Barriers to OUD Treatment and Strategies for Overcoming Them

In this video, Karen Scott, MD, MPH, President of the Foundation for Opioid Response Efforts (FORE), New York, New York, outlines the most common barriers people face to receiving treatment for opioid use disorder (OUD), populations which are least likely to receive care for the disorder, and some strategies which have been successful in reaching and delivering care to vulnerable populations. These topics were among those addressed at the recent virtual Rx Drug Abuse & Heroin Summit.  

Read the transcript:

Common Barriers to OUD Treatment

We think about the barriers to treatment for opioid use disorder in 3 intersecting buckets, if you will.

The first is the capacity in terms of having trained health care professionals who are trained in addiction medicine, who are not only able to prescribe medications for opioid use disorder but also able to support patients over a long period of time as they go through treatment and to help them maintain their recovery.

In addition to physicians and nurse practitioners and physician assistants who are doing waiver training to be able to appropriately prescribe medications for opioid use disorder, we know we also need a strong workforce in terms of nurses and social workers and peers who provide many of those supports and wraparound services as part of a care team over a long period of time for patients.

The second piece is a set of barriers that relate to challenges with accessing health care in this country for many people. Part of that are financial, certainly, the affordability of treatment.

Even people with insurance may face barriers in terms of deductibles and copayments. Insurance companies sometimes have barriers in terms of prior authorization, so putting up more hurdles for someone to start medication treatment, or have limitations on how long they will pay for particular prescription medications.

It's a set of barriers around the finances and affordability of care which are then even more significant for people who do not have health insurance at all.

One of the best examples of seeing how insurance makes a difference is that we have seen over the last few years that states that expanded Medicaid and provide strong Medicaid coverage for opioid use disorder treatment have seen a significant increase in the number of people who are able to access care.

The third bucket that I would highlight are the social determinants of health that serve as barriers to starting treatment or staying in treatment.

These are what we've heard from many of our grantees in our network, that if people are struggling to have a job or stay in a job or struggling with their housing security or struggling with issues related to family separation . . . These are all challenges that very often will take priority, understandably, over being able to make it to doctor’s appointments regularly or to stick with group visits and recovery services over a long period of time.

We really need to understand all of the factors that a person in treatment and recovery needs support with and assistance with to be able to make sure they can stay in treatment for a long period of time and get the maximum benefits from treatment.

Access to OUD Care Across Populations (3:28)

We know that some of the populations that are higher risk for delayed or no care for opioid use disorder includes minority populations, black, Hispanic, Native populations, as well as those in very rural or remote areas.

For many of the reasons that I've just mentioned in terms of barriers in access to care, not having providers that are trained and in those communities, not having the financial means or the insurance coverage to access treatment and stay in treatment. I would add to that also for many populations, the stigma around a condition that for so long was viewed as a criminal activity rather than a health care condition.

There's a lot of work to do in many communities around the education that opioid use disorder is a treatable condition—it's a health care condition, and it's treatable—as well as making health care available in different communities so that it's easily accessible.

I would also say that we have prioritized, we consider, thinking about the populations that our projects will reach also, in terms of those high-risk populations where we know from the data that there's a higher rate of overdose mortality in particular periods, particularly around particular kinds of transitions.

Two of those high-risk populations are women postpartum. In 6 to 7 months postpartum, studies have shown an increase in overdose for women who had an opioid use disorder prior to their pregnancy and prior to their delivery.

We are looking at how to make sure that women have supports throughout that first year postpartum rather than care that often can drop off in the weeks following the birth of their child.

Another very high-risk population with a spike at a transition point are people coming out of jails and prisons. There's some very strong data that shows significant increases in overdose mortality within the first 3 or 4 weeks after leaving an incarceration. It's another reason why there's so much attention really on starting medications for opioid use disorder while someone is within the correctional system and then making sure they're linked to care as they leave that system.

Can you describe some successful strategies being used to expand access to OUD treatment for underserved and high-risk populations?

Reaching Underserved and High-Risk Populations (6:14)

A number of our grantees are developing and testing strategies that are very much focused on how to better reach and stay connected with these vulnerable populations. I'll highlight a couple of those.

One strategy—an example of it is our project with the University of Miami—is engaging and developing a peer workforce that is very much from the community, so not only has lived experience with respect to a substance use or opioid use disorder but has lived experiences, other shared lived experiences, with the patient population that they are engaging with.

That project is particularly focused on two very African American communities within Miami, areas where the patients that are now engaging with a peer have said, "We never imagined care would come to us. We never imagined that we would have a chance to get this kind of treatment." Very promising in terms of that model and the added benefit of the peer added to the health care team there.

Another very promising strategy is just that whole concept of meeting people where they are and really taking the care to where they are. A couple of examples from our grantees . . .

In Pennsylvania, one based in Philadelphia is reaching a homeless population. They're bringing the health care services, including medications for opioid use disorder, to a population that is homeless or housing-insecure and bringing the health care services to the nonprofit organizations that are providing other services for that homeless population.

Similarly, in more rural counties in Pennsylvania, Allegheny Health Network Project includes mobile health services where paramedics go out and do outreach to patients who have been on the inpatient service for their addiction treatment to do a follow-up to keep them engaged in their care.

That strategy around, again, very much thinking about how to be flexible, how to meet people and bring care services to where they are, is, again, another very promising way for us to think a little bit differently about care delivery for this population.

Dr. Karen Scott has more than 20 years of experience in health care policy, quality improvement, health services research, and public health. She has worked with public health and delivery system leaders to redesign care and promote health equity, quality and patient safety, and population health improvement. Dr. Scott has led large-scale change initiatives within delivery systems, focusing on public and safety net providers, and the populations they serve. She served as Chief Medical Officer in the Office of Assistant Secretary for Health at the US Department of Health and Human Services (HHS). Dr. Scott also collaborated to advance policy on social determinants of health and concurrently served in the role of interim acting director of the HHS Office on Women’s Health. Dr. Scott is a board-certified physician in preventive medicine.