New Research May Show Why Medication-Assisted Treatment (MAT) Is not Catching On

This research update reports the results of a new study on Medication-Assisted Treatment (MAT).

What is MAT and What Are the Benefits?

Medication-assisted treatment (MAT) combined with counseling has been shown by research to be an effective treatment approach for people diagnosed with Opioid use disorder (OUD) (Sofuoglu, DeVito, & Carroll, 2018). As the Catalyst blog post Overcoming Barriers to MAT: Bridging the Gap Between Research and Treatment in Nevada described, the benefits of MAT include:

• Improved survival
• Increased retention in treatment
• Decreased illicit opiate use
• Decreased hepatitis and HIV seroconversion
• Decreased criminal activities
• Increased employment
• Improved birth outcomes with perinatal drug users

(The Connecticut Certification Board, 2018)

Three medications approved for use for opioid use disorder (OUD) are Buprenorphine, which works for medically supervised withdrawal and for maintenance, Naltrexone, which assists with preventing opioid dependence after medically supervised opioid withdrawal by blocking the effects of opioid agonists, and Methadone, which reduces opioid craving and withdrawal and blocks the effects of opioids.

Despite large amounts of federal funding and other resources to support the use of MAT, providers have not been able to meet the needs of those in treatment. One reason was that clinicians need specialized training and a waiver of the Drug Addiction Treatment Act (DATA) of 2000. A multitude of other reasons cited by providers are listed in detail in “Table 1. Prescribing MAT (buprenorphine, naltrexone) at Capacity in Nevada – Barriers and Solutions” in the Overcoming Barriers to MAT: Bridging the Gap Between Research and Treatment in Nevada Catalyst blog post, and included bureaucracy, insufficient resources, insurance and reimbursement issues, motivation, poor care coordination, stigma, and workforce barriers (Powell, 2020). Many states, including Nevada, have developed complex programs to eliminate the barriers to MAT. A detailed description of the steps Nevada has taken over the past several years can be found in the previous blog post.

At the time of writing of the previous Catalyst blog article, “Of the 2.5 million Americans 12 years of age or older with [opioid use disorders] OUDs, fewer than 128,000 [less than 0.05%] of those attending specialty treatment programs had treatment plans that included pharmacotherapy” (Molfenter et al., 2017, p.2). More currently, the results of a study published in July 2020 looked at the  availability and use of three medications for opioid use disorder (MOUDs), extended-release naltrexone, buprenorphine, and methadone (Huhn et al., 2020).

New Study Results

Researchers looked at data from 2863 facilities and 232414 admissions from the 2017 National Survey of Substance Abuse Treatment Services Treatment Episode Data Set.

The results showed that of the 2863 residential treatment facilities in the U.S. included in the study:

• 854 residential treatment facilities (29.8%) offered XR-NTX (oral and extended-release naltrexone)
• 953 (33.3%) offered buprenorphine
• 60 (2.1%) offered methadone.
• 1717 (60.0%) did not offer MOUDs
• 35 (1.3%) offered all three MOUDs included in the study (i.e., extended-release naltrexone, buprenorphine, and methadone)

The residential facilities by and large offered long-term residential treatment, most commonly accepted insurance, and were licensed through state or hospital authority.

There was no significant difference in the availability of MOUD  between those that did or did not expand Medicaid, although there were some differences in usage of MOUDs based on prescribing restrictions. In both states that expanded Medicaid and those that did not, patients in states that had prescribing restrictions had lower odds that MOUDs would be used in treatment than those in states that did not have prescribing restrictions. Some facility-related factors were associated with low rates of MOUD availability. Facilities that did not offer MOUDs were less likely:

• to offer psychiatric medications
• be accredited by a health organization
• be licensed by a state or hospital authority
• accept private insurance.

Facilities that did not offer MOUDs were also more likely to accept only cash payments.

Some patient-specific differences in MOUD availability were found. Patients less likely to receive MOUDs were:

• male patients
• black or African American patients
• patients referred from the criminal justice system less like.

Patients older than age 55 were also more likely to have MOUDs included in their treatment plans than those under age 55.

Opioid overdose mortality also appeared to drive availability of MOUDs, with states with higher opioid overdose fatalities per 1000 residents having statistically significant higher rates of availability of MOUDs than states with lower opioid overdose fatalities.

Factors That Create Barriers to MAT

To conclude, this particular study found that MOUD availability and use were sparse in general among residential treatment facilities in the U.S., and, for this study at least, the differences appeared to be associated with state rates of opioid-related fatalities, state prescribing restrictions, facility licensing and accreditation, sex, race, age, and involvement in the criminal justice system. The authors observed that states with resistance to Medicaid expansion and with prescribing restrictions have less MOUD availability. Other affecting factors may be legal and regulatory barriers, insurance reimbursement variability, and “lack of integration between paraprofessionals and clinicians.” The authors stated that “Public health and policy efforts to improve access to and use of MOUDs in residential treatment facilities could improve treatment outcomes for individuals with opioid use disorder who are initiating recovery” (Huhn et al., 2020).

For additional information regarding MAT, see the related Catalyst blog posts and the Resources and Downloads page of this website.

Bipolar Disorder: Making the Shift To a Patient-Centered Approach

DEA to Streamline Registration Process for Medication Assisted Treatment for Opioid Use Disorder

Overcoming Barriers to MAT: Bridging the Gap Between Research and Treatment in Nevada

Medication Assisted Treatment: The Basics in Nevada

7 things you should know about Naloxone in Nevada

References

Huhn AS, Hobelmann JG, Strickland JC, et al. Differences in Availability and Use of Medications for Opioid Use Disorder in Residential Treatment Settings in the United States. JAMA Netw Open. 2020;3(2):e1920843. doi:10.1001/jamanetworkopen.2019.20843

Methadone. (2020). Retrieved October 08, 2020, from https://www.samhsa.gov/medication-assisted-treatment/medications-counseling-related-conditions/methadone

Molfenter, T., Knudsen, H. K., Brown, R., Jacobson, N., Horst, J., Van Etten, M., . . . Madden, L. (2017). Test of a workforce development intervention to expand opioid use disorder treatment pharmacotherapy prescribers: Protocol for a cluster randomized trial. Implementation Science: IS, 12(1), 135-9. doi:10.1186/s13012-017-0665-x

Paolo Mannelli & Li-Tzy Wu (2019) Opioid use disorder deaths and the effects of medication therapy, The American Journal of Drug and Alcohol Abuse, 45:3, 227-229, DOI: 10.1080/00952990.2019.1580289

Powell, N. (2020, July 29). Overcoming Barriers to MAT: Bridging the Gap Between Research and Treatment in Nevada. Retrieved October 07, 2020, from https://casatondemand.org/2018/12/28/documented-barriers-to-the-implementation-of-best-practice-in-medication-assisted-treatment-mat-for-opioid-use-disorder-oud/

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