In 2019, the opioid use and overdose crisis was considered the primary public health crisis facing people in the U.S. The crisis – also known as the opioid epidemic – developed over the previous two decades. It affected people across the country. No demographic was immune. From farm workers in rural states to doctors in urban areas to factory workers in the blue-collar industrial communities, the crisis touched individuals and families everywhere.
Then COVID-19 arrived, and our attention – rightly so – shifted to the immediate crisis threatening our health and well-being. Everything about the pandemic has been thoroughly covered by the media, and on our blog. We’ve published several articles on the impact of COVID-19 on the opioid crisis, like this one:
Opioid Crisis Report: COVID-19 Increased Overdose Risk in Rural Communities
In this article, however, we’ll look at a study conducted before the COVID-19. This study examines access to a medication called methadone, which is one of three drugs used to treat opioid use disorder (OUD): methadone, buprenorphine, and naltrexone. These medications, approved by Food and Drug Administration (FDA), are collectively known as medications for opioid use disorder, or MOUD. They’re a core component of an approach to treating OUD called medication-assisted treatment, or MAT.
What is Medication-Assisted Treatment (MAT)?
MAT is currently considered the gold standard approach to treating opioid use disorder. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), MAT is defined “The use of medications, in combination with counseling and behavioral therapies, to provide a ‘whole-patient’ approach to the treatment of substance use disorders.” Data from SAMHSA indicates the significant benefits of MAT for people with OUD, including the following.
Benefits of MAT
- Reduced opioid withdrawal symptoms
- Decreased cravings for opioids
- Blocking the action of opioids in the brain
- Decreased risk of fatal or nonfatal overdose
- Decreased overall opioid-related death
- Reduced drug use, opioid and non-opioid
- Reduced risky behavior related to drug seeking drug use
- Increased capacity to engage in treatment
- Increased ability to seek and secure employment
- Improved relationships with peers, family, and coworkers
In a nutshell, MAT improves lives: that’s why it’s considered the gold-standard treatment for OUD. The presence of an effective treatment for OUD means we can work to mitigate the harm caused by the opioid crisis.
Here’s the latest data on the crisis, reported by the Centers for Disease Control (CDC):
- In 2019: 72,151 people died of drug overdose: over 50,000 involved opioids
- In 2020, 92,478 died of drug overdose: over 69,000 involved opioids
- In 2021, 107, 521 people died of drug overdose: final opioid fatality data pending
- In the 12-month period ending in July 2022, the CDC reports 102,249 drug overdose deaths, with final opioid data pending
That data tells us that during COVID-19, the opioid crisis did not go away: it got worse. But as it got worse, did more people seek treatment?
Treatment for OUD with MAT: The Latest Data
Now let’s look at two more figures: the number of people with OUD in the U.S., and the number of people who received MAT for OUD. We retrieved this data from the 2021 National Survey on Drug Use and Health (2021 NSDUH). This report shows that in the U.S. in 2021:
- 4 million people – about 2.4% of the adult population of the U.S. – had a clinical diagnosis for opioid use disorder.
- Among individuals diagnosed with OUD, around 800,000 – about 14% – received medication-assisted treatment (MAT)
That means around 86 percent of people with OUD did not get the treatment they needed. This is known as the treatment gap.
That’s a big gap – and it’s something we’re working to close. One thing that affects the MAT treatment gap is access to MAT itself. Published in 2021, the study we discuss in this article, called “Pronounced Regional Disparities in United States Methadone Distribution” examines the relative differences in access to methadone across the U.S. Before we look at the data, it’s important to understand that before COVID-19, federal regulations around methadone were strict. During the pandemic, authorities eased restrictions – we’ll tell you how after we discuss the study. For now, we’ll offer the set of rules and regulations for MAT with methadone before COVID-19.
Pre-COVID Federal Guidelines for Methadone
- Patients had to receive medication in-person, six days a week
- Methadone distribution was limited special clinics call Opioid Treatment Programs (OTPs):
- Only 1700 OTPs existed in the U.S. before COVID
- They were most common in urban areas
- OTPs were rare in rural areas
- Rules prevented patients from receiving any take-home doses for the first three months of treatment
- Rules mandated patients provide urine samples under the observation of clinicians
- Initiation of treatment was limited to in-person visits to licensed OTPs
That was the default situation at the time researchers conducted this study. We’ll look back at this pre-COVID data to help us understand where we’ve been, which will help clarify where we are now, and inform our decisions for the future.
Access to Methadone: Were There Regional Differences?
One advantage of the strict rules and regulations around methadone is that they include detailed record-keeping and mandatory reporting to the Drug Enforcement Agency (DEA). This allows the public to understand exactly how much methadone doctors prescribe and distribute, and whether the prescriptions are for MAT or for methadone as a pain-relieving analgesic.
For the purposes of this study researchers examined data collected from the Automated Reports and Consolidated Ordering System. They collected data on the following metrics:
1. Distribution:
- Nationwide total
- Total for OTP programs for MAT
- Total for pain relief
2. Regional Distribution:
- West
- Midwest
- South
- Northeast
3. Distribution by State
Total Number of OTPs
- By State
- By Region
Let’s take a look at what they found, starting with the nationwide totals for methadone distribution.
Methadone Distribution 2017-2019: National Totals
- Overall:
- 2017: 14,750 kg
- 2018: 13,815 kg
- That’s a 6.3% decrease from 2017
- 2019: 15,172 kg
- That’s an 2.86% increase from 2017
- To OTPs:
- 2017: 13,800 kg
- 2018: 13,4315 kg
- That’s a 2.77% decrease from 2017
- 2019: 15,500 kg
- That’s a 12.30% increase from 2017
- For Pain Relief:
- 2017: 2,900 kg
- 2018: 2,315 kg
- That’s a 20.34% decrease from 2017
- 2019: 1,897 kg
- That’s a 34.57% decrease from 2017
We’ll step in here to offer a brief, initial interpretation of these figures. The relative increases and decreases present reflect the effect of two initiatives enacted to address the opioid crisis. One initiative targeted a reduction in methadone prescriptions for pain, reflected in the decreases reported in the last section of bullets. The other initiative targeted an increase on OTPs that used methadone for OUD for people in MAT. This is also clearly reflected in the data: decreases in overall distribution and distribution to OTPs decreased from 2017-2018 after guidelines for methadone prescriptions for pain changed, but before initiatives to increase OTPs were implemented. The increases in overall and OTP distribution from 208-2019 reflect the increase in OTP clinics nationwide.
Methadone Distribution by Region, Percent Change, 2017-2019
- West
- Total: 1.4% decrease
- For OTPs: 37.8% increase
- For pain: 11.2% decrease
- Midwest
- Total: 8.44% decrease
- For OTPs: 33.5% increase
- For pain: 31.4% decrease
- South
- Total: 2.4% decrease
- For OTPs: 37.6% increase
- For pain: 3.8% decrease
- Northeast
- Total: 5.6% decrease
- For OTPs: 25.8% increase
- For pain: 10.7% decrease
Those figures also align with what we know about the broad strokes of the opioid crisis. Between 2010 and 2015, opioid overdose rates in rural areas in the West and Midwest skyrocketed. When the CDC issued new guidance for methadone prescriptions and the federal government announced an increase in funding for OTPs between 2014 and 2016, those changes had a significant impact on methadone distribution, exactly as intended. The data above shows increases in distribution to OTPs and decreases in distribution for pain relief, and those relative changes appeared most substantially in the rural West and Midwest.
Now let’s look at one last set of data: the change in OTPs by region.
Change in Number of OTPs By Region, 2017-2019
- West: OTPs increased by 11.2%
- Midwest: OTPs increased by 25.3%
- South: OTPs increased by 3.8%
- Northeast: OTPs increased by 7.6%
This data also reflects nationwide trends we’re aware of. In the Midwest, for example, in states like Ohio – where we operate MAT programs with methadone – officials implemented robust, aggressive strategies to mitigate the harm caused by the opioid crisis. Policymakers endorsed an all-of-the-above, all-hands-on-deck approach, which included expanding funding for treatment specific to opioid use disorder, such as MAT programs using methadone in OTPs.
To learn more about the response to the opioid crisis in Ohio, please read these two articles:
The Opioid Crisis in Ohio
Opioid Overdose in Ohio: Local Efforts Offer Communities Hope
Before we conclude this article, we’ll to point out that local, state, and federal initiatives to address the opioid crisis before the COVID-19 pandemic effectively targeted areas of need. Between 2010 and 2014, the increase in opioid overdose in the rural West and Midwest was shocking. When states reacted with organized efforts to meet the needs of their populations, they decreased all opioid pain prescriptions –including for methadone – and increased funding for OTPs that offer methadone as part of MAT.
We see those changes clearly reflected in the data we report above.
Methadone Availability Post-COVID
Those changes and the data that show them help us understand how to best prioritize and allocate our resources for the future. Despite these positive developments, one thing we didn’t report in the data is the variable availability of methadone and OTPs in extremely rural areas in the West and Midwest. Although the number of OTPs and amount of methadone distributed in the West and Midwest increased overall between 2017 and 2019, there are still large gaps in the availability of care.
For instance, the state of Wyoming has no OTPs at all. States like South Dakota, North Dakota, and Nebraska have so few OTPs that their absence creates a significant barrier to care. Here’s how the study authors describe the situation:
“The lack of convenient access to methadone places patients with OUD at an increased mortality risk because the likelihood of leaving treatment is directly related to barriers in accessing methadone at OTPs.”
That means that although lifechanging, lifesaving care is within reach, many people cannot access this care because the logistics make it impossible. With that said, the federal government did make changes during COVID-19 in order to reduce barriers to care.
Here’s what they did.
Changes to Methadone Rules During COVID-19
- Allowed providers to offer patients stable on methadone 28 days of take-home doses after initiation of treatment. Before COVID, more than one take-home dose was only allowed after 90 days of treatment.
- Allowed providers to offer less stable methadone patients 14 days of take-home doses 14 days after initiation of treatment. Before COVID, more than one take-home dose was only allowed after 90 days of treatment
- Permitted OTP clinicians to continue to treat existing methadone patients via telehealth
- Permitted OTP clinicians to continue to prescribe methadone to existing patients via telehealth
- Allowed OTP clinicians to offer counseling services via telehealth
- Allowed OTPs in rural areas to deliver methadone via mobile MAT units to patients
If federal authorities make these changes permanent, it would expand access to care for patients with OUD and allow them to experience the benefits of MAT in a safe and convenient manner. Another area of change that can increase access is to expand the ability of primary care practitioners to prescribe MOUD for MAT such as methadone in the primary care setting. All these changes would significantly reduce the ongoing harm caused by the opioid and overdose epidemic. We’ll give the final word on this topic to the researchers who did this important work:
“This study has demonstrated that despite the increase in distribution of methadone and increase in the number of OTPs across the United States, access to this medication in some areas is limited because of geographic, societal, economic, and legislative barriers.”
Okay, not the final word: we know, based on the progress we’ve made over the past several years, that increasing MAT access can save lives. We will work to overcome the “geographic, societal, economic, and legislative barriers” until we’re able to offer the best possible treatment and support for OUD to anyone and everyone who needs it.