By Katharine Neill Harris, Ph.D.
Alfred C. Glassell, III, Fellow in Drug Policy
Medication-assisted treatment (MAT), which uses medications along with therapy to treat individuals with opioid dependence, is considered the most effective treatment for opioid use disorder (OUD).
There are three drugs approved by the Food and Drug Administration (FDA) to treat OUD: methadone, buprenorphine, and naltrexone. Methadone and buprenorphine are opioid agonists that satisfy a person’s physical cravings for opioids, without providing the same blissful effects. Naltrexone is an opioid antagonist that works by blocking the euphoria a person would ordinarily get from consuming opioids.
Numerous studies have found that MAT reduces illicit opioid use and thus the risk of overdose among patients; reduces the spread of communicable diseases from needle-sharing; lowers arrest rates; and provides individuals with enough stability that they are able to maintain employment and family obligations. MAT will not solve the opioid epidemic, but it does address many aspects of what has become a pubic health crisis.
Despite the wealth of evidence attesting to MAT’s efficacy, the majority of Americans who need it cannot get it. Decades of stigma against non-abstinence-based drug treatment combined with insufficient insurance coverage for treatment services have contributed to a scarcity in affordable and accessible MAT. The opioid epidemic has forced a change in attitudes toward MAT and has elicited increased government funding for MAT services, but the shortage remains a serious obstacle to addressing the current problem.
Rural areas grappling with a lack of basic health care services are often, and correctly, identified as locations in dire need of more MAT services. But large cities that boast a wealth of medical resources also lack MAT. Harris County, TX, home to Houston and one of the largest medical centers in the world, has relatively few treatment providers that offer one of the three FDA-approved MATs for OUD.
A Pew study found that Harris County ranked last out of 10 major cities in methadone availability, with only .3 facilities per 100,000 people, and last in the rate of certified buprenorphine clinicians, with just 5.3 per 100,000 people. (For comparison Baltimore, which ranked first in both categories, had 4.7 methadone facilities per 100,000 people and 52.4 buprenorphine clinicians per 100,000 people.) Consistent with these findings, according to a national survey of drug treatment providers, only 24 facilities in Harris County offer buprenorphine or methadone. Just four facilities offer both of these drugs. Naltrexone is only offered at eight facilities.
Detoxification services, which provide medical assistance to people withdrawing from opioids, are also lacking. Detox is necessary for patients who want to reduce their drug use, use a non-narcotic MAT such as naltrexone, or attempt abstinence. The withdrawal process can be incredibly difficult and painful, and without medical assistance during detox individuals are less likely to stop or moderate their opioid use. Just 20 providers in Harris County offer some form of detox assistance.
These limited services are often inaccessible for uninsured and indigent populations. An extensive review found just eight providers in Harris County that offer at least one of the three MATs and either accept Medicaid or receive government funding for providing services to indigent clients. Only eight detox facilities accept Medicaid. For individuals who depend on state funding for treatment, there are very few detox beds available—approximately 32 in the entire county. While these data only cover Harris County, it is likely that the rest of the state faces similar shortages in accessible care.
Increasing support for MAT but stigma remains
Stigma surrounding MAT is decreasing, but it has not disappeared. Sometimes this stigma is expressed as a preference for non-narcotic MAT options (i.e., naltrexone and its formularies), even though these options do not work for everyone. Bias against individuals on methadone or buprenorphine continues in the employment and housing sectors, as well as within the recovery community. The treatment field itself is still wrestling with acceptance of MAT. I spoke with treatment providers in Harris County and found that while most were generally supportive of it, several were not. One provider stated that “I don’t believe in [MAT] personally. A person needs to have control of their own mind.” Other providers commented on the split within the treatment community, with people who have been “in the system” a longer time tending to be less supportive of the use of medications. This dispute in the field is not unique to Harris County; other documented instances of this debate suggest it is a systemic issue.
Continued stigma against MAT is also evident in the lack of physicians willing to prescribe buprenorphine to patients. Unlike methadone, which requires a separate clinic and additional federal licensing requirements, buprenorphine can be prescribed in an office setting. This makes it, in theory, more available to patients but, as noted above, Harris County has one of the lowest rates of buprenorphine-certified prescribers among large cities.
One barrier to increasing the number of prescribers is that doctors need a special license from the DEA to prescribe buprenorphine for addiction treatment. (Ironically, physicians do not need special licenses to prescribe opioids.) Even when doctors do become licensed to prescribe it, they may not be willing to accept a rush of new clients, particularly those relying on state funds. As one person involved in the state funding process explained, “when we have funding that becomes available, finding a prescriber willing to take that funding and serve an indigent population has been difficult to achieve.”
Calls to expand treatment access left unfunded
Resistance to MAT is an obstacle to expanding access, but resource shortages ultimately are a bigger problem. Because Texas is not a Medicaid expansion state, treatment providers rely on state funding to serve most indigent clients. The Texas Health and Human Services Commission (HHSC), which oversees funds for drug treatment, acknowledges the need for greater funding for these services, but currently these resource needs are not being met. For providers who offer MAT services, it is a financial challenge to accept clients whose bill is paid for by the state because the state reimbursement rates are too low to be economically viable, often not covering the full cost of service provision. Most facilities that do accept state-funded clients can only serve a limited number at a time, having to reserve the remainder of treatment slots for clients with better insurance coverage or who can self-pay. Waitlists for state-funded services are common.
Elected officials on both sides of the aisle have called for improving access to drug treatment. Without question, expanding Medicaid coverage is the one policy change that would do the most to increase treatment access. Medicaid expansion would insure an estimated 1.6 million Texans and incentivize care providers to offer services covered by Medicaid. Even providers still skeptical of MAT may be willing to offer these services if they can get reimbursed for doing so. If the Texas legislature will not expand Medicaid—and it almost certainly will not for the foreseeable future—it should at least commit to a significant increase in resources for drug treatment. For fiscal years 2018-2019, Texas HHSC allocated $177 million for substance use disorder prevention, intervention, and treatment services combined, three-quarters of which came from federal funds. This may sound like a lot of money, but is paltry compared to the $1.54 billion the state budgeted for mental health services.
The 86th Texas Legislature did little to address this resource shortage, which is not too surprising given that some big-ticket legislative items (tax reform, school financing) suggested few resources left to spar over. But opioid addiction, and substance misuse generally, are public health problems that don’t just affect individuals and families but entire communities and systems of care. The continued inability and unwillingness to address this problem adequately mean that the public health crisis of substance use will continue, and will continue to impact all Texans.
*Data discussed in this essay are drawn from a forthcoming report on drug treatment availability in Harris County, Texas.