Rural areas must be considered in new MAT policies

Recently, President Obama entered the abstinence vs. medication assisted treatment (MAT) controversy, squarely on the side of MAT.

Like climate change, the president insists that the science is in, regarding opioid treatment. In an order to federal healthcare agencies to identify barriers to MAT, he said, “only a small minority of Americans who might benefit from this treatment are receiving it.” The president also set a federal goal to double the number of physicians who prescribe buprenorphine from 30,000 to 60,000. Many providers would also like to see the number of patients each physician is allowed to treat also increased, along with the extension of the prescription privilege to nurse practitioners.

In February, federal authorities also announced that drug courts that banned MAT would not receive federal funding. Many judges, prosecutors and law enforcement officials are still suspicious of MAT. Some of this distrust is derived from the traditional ideology of ultra-orthodox AA and NA groups that prohibit any use of psychotropic drugs.

Another source is from the excesses observed in poorly regulated methadone clinics, which I have heard at least one prosecutor say were equivalent to “legalized drug dealing.” Just the word “methadone” has negative connotations and in many cases an emotional impact on people who immediately associate it with a permissive approach to innercity heroin addiction. 

Supporting methadone clinics, like supporting needle exchanges and other harm reduction techniques can have dire political consequences for candidates in conservative regions of the country. Voters may easily view such treatments as tantamount to hug-a-thug.

Access in rural areas

Last year in an editorial in the Journal of the American Medical Association, methadone clinic director and University of Vermont College of Medicine professor Stacey Sigmon and her associates discussed access to treatment for opioid dependence in rural America. Sigmon believes that among the greatest barriers is limited capacity and the lack of subsidized programs. Up to two year waiting lists for treatment are common in some rural states such as Vermont and Kentucky.

Another major barrier is transportation time, as it interferes with employment and the costs can be prohibitive. Historically, methadone clinics served urban populations with public transportation so the rural application presents a host of problems. I would add that finding qualified staff to work in such isolated areas is another significant problem. Indiana has just revived a federal grant to facilitate access to MAT and is wrestling with many of these issues.  

Sigmon describes two avenues that she believes hold promise for increasing access to opioid treatment in the future. First is the use of sustained release of opioid antagonist medications through the use of implants or similar techniques. This would reduce the burden of frequent dosing. For example, one buprenorphine implant requires only semiannual dosing while decreasing the likelihood for diversion.

The second set of approaches would exploit the use of technology to allow greater connectivity of socially isolated patients in rural areas. Various mobile heath technologies, computerized adherence monitoring systems, telehealth therapy, and web-based recovery support services are promising possibilities from this perspective.

I am wondering what your organizations are doing to reduce the stigma and barriers to MAT. Does your CMHC operate a methadone clinic or would it consider doing so? Also what have you found that works in regard to opioid treatment in isolated and economically depressed rural areas? From the federal perceptive the ball is in the provider’s court.