MAT is a treatment approach that combines medications with counseling and behavioral therapies to treat substance use disorders. Medications used in MAT are FDA-approved and clinically-driven; however, several MAT access issues create obstacles to achieving its full success in mitigating the opioid epidemic. Insurance access and coverage, geography/location, treatment cost, and drug policy emerge as the most formidable pain points to accessing MATs for opioid addiction treatment.
According to the President’s Commission on Combating Drug Addiction and the Opioid Crisis, substance use disorder treatment facilities providing MAT-enhanced opioid treatment programs (OTP) can be sparse, especially in rural areas. Among the most rural U.S. counties, 55% do not have a substance use treatment facility. On a broader scale, 85% of U.S. counties have no OTP facilities that provide MAT for people diagnosed with an opioid use disorder. Increasing access will reduce overdose episodes and deaths. To achieve this, public health professionals and lawmakers need to collaborate on developing a new opioid epidemic mitigation framework rooted in more robust data, stronger interoperable communications, and better industry oversight among governments, healthcare providers, and insurers.
Insurance access and coverage
Government-sponsored insurance has been especially lacking in substance use disorder treatment. For instance, Medicaid coverage of substance use treatment and medications such as buprenorphine varies considerably by state and by whether or not the state’s Medicaid plan is offered under managed care or HMO arrangements. Coverage in many states is also subject to rules about prior authorization and medical necessity. As of 2013, only 13 state Medicaid programs included all available medications for treating opioid use disorders in their Medicaid Preferred Drug Lists (PDLs). The government currently has not published updated figures.
These restrictions have been receding over time, particularly evidenced by the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). The Act asserts that if an insurer covers mental health or substance use disorder benefits, it cannot impose limitations on those benefits disproportionately as compared to medical/surgical benefits. As more medical treatments for opioid addiction become available, the more those treatments are being included in medical system care and education.
Enforcing MHPAEA is vital to ensuring that this trend continues; the need to systematically monitor and enforce MHPAEA with a standardized tool and the enforcement of actual penalties for non-compliance are currently under discussion by the President’s Commission. Ensuring parity in the insurance coverage of mental health and addiction treatment services is essential to properly closing the MAT access gaps harbored by insurance providers.
Federal Drug Policy
Buprenorphine waivers are regulated under the Drug Addiction Treatment Act (DATA), which “waives the requirement for obtaining a separate Drug Enforcement Administration (DEA) registration as a Narcotic Treatment Program (NTP) for qualified physicians administering, dispensing, and prescribing these specific FDA approved controlled substances.” The Act places a limit of 30 or 100 patients at any one time for whom qualifying physicians can provide MAT; the exact patient number depends on individual authorization from the Center for Substance Abuse Treatment. Unfortunately, as of June 2018, 56.3% of all rural U.S. counties still lack a DATA-waived physician provider.
Although limiting in some respects, federal policy has otherwise expanded provider MAT availability. The 2016 Comprehensive Addiction and Recovery Act authorized the Substance Abuse and Mental Health Services Administration (SAMHSA) to extend to nurse practitioners and physician assistants the ability to apply for buprenorphine waivers. Provider MAT access barriers are gradually decreasing in general as MAT becomes more widely accepted and written into U.S. federal drug policy.
Methadone is colored by a historical stigma which imposes an archaic regulatory scheme upon it, requiring different licensure from other MATs and perpetuating the notion that it is simply another opiate. This severely limits its geographic availability–approximately only 10% of conventional drug treatment facilities in the United States provide MAT in general for opioid use disorder. For this reason, methadone is one of the hardest MATs to access.
As an important distinction between MATs, methadone is subject to required observed daily dosing in a methadone clinic, whereas buprenorphine can be prescribed in a local physician’s office and can be obtained in local pharmacies. From a patient perspective, those who pursue methadone treatment might be faced with the challenge of traveling a daunting physical distance to a clinic. Although buprenorphine access does not depend on prescribing clinics, it does rely on the availability of trained physicians and participating pharmacies that carry buprenorphine, which may also be extremely limited depending on the state and county.
As of June 2018, methadone treatment costs approximately $126.00 per week or $6,552.00 per year, while buprenorphine is slightly cheaper at approximately $115.00 per week or $5,980.00 per year. Additionally, injectable and implantable buprenorphine is expensive — approximately $1,000 for one treatment. Formulary tiering contributes to this cost issue. Injectable and implantable MATs are harder to procure because they need to be purchased in advance of the administration time and then reimbursed later. However, many physicians are not comfortable with absorbing these high costs with an uncertain waiting period for reimbursement.
Mitigating access gaps
First, more research and oversight are necessary, particularly into the needs of rural, homeless, and underinsured/uninsured populations. These patient groups are minimally represented in currently available opioid epidemic research. The Office of National Drug Control Policy can lend an even stronger hand to the research effort by sponsoring additional Federal-level investigations that can delve deeper into the crisis as it exists for these disenfranchised individuals.
Second, the Federal government should create an integrated data environment that joins publicly available data with agency-specific data. Seamless information sharing is vital to a strong collaboration of efforts within the medical and public health communities that are involved in mitigating the opioid crisis. With a more streamlined communication framework, states and the Federal government can ensure a more informed public that is motivated to seek MAT in the recovery process.
Third, states need to assess the MAT access gaps in their most affected counties and then invest opioid abuse MAT funding accordingly. Quality treatment services and the associated workforce have failed to expand proportionally in response to the growing crisis. Medical practitioners need to increasingly strive to attain MAT administration training and DATA waivers to provide buprenorphine treatment for opioid dependency.
Although these solutions will be challenging, likely time-consuming, and potentially mired in politics, their success is imperative to minimizing, and ideally halting, the loss of life that has been the tragic cornerstone of our nation’s opioid crisis.