As the country reels from record-high rates of opioid abuse and overdoses, medication-assisted treatment — which combines medication and behavioral therapy — has shown particular promise in combating the epidemic. But it also faces major challenges to widespread use, including the costs and limits on doctors who can provide it.
President Trump on Thursday declared a nationwide public health emergency to battle the opioid crisis. It’s not as aggressive of a response as the president’s commission recommended in July, but a public health emergency, which lasts for 90 days, does allow the Department of Health and Human Services to redirect existing resources to combat opioid abuse. And under the Public Health Service Act, the determination could allow HHS specifically to waive restrictions on doctors who want to prescribe drugs used in medication-assisted treatment.
Medication-assisted treatment, or MAT, is proven to be among the most effective treatments for opioid abuse disorders. While methadone is the most well-known medication to help reduce opioid use and assist with recovery, it is only provided in clinics and requires daily visits from patients. Of the other drugs used to treat opioid addictions, buprenorphine has the advantage of being long-acting, so addicts may not need to take it every day. Buprenorphine, a controlled substance, is also available outside of addiction clinics, though there are barriers for any doctors who may want to offer it, including restrictions on prescribing as well as a lack of resources when handling patients with addiction.
Physicians must acquire special certifications and apply for waivers to prescribe buprenorphine. They are allowed to treat no more than 30 patients at a time for the first year, 100 the second year if they apply for an increase and, as a result of a rule issued last year, up to 275 patients the third year after applying for yet another increase.1
The emergency declaration could open up more access to treatment in rural areas, where resources to combat the opioid crisis are limited, by providing more buprenorphine waivers to doctors, crucially for those who may not be attached to an addiction center.
Currently, physicians who offer buprenorphine treatment are concentrated in urban counties.2 We took a look at the Behavioral Health Treatment Services Locator Map from the Substance Abuse and Mental Health Services Administration to determine the locations of physicians offering buprenorphine across the country.3 Then using the National Center for Health Statistics’ urban vs. rural classification, we determined that about 91 percent of those physicians offering buprenorphine treatment are in urban counties, while about 9 percent are in rural counties.4
In 2015, overdose deaths occurred in rural populations at a rate of 17.0 per 100,000 people, according to a recent report from the Centers for Disease Control and Prevention, compared with 16.2 deaths per 100,000 people in metropolitan areas. The rural rate had risen steadily over the previous decade, from 11.7 in 2006 — which the CDC highlighted as a cause for concern. Data on opioid-specific deaths is difficult to parse out because of the overlap in drugs involved in overdose deaths. But the CDC noted opioids as the main driver of overdose deaths in 2015, with 33,091 deaths that involved an opioid out of a total of 52,404 overdose deaths.5
Dr. Corey Waller, chair of the American Society of Addiction Medicine’s legislative advocacy committee, said that more waivers under the emergency declaration could allow programs to bump up the number of patients they see more quickly — and more doctors might want to apply for permission to provide the treatment in the first place.
Even with waivers, individual physicians often face additional challenges stemming from a lack of support that specialized clinics may have. Research shows that even the limited number of physicians who do possess waivers sometimes are unwilling to prescribe or have little confidence dealing with patients battling addiction.
“In the rural space, there aren’t as many prescribers in general. They don’t want to become the de facto addiction center by taking this waiver,” Waller said. “But if every primary care doctor had a waiver and each took, say, 10 patients, they wouldn’t feel as much of a burden.”
Including medication-assisted treatment as a part of general medical practices more often could also ease concerns of patients who don’t want to visit substance abuse treatment centers because of the stigma attached to addiction.
However, experts say it’s important to keep in mind the maintenance portion of medication-assisted treatment and additional resources to combat addiction as policymakers continue to weigh the options — and to consider additional support from addiction experts and resources to help physicians if treatment does expand. Katherine Watkins, a senior physician policy researcher at the RAND Corporation, said it’s dangerous to start and stop MAT — and doing so actually increases mortality rates as users could become more sensitive to stronger opioids. Watkins said it’s important to monitor the access to treatment beyond simply tracking how many patients are starting it.
“As we think about increasing access, we have to be saying: Increase access without breaks or interruptions,” Watkins said. “It’s long-term. It’s not short-term.”