L, Flanigan C. Risk factors for HCV infection among young adults in rural New York who inject prescription opioid analgesics. Am J Public Health. 2014;104(11):2226–32. DOI: https://doi.org/10.2105/AJPH.2014.302142

American Psychiatric Association. Diagnostic and statistical manual of mental disorders. Fifth ed. Arlington: Author; 2013. DOI: https://doi.org/10.1176/appi.books.9780890425596

Mattick RP, Breen C, Kimber J, Davoli M. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database Syst Rev. 2009;3:CD002209. doi:10.1002/14651858.CD002209.pub2. DOI: https://doi.org/10.1002/14651858.CD002209.pub2

SAMHSA. Buprenorphine waiver management. Retrieved from: http://www.samhsa.gov/medication-assisted-treatment. Accessed 1 Oct 2016.

Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2014;2:CD002207. doi:10.1002/14651858.CD002207.pub4. DOI: https://doi.org/10.1002/14651858.CD002207.pub4

Auriacombe M, Fatseas M, Dubernet J, Daulouede JP, Tignol J. French field experience with buprenorphine. Am J Addict. 2004;13(Suppl 1):S17–28. doi:10.1080/10550490490440780. DOI: https://doi.org/10.1080/10550490490440780

Caplehorn JR, Dalton MS, Haldar F, Petrenas AM, Nisbet JG. Methadone maintenance and addicts’ risk of fatal heroin overdose. Subst Use Misuse. 1996;31(2):177–96. doi:10.3109/10826089609045806. DOI: https://doi.org/10.3109/10826089609045806

Degenhardt L, Bucello C, Mathers B, Briegleb C, Ali H, Hickman M, et al. Mortality among regular or dependent users of heroin and other opioids: a systematic review and meta-analysis of cohort studies. Addiction. 2011;106(1):32–51. doi:10.1111/j.1360-0443.2010.03140.x. DOI: https://doi.org/10.1111/j.1360-0443.2010.03140.x

Gibson A, Degenhardt L, Mattick RP, Ali R, White J, O'Brien S. Exposure to opioid maintenance treatment reduces long-term mortality. Addiction. 2008;103(3):462–8. doi:10.1111/j.1360-0443.2007.02090.x. DOI: https://doi.org/10.1111/j.1360-0443.2007.02090.x

Langendam MW, van Brussel GH, Coutinho RA, van Ameijden EJ. The impact of harm-reduction-based methadone treatment on mortality among heroin users. Am J Public Health. 2001;91(5):774–80. DOI: https://doi.org/10.2105/AJPH.91.5.774

Schwartz RP, Gryczynski J, O'Grady KE, Sharfstein JM, Warren G, Olsen Y, et al. Opioid agonist treatments and heroin overdose deaths in Baltimore, Maryland, 1995–2009. Am J Public Health. 2013;103(5):917–22. doi:10.2105/AJPH.2012.301049. DOI: https://doi.org/10.2105/AJPH.2012.301049

Krupitsky E, Nunes EV, Ling W, Illeperuma A, Gastfriend DR, Silverman BL. Injectable extended-release naltrexone for opioid dependence: a double-blind, placebo-controlled, multicentre randomised trial. Lancet. 2011;377(9776):1506–13. doi:10.1016/S0140-6736(11)60358-9. DOI: https://doi.org/10.1016/S0140-6736(11)60358-9

Lee JD, Friedmann PD, Kinlock TW, Nunes EV, Boney TY, Hoskinson Jr RA, et al. Extended-release naltrexone to prevent opioid relapse in criminal justice offenders. N Engl J Med. 2016;374(13):1232–42. doi:10.1056/NEJMoa1505409. DOI: https://doi.org/10.1056/NEJMoa1505409

Department of Health and Human Services (DHHS). Opioid abuse in the U.S. and HHS actions to address opioid-drug related overdoses and deaths, March 26, 2015. Retrieved from: https://aspe.hhs.gov/sites/default/files/pdf/107965/ib_Opioidinitiative.pdf. Accessed 3 Oct 2016.

•• Jones CM, Campopiano M, Baldwin G, McCance-Katz E. National and state treatment need and capacity for opioid agonist medication-assisted treatment. Am J Public Health. 2015;105(8):e55–63. doi:10.2105/AJPH.2015.302664. DOI: https://doi.org/10.2105/AJPH.2015.302664

SAMHSA. National Survey of Substance Abuse Treatment Services: 2013. Data on substance abuse treatment facilities. HHS Publication No. SMA 14–4890. Rockville, MD. Substance Abuse and Mental Health Services Administration; 2014.

Sigmon SC, CM A, Hruska B, Ochalek T, Rose G, Badger GJ, et al. Bridging waitlist delays with interim buprenorphine treatment: initial feasibility. Addict Behav. 2015;51:136–42. doi:10.1016/j.addbeh.2015.07.030. DOI: https://doi.org/10.1016/j.addbeh.2015.07.030

SAMHSA. Opioid treatment program survey: data on substance abuse treatment facilities with OTPs, 2011. BHSIS Series S-65, HHS Publication No. (SMA) 14–4807. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013.

Ducharme LJ, Abraham AJ. State policy influence on the early diffusion of buprenorphine in community treatment programs. Subst Abuse Treat Prev Policy. 2008;3:17. doi:10.1186/1747-597X-3-17. DOI: https://doi.org/10.1186/1747-597X-3-17

Molfenter T, Sherbeck C, Zehner M, Quanbeck A, McCarty D, Kim JS, et al. Implementing buprenorphine in addiction treatment: payer and provider perspectives in Ohio. Subst Abuse Treat Prev Policy. 2015;10:13. doi:10.1186/s13011-015-0009-2. DOI: https://doi.org/10.1186/s13011-015-0009-2

Aletraris L, Bond Edmond M, Roman PM. Adoption of injectable naltrexone in U.S. substance use disorder treatment programs. J Stud Alcohol Drugs. 2015;76(1):143–51. DOI: https://doi.org/10.15288/jsad.2015.76.143

Levit KR, Stranges E, Coffey RM, Kassed C, Mark TL, Buck JA, et al. Current and future funding sources for specialty mental health and substance abuse treatment providers. Psychiatr Serv. 2013;64(6):512–9. doi:10.1176/appi.ps.201200298. DOI: https://doi.org/10.1176/appi.ps.201200298

Mark TL, Levit KR, Vandivort-Warren R, Buck JA, Coffey RM. Changes in US spending on mental health and substance abuse treatment, 1986–2005, and implications for policy. Health Aff (Millwood). 2011;30(2):284–92. doi:10.1377/hlthaff.2010.0765. DOI: https://doi.org/10.1377/hlthaff.2010.0765

•• Burns RM, Pacula RL, Bauhoff S, Gordon AJ, Hendrikson H, Leslie DL, et al. Policies related to opioid agonist therapy for opioid use disorders: the evolution of state policies from 2004 to 2013. Subst Abus. 2016;37(1):63–9. doi:10.1080/08897077.2015.1080208. DOI: https://doi.org/10.1080/08897077.2015.1080208

Cowell A, McCarty D, Cowell A. Impact of federal substance abuse block grants on state substance abuse spending: literature and data review. J Ment Health Policy Econ. 2003;6(4):173–9.

Woodward A. The CBHSQ Report: the substance abuse prevention and treatment block grant is still important even with the expansion of Medicaid. Rockville, MD: Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality; 2015.

•• Saloner B, Stoller KB, Barry CL. Medicaid coverage for methadone maintenance and use of opioid agonist therapy in specialty addiction treatment. Psychiatr Serv. 2016;67(6):676–9. doi:10.1176/appi.ps.201500228. DOI: https://doi.org/10.1176/appi.ps.201500228

• Hutchinson E, Catlin M, Andrilla CH, Baldwin LM, Rosenblatt RA. Barriers to primary care physicians prescribing buprenorphine. Ann Fam Med. 2014;12(2):128–33. doi:10.1370/afm.1595. DOI: https://doi.org/10.1370/afm.1595

Fiellin DA, Barry DT, Sullivan LE, Cutter CJ, Moore BA, O'Connor PG, et al. A randomized trial of cognitive behavioral therapy in primary care-based buprenorphine. Am J Med. 2013;126(1):74 e11–7. doi:10.1016/j.amjmed.2012.07.005. DOI: https://doi.org/10.1016/j.amjmed.2012.07.005

Ling W, Hillhouse M, Ang A, Jenkins J, Fahey J. Comparison of behavioral treatment conditions in buprenorphine maintenance. Addiction. 2013;108(10):1788–98. doi:10.1111/add.12266. DOI: https://doi.org/10.1111/add.12266

Weiss RD, Potter JS, Fiellin DA, Byrne M, Connery HS, Dickinson W, et al. Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence: a 2-phase randomized controlled trial. Arch Gen Psychiatry. 2011;68(12):1238–46. doi:10.1001/archgenpsychiatry.2011.121. DOI: https://doi.org/10.1001/archgenpsychiatry.2011.121

• Alanis-Hirsch K, Croff R, Ford 2nd JH, Johnson K, Chalk M, Schmidt L, et al. Extended-release naltrexone: a qualitative analysis of barriers to routine use. J Subst Abus Treat. 2016;62:68–73. doi:10.1016/j.jsat.2015.10.003. DOI: https://doi.org/10.1016/j.jsat.2015.10.003

Federal Register. Medication assisted treatment for opioid use disorders. a rule by the Health and Human Services Department on 07/08/2016. Retrieved from: https://www.federalregister.gov/documents/2016/07/08/2016-16120/medication-assisted-treatment-for-opioid-use-disorders.

Legal Action Center. Know your rights: rights for individuals on medication-assisted treatment. HHS Publication No. (SMA) 09–4449. Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration; 2009.

Schwartz RP, Highfield DA, Jaffe JH, Brady JV, Butler CB, Rouse CO, et al. A randomized controlled trial of interim methadone maintenance. Arch Gen Psychiatry. 2006;63(1):102–9. doi:10.1001/archpsyc.63.1.102. DOI: https://doi.org/10.1001/archpsyc.63.1.102

Yancovitz SR, Des Jarlais DC, Peyser NP, Drew E, Friedmann P, Trigg HL, et al. A randomized trial of an interim methadone maintenance clinic. Am J Public Health. 1991;81(9):1185–91. DOI: https://doi.org/10.2105/AJPH.81.9.1185

Greenfield L, Brady JV, Besteman KJ, De Smet A. Patient retention in mobile and fixed-site methadone maintenance treatment. Drug Alcohol Depend. 1996;42(2):125–31. DOI: https://doi.org/10.1016/0376-8716(96)01273-2

Knudsen HK. The supply of physicians waivered to prescribe buprenorphine for opioid use disorders in the United States: a state-level analysis. J Stud Alcohol Drugs. 2015;76(4):644–54. DOI: https://doi.org/10.15288/jsad.2015.76.644

Rosenblatt RA, Andrilla CH, Catlin M, Larson EH. Geographic and specialty distribution of US physicians trained to treat opioid use disorder. Ann Fam Med. 2015;13(1):23–6. doi:10.1370/afm.1735. DOI: https://doi.org/10.1370/afm.1735

•• Stein BD, Gordon AJ, Dick AW, Burns RM, Pacula RL, Farmer CM, et al. Supply of buprenorphine waivered physicians: the influence of state policies. J Subst Abus Treat. 2015;48(1):104–11. doi:10.1016/j.jsat.2014.07.010. DOI: https://doi.org/10.1016/j.jsat.2014.07.010

McCarty D, Rieckmann T, Green C, Gallon S, Knudsen J. Training rural practitioners to use buprenorphine; using the change book to facilitate technology transfer. J Subst Abus Treat. 2004;26(3):203–8. doi:10.1016/S0740-5472(03)00247-2. DOI: https://doi.org/10.1016/S0740-5472(03)00247-2

Walley AY, Alperen JK, Cheng DM, Botticelli M, Castro-Donlan C, Samet JH, et al. Office-based management of opioid dependence with buprenorphine: clinical practices and barriers. J Gen Intern Med. 2008;23(9):1393–8. doi:10.1007/s11606-008-0686-x. DOI: https://doi.org/10.1007/s11606-008-0686-x

DeFlavio JR, Rolin SA, Nordstrom BR, Kazal Jr LA. Analysis of barriers to adoption of buprenorphine maintenance therapy by family physicians. Rural Remote Health. 2015;15:3019. DOI: https://doi.org/10.22605/RRH3019

Friedmann PD, Hoskinson R, Gordon M, Schwartz R, Kinlock T, Knight K, et al. Medication-assisted treatment in criminal justice agencies affiliated with the criminal justice-drug abuse treatment studies (CJ-DATS): availability, barriers, and intentions. Subst Abus. 2012;33(1):9–18. doi:10.1080/08897077.2011.611460. DOI: https://doi.org/10.1080/08897077.2011.611460

Hunt DE, Lipton DS, Goldsmith DS, Strug DL, Spunt B. “It takes your heart”: the image of methadone maintenance in the addict world and its effect on recruitment into treatment. Int J Addict. 1985;20(11–12):1751–71. DOI: https://doi.org/10.3109/10826088509047261

Mitchell SG, Willet J, Monico LB, James A, Rudes DS, Viglioni J, et al. Community correctional agents’ views of medication-assisted treatment: examining their influence on treatment referrals and community supervision practices. Subst Abus. 2016;37(1):127–33. doi:10.1080/08897077.2015.1129389. DOI: https://doi.org/10.1080/08897077.2015.1129389

Schwartz RP, Kelly SM, O'Grady KE, Mitchell SG, Peterson JA, Reisinger HS, et al. Attitudes toward buprenorphine and methadone among opioid-dependent individuals. Am J Addict. 2008;17(5):396–401. doi:10.1080/10550490802268835. DOI: https://doi.org/10.1080/10550490802268835

Stancliff S, Myers JE, Steiner S, Drucker E. Beliefs about methadone in an inner-city methadone clinic. J Urban Health. 2002;79(4):571–8. DOI: https://doi.org/10.1093/jurban/79.4.571

Wallack SS, Thomas CP, Martin TC, Chilingerian J, Reif S. Substance abuse treatment organizations as mediators of social policy: slowing the adoption of a congressionally approved medication. J Behav Health Serv Res. 2010;37(1):64–78. doi:10.1007/s11414-008-9132-4. DOI: https://doi.org/10.1007/s11414-008-9132-4

White W, Coon B. Methadone and the anti-medication bias in addiction treatment. Counselor. 2003;4(5):58–63.

Boutwell AE, Nijhawan A, Zaller N, Rich JD. Arrested on heroin: a national opportunity. J Opioid Manag. 2007;3(6):328–32. DOI: https://doi.org/10.5055/jom.2007.0021

Rich JD, McKenzie M, Larney S, Wong JB, Tran L, Clarke J, et al. Methadone continuation versus forced withdrawal on incarceration in a combined US prison and jail: a randomised, open-label trial. Lancet. 2015;386(9991):350–9. doi:10.1016/S0140-6736(14)62338-2. DOI: https://doi.org/10.1016/S0140-6736(14)62338-2

Fu JJ, Zaller ND, Yokell MA, Bazazi AR, Rich JD. Forced withdrawal from methadone maintenance therapy in criminal justice settings: a critical treatment barrier in the United States. J Subst Abus Treat. 2013;44(5):502–5. doi:10.1016/j.jsat.2012.10.005. DOI: https://doi.org/10.1016/j.jsat.2012.10.005

Mitchell SG, Kelly SM, Brown BS, Reisinger HS, Peterson JA, Ruhf A, et al. Incarceration and opioid withdrawal: the experiences of methadone patients and out-of-treatment heroin users. J Psychoactive Drugs. 2009;41(2):145–52. doi:10.1080/02791072.2009.10399907. DOI: https://doi.org/10.1080/02791072.2009.10399907

National Association of Drug Court Professionals. History of drug courts. Retrieved from: http://www.nadcp.org/learn/what-are-drug-courts/drug-court-history. Accessed 17 Oct 2016.

•• Matusow H, Dickman SL, Rich JD, Fong C, Dumont DM, Hardin C, et al. Medication assisted treatment in US drug courts: results from a nationwide survey of availability, barriers and attitudes. J Subst Abus Treat. 2013;44(5):473–80. doi:10.1016/j.jsat.2012.10.004. DOI: https://doi.org/10.1016/j.jsat.2012.10.004

Brooner R, Kidorf M, King V, Beilenson P, Svikis D, Vlahov D. Drug abuse treatment success among needle exchange participants. Public Health Rep. 1998;113(Suppl 1):129–39.

Hagan H, McGough JP, Thiede H, Hopkins S, Duchin J, Alexander ER. Reduced injection frequency and increased entry and retention in drug treatment associated with needle-exchange participation in Seattle drug injectors. J Subst Abus Treat. 2000;19(3):247–52. DOI: https://doi.org/10.1016/S0740-5472(00)00104-5

Strathdee SA, Ricketts EP, Huettner S, Cornelius L, Bishai D, Havens JR, et al. Facilitating entry into drug treatment among injection drug users referred from a needle exchange program: results from a community-based behavioral intervention trial. Drug Alcohol Depend. 2006;83(3):225–32. doi:10.1016/j.drugalcdep.2005.11.015. DOI: https://doi.org/10.1016/j.drugalcdep.2005.11.015

Fox AD, Chamberlain A, Sohler NL, Frost T, Cunningham CO. Illicit buprenorphine use, interest in and access to buprenorphine treatment among syringe exchange participants. J Subst Abus Treat. 2015;48(1):112–6. doi:10.1016/j.jsat.2014.07.015. DOI: https://doi.org/10.1016/j.jsat.2014.07.015

Mannelli P, Wu LT, Peindl KS, Swartz MS, Woody GE. Extended release naltrexone injection is performed in the majority of opioid dependent patients receiving outpatient induction: a very low dose naltrexone and buprenorphine open label trial. Drug Alcohol Depend. 2014;138:83–8. DOI: https://doi.org/10.1016/j.drugalcdep.2014.02.002

Friedmann PD, Lemon SC, Stein MD, D'Aunno TA. Accessibility of addiction treatment: results from a national survey of outpatient substance abuse treatment organizations. Health Serv Res. 2003;38(3):887–903. DOI: https://doi.org/10.1111/1475-6773.00151

Noysk B, Anglin M, Brissette S, Kerr T, Marsch D, Schackman B, et al. A call for evidence-based medical treatment of opioid dependence in the United States and Canada. Health Aff. 2013;32:1462–9. DOI: https://doi.org/10.1377/hlthaff.2012.0846

SAMHSA. Federal guidelines for opioid treatment programs. HHS Publication No. (SMA) PEP15-FEDGUIDEOTP. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2015.

American Academy of Addiction Psychiatry. Providers’ clinical support system for opioid therapies. Retrieved from: http://pcssmat.org/ Accessed 17 Oct 2016.

Hall G, Neighbors CJ, Iheoma J, Dauber S, Adams M, Culleton R, et al. Mobile opioid agonist treatment and public funding expands treatment for disenfranchised opioid-dependent individuals. J Subst Abus Treat. 2014;46(4):511–5. doi:10.1016/j.jsat.2013.11.002. DOI: https://doi.org/10.1016/j.jsat.2013.11.002

Musto D. The American disease: origins of narcotics control. Third ed. Oxford: Oxford University Press; 1999. DOI: https://doi.org/10.1093/oso/9780195125092.001.0001