Facing Regional, Financial & Access Hurdles in Opioid Addiction

Lindsey Jennings, MD, MPH

The impact of the opioid epidemic on the United States has been devastating. In 2017 alone, there were nearly 30,000 overdose deaths due to synthetic opioids, according to the latest data from the National Center for Health Statistics at the Centers for Disease Control and Prevention.¹

The health care community continues to make efforts to combat the epidemic though, and some institutions, such as the Medical University of South Carolina (MUSC), are utilizing strategies like pilot programs to connect patients with opioid addictions to immediate treatment in the emergency department.

Despite efforts though, regional, financial, and access hurdles still remain, making treatment difficult for many individuals.

Lindsey Jennings, MD, MPH, assistant residency director and assistant professor, department of emergency medicine; and Carolyn Bogdon, MSN, FNP-BC, director, Emergency Department Medication Assisted Treatment Program, department of psychiatry & behavioral sciences, both at MUSC, discussed the challenges facing health care providers who are on the front line of battling the opioid epidemic in an exclusive interview with MD Magazine^®.

[Editor’s note: Transcript s lightly modified for readability.]

MD Mag: What is the extent of the opioid crisis in the United States, and why do some regions have higher or lower rates of opioid addiction and related deaths?

Jennings: Overall, it’s been a huge epidemic across the country and is something that has been rapidly increasing over the past couple years. It is a major public health crisis across the board.

Bogdon: For rural states, I would definitely agree that we [South Carolina] are in the top 4 tiles for opioid overdose deaths as well as overdoses in general. Charleston county though, [which] is within our state where MUSC is located—I believe—is number 1 in the state for opioid overdose deaths [according to data from 2017].

We have been working with our data folks to figure out why this is happening. The population [of individuals] has an impact, especially when you look at a rural state. We also speculate that tourism has some part in it because you see Charleston, Myrtle Beach, and more of the densely populated and highly-visited tourist correlating with increased overdoses and overdose deaths. However, that’s anecdotal speculation at this point.

Jennings: [When] you look at systems of care, you see significant barriers to getting patients into treatment for opioid use disorders. Medication-assisted treatment is the standard of care for patients with opioid disorders, but there is a huge gap in terms of the number of patients who need treatment and the number of patients who have access to treatment, [for example] in terms of the number of providers that have received the buprenorphine waiver that allows the provider to prescribe buprenorphine.

In order for a provider to prescribe buprenorphine, they have to do additional training—324 hours, depending on if you’re an MD or a physician assistant—and get a waiver that allows them to write a prescription for buprenorphine.

I think access [to this treatment] is one of the big things that can affect opioid deaths across different regions.

Medication-assisted treatments involve medications and then therapy and psychosocial assessment in order to treat opioid disorder. There are 3 different medicines that we can use within medication-assisted treatment: naltrexone, methadone, and buprenorphine.

Buprenorphine is what our project [at MUSC] has focused on. Even if you have a Drug Enforcement Administration (DEA) license as a physician or as an advanced practice provider, you are unable to write buprenorphine unless you have additional training.

Looking at the number of people who are waivered who would have access to give these medications, there is a big gap between the number of [waivered] providers available and the number of patients who need treatment.

Bogdon: As far as coverage, the treatment is typically covered. At least some or all of the modalities—naltrexone, methadone, and then buprenorphine—are covered, depending on the payer (Medicaid, Medicare, and private insurers). Some will cover all 3, some will cover 1 or 2, but at least there is, typically, an option available for patients.

However, in some states without Medicaid or Medicaid expansion, and even in some states that do, there is a huge gap in those who have insurance coverage to pay for the treatment.

The cost of the standard prescription of buprenorphine (16mg) can cost about $16 to $20 a day. That [cost] does not include the provider visits, drug screening, counseling visits.

[For] methadone, patients will be daily dosed at a clinic, and that has a cost involved as well, for the medication as well as for the provider visits, and any other testing that need to go on with it, [as well as] counseling.

Naltrexone is typically given in an injection on a monthly basis, and that can range from $1000 to $1500 a month, in addition to the provider visit and counseling that goes along with it.

[Opioid addiction] is a costly disease to treat, just like any other chronic illness.

MD Mag: Would you say financial hurdles are 1 of the major contributors to opioid treatment?

Jennings: I would definitely say financial hurdles and patients being able to find treatment at all [and] being able to access providers or care centers that can actually provide medication-assisted treatment are issues. Both are significant.

Bogdon: Thankfully, at this program [at MUSC], we have funding from the South Carolina Department of Health and Human services, and we collaborate with the South Carolina Department of Alcohol and Other Drug Abuse Services [DAODAS].

They have given us funding to be able to implement these programs in the emergency department. We use state and federal funding to help these patients cover the cost of treatment in the emergency department and [the costs of those] who are inducted through the program.

In general, financial hurdles are pretty great [and] we could not run our program without the support we have.

Reference:

1. Overdose Rates. National Institute on Drug Abuse website. drugabuse.gov/related-topics/trends-statistics/overdose-death-rates. Updated August 2018. Accessed October 26, 2018.