Every day, 130 people in the U.S. die from an opioid-related overdose. Despite the urgency of the situation, barriers to treatment—including stigma, insurance and cost—remain for medication-assisted treatment (MAT) for patients with opioid-use disorder (OUD).
The Food and Drug Administration has approved methadone, buprenorphine, naltrexone and buprenorphine-naloxone combination products for MAT—but that doesn’t mean that everyone has equal access to them.
The barriers have also served to heighten racial inequities in access to treatment, according to a JAMA Psychiatry research letter written by researchers at the University of Michigan (UM) and the VA (Veterans Affairs) Ann Arbor Healthcare System, who found that buprenorphine treatment “is concentrated among white persons and those with private insurance or use self-pay.”
They calculated that there were 13.4 million patient visits resulting in a buprenorphine prescription between 2012 and 2015, with white patients accounting for 12.7 million of those visits and minority patients accounting for only 363,000.
So, even though OUD rates are similar for the two groups (3.5% for blacks, 4.7% for whites), 35 white patients received a buprenorphine prescription for every patient of another race or ethnicity who received one. Compared with white patients, black patients had 77% lower odds of having an office visit that included a buprenorphine prescription.
“We shouldn’t see differences this large,” lead author Pooja Lagisetty, MD, an assistant professor of internal medicine at the UM School of Medicine, said in a news release. “As the number of Americans with opioid-use disorder grows, we need to increase access to treatment for black and low-income populations and be thoughtful about how we reach all those who could benefit from this treatment.”
Another key finding was that almost 40% of outpatient visits resulting in a buprenorphine prescription between 2012 and 2015 were paid for out of a patient’s own pocket. Private insurance paid for 34% and only 19% were paid for by either Medicare or Medicaid.
“Cash-only buprenorphine clinics have proliferated in recent years, which may be expanding access for those with the means to pay in certain regions,” Dr. Lagisetty added. “But the high costs may be prohibitive for those who cannot afford to pay.”
The AMA has released a national policy roadmap, “National Spotlight on State-Level Efforts to End the Opioid Epidemic, Leading-edge Practices and Next Steps,” which identified best practices developed by state Medicaid directors, insurance commissioners and other state officials.
Among its top recommendations were removing barriers such as prior authorization for MAT, ensuring that MAT is affordable and that health insurance companies have an adequate network of addiction medicine and mental health physicians.
The roadmap also declares that “meaningful oversight and enforcement of mental health and substance-use disorder (SUD) parity are critical to reversing the opioid epidemic.”
SUD treatment is an essential health benefit for individual and small-group coverage under the Affordable Care Act. The Mental Health Parity and Addiction Equity Act, which was enacted in 2008, requires that—when mental health or SUD benefits are covered—they be covered equally with physical health services.
“Unfortunately, mental health and SUD parity compliance is clearly still a work in progress across all public coverage programs as well as commercial insurance,” says the AMA roadmap, even though the law has been in place for more than a decade.