Problem

Americans from all walks of life suffer from opioid use disorder, but certain communities are disproportionately affected. Women, persons of color, veterans, and rural Americans all die from overdoses at alarming rates and lack equal access to lifesaving treatment.

Pregnant people

Drug overdose is a primary cause of death for new mothers.

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Max Jordan Nguemeni Tiako, MS et al., Prevalence and Geographic Distribution of Obstetrician-Gynecologists Who Treat Medicaid Enrollees and Are Trained to Prescribe Buprenorphine, 3(12) JAMA Network Open (Dec. 11, 2020), https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2774073 (“The incidence of opioid use during pregnancy is increasing, and drug overdoses are a leading cause of postpartum mortality.”).

The American College of Obstetricians and Gynecologists recommends buprenorphine as a standard of care for pregnant patients with opioid use disorder.

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Society for Maternal Fetal Medicine, Substance use disorders in pregnancy: clinical, ethical, and research imperatives of the opioid epidemic: a report of a joint workshop of the Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists, and American Society of Addiction Medicine (July 2019), https://www.ajog.org/article/S0002-9378(19)30500-9/fulltext (“All pregnant women with OUD should be offered maintenance therapy with methadone or buprenorphine.”); American College of Obstetricians and Gynecologists and American Society of Addiction Medicine, Committee Opinion: Opioid Use and Opioid Use Disorder in Pregnancy, No. 711 (Aug. 2017), https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/08/opioid-use-and-opioid-use-disorder-in-pregnancy (“The rationale for opioid agonist pharmacotherapy during pregnancy is multifold. Opioid agonist pharmacotherapy prevents opioid withdrawal symptoms and is shown to prevent complications of nonmedical opioid use by reducing relapse risk and its associated consequences. It also improves adherence to prenatal care and addiction treatment programs. Opioid agonist pharmacotherapy in combination with prenatal care has been demonstrated to reduce the risk of obstetric complications…For pregnant women with an opioid use disorder, opioid agonist pharmacotherapy is the recommended therapy and is preferable to medically supervised withdrawal because withdrawal is associated with high relapse rates, ranging from 59% to more than 90% and poorer outcomes. Relapse poses grave risks, including communicable disease transmission, accidental overdose because of loss of tolerance, obstetric complications, and lack of prenatal care.”).

Medications for opioid use disorder can nearly eliminate the risk of overdose when taken throughout pregnancy.

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Marian Jarlenski, PhD, MPH, et al., Association of Duration of Methadone or Buprenorphine Use During Pregnancy With Risk of Nonfatal Drug Overdose Among Pregnant Persons With Opioid Use Disorder in the US, JAMA Network Open (Apr. 2022), https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2791297 (“Finally, those with continuous MOUD use throughout pregnancy (i.e., initiated before pregnancy) had a 97% reduced risk of nonfatal overdose (aRR, 0.03 [95% CI, 0.00-0.79]).”).

But fewer than 1 in 100 OB-GYNs have federal approval to prescribe buprenorphine for opioid use disorder.

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Max Jordan Nguemeni Tiako, MS et al., Prevalence and Geographic Distribution of Obstetrician-Gynecologists Who Treat Medicaid Enrollees and Are Trained to Prescribe Buprenorphine, 3(12) JAMA Network Open (Dec. 11, 2020), https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2774073 (“A recent study showed that only 0.4% of obstetrician-gynecologists were X-waivered.”).

As a result, most pregnant patients with opioid use disorder do not receive this lifesaving medication, greatly increasing their risk of overdose.

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Max Jordan Nguemeni Tiako, MS et al., Prevalence and Geographic Distribution of Obstetrician-Gynecologists Who Treat Medicaid Enrollees and Are Trained to Prescribe Buprenorphine, 3(12) JAMA Network Open (Dec. 11, 2020), https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2774073 (“Despite its effectiveness, buprenorphine remains inaccessible for many women with OUD who are pregnant. A study of treatment episodes for prescription OUD during pregnancy showed that medication for OUD was administered only during a third of treatment episodes, and a more recent study of women enrolled in Medicaid who were pregnant noted that nearly half of pregnant patients with OUD receive no medication for OUD. The low rate of pregnant women with OUD receiving evidence-based care is due, in part, to barriers physicians face in terms of the ability to prescribe the medication. The Drug Addiction Treatment Act requires 8 hours of training for physicians and 24 hours for nurse practitioners and physician assistants to receive approval via a waiver (hereafter called the X-waiver) by the Drug Enforcement Agency to prescribe buprenorphine.”).

Persons of color

Black and Indigenous persons have experienced the fastest growing rate of overdose deaths in recent years.

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CDC, Vital Signs: Drug Overdose Deaths, by Selected Sociodemographic and Social Determinants of Health Characteristics — 25 States and the District of Columbia, 2019–2020 (2022) https://bit.ly/3aWAhHj (“From 2019 to 2020, overall drug overdose death rates increased in 25 states and DC; the largest increases occurred among certain racial/ethnic minority populations. Relative rate increases were highest among Black (44%) and AI/AN persons (39%) (Table 1). Among White persons, the rate increased by 22%.”).

Hispanic youth and seniors are facing significant losses.

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CDC, Vital Signs: Drug Overdose Deaths, by Selected Sociodemographic and Social Determinants of Health Characteristics — 25 States and the District of Columbia, 2019–2020 (2022) (Table 1) https://bit.ly/3aWAhHj (showing rate of overdose death increases for Hispanic persons aged 15-24 of 51% and aged 65+ of 46%).

Due to racial segregation, white Americans have near exclusive access to buprenorphine. Medical providers who have federal approval to prescribe buprenorphine for opioid use disorder are more likely to be located in white neighborhoods.

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Max Jordan Nguemeni Tiako, MS et al., Prevalence and Geographic Distribution of Obstetrician-Gynecologists Who Treat Medicaid Enrollees and Are Trained to Prescribe Buprenorphine, 3(12) JAMA Network Open (Dec. 11, 2020), https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2774073 (“Studies have shown that, as a result of racial segregation, buprenorphine availability is associated with a greater proportion of White residents at the neighborhood and county levels, and methadone availability is associated with greater proportions of Hispanic and Black residents…Within the context of pregnancy, a study reported that Black and Hispanic women (both overrepresented among Medicaid recipients) are less likely to receive any pharmacotherapy for OUD.”).

White Americans are nearly 35 times more likely to have a buprenorphine-related visit than Black Americans.

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Martha Bebinger, “Opioid Addiction Drug Going Mostly To Whites, Even As Black Death Rate Rises”, NPR (May 8, 2019), https://www.npr.org/sections/health-shots/2019/05/08/721447601/addiction-medicine-mostly-prescribed-to-whites-even-as-opioid-deaths-rose-in-bla (“White drug users addicted to heroin, fentanyl and other opioids have had near exclusive access to buprenorphine…‘White populations are almost 35 times as likely to have a buprenorphine-related visit than black Americans,’ says Dr. Pooja Lagisetty, an assistant professor of medicine at the University of Michigan Medical School and the study's corresponding author.”).

As a result, opioid overdose deaths continue to grow at alarming rates among persons of color.

Veterans

Buprenorphine reduces the risk of suicide for veterans with opioid use disorder by 65% when compared to other treatments.

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Larissa J. Mooney, M.D., “Medication Treatment for Opioid Use Disorder Reduces Suicide Risk”, Am. J. Psychiatry (Apr. 1, 2022), https://bit.ly/3M21N2T (“When comparing effects on mortality risk across the three MOUD types, only buprenorphine had a significant effect on reducing suicide mortality and external causes of mortality in models adjusted for demographic characteristics, comorbidities, and health care utilization. Methadone was associated with reduced suicide mortality risk in unadjusted models only. All three MOUD types were associated with a significant protective effect in all-cause mortality, although naltrexone had a lesser magnitude of effect than buprenorphine or methadone. Overall, MOUD was associated with a greater than 50% reduction in risk of suicide mortality during periods of stable treatment, with an even larger reduction in external and all-cause mortality. The effect of buprenorphine treatment stood out as superior and was associated with a 65% reduction in suicide mortality risk.”).

Veterans are 1.5 times more likely to die of an opioid overdose than the general population.

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U.S. Government Accountability Office (“GAO”), Report to Congressional Committees: Veterans Healthcare, Services for Substance Use Disorders, and Efforts to Address Access Issues in Rural Areas, at 1 (Dec. 2019), https://www.gao.gov/assets/710/702940.pdf (“Veterans are 1.5 times more likely to die from opioid overdose than the general population, according to VA and Centers for Disease Control and Prevention data.”).

But only 1 in 3 veterans receive medications to treat opioid use disorder due in part to a shortage of providers who have federal approval to prescribe buprenorphine.

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U.S. Government Accountability Office (“GAO”), Report to Congressional Committees: Veterans Healthcare, Services for Substance Use Disorders, and Efforts to Address Access Issues in Rural Areas, at 19, 26-27 (Dec. 2019), https://www.gao.gov/assets/710/702940.pdf (“In fiscal year 2018, 23,798 veterans received medication-assisted treatment, which was 33.6 percent of veterans diagnosed with an opioid use disorder…Across all 140 VHA health care systems, veterans with an opioid use disorder received medication-assisted treatment (in specialty and nonspecialty settings) at a higher rate in urban locations (34 percent) than in rural locations (27 percent) in fiscal year 2018…Despite the similar rates of waivered providers in rural and urban areas, as previously mentioned, rural veterans with opioid use disorder use medication-assisted treatment at a lower rate…Officials from three of the six VHA health care systems we interviewed noted a shortage of SUD specialists in their area, including addiction therapists and providers with a waiver to prescribe buprenorphine. According to one study and agency documents we reviewed, veterans may reside in mental health professional shortage areas at a higher rate than the general population, therefore they may have less access to providers qualified to offer medication-assisted treatment or other mental health treatment.”).

Rural Americans

More than half of counties with the highest rates of opioid prescriptions, nonprescribed use of opioids, and overdose deaths are rural.

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U.S. Dep't. Health and Human Svcs., Geographic Disparities Affect Access to Buprenorphine Services for Opioid Use Disorder (2020), https://oig.hhs.gov/oei/reports/oei-12-17-0240.pdf?utm_source=newsletter&utm_medium=email&utm_campaign= newsletter_axiosvitals&stream=top (“In total, 1,119 counties had high indicators for at least two of the three opioid misuse and abuse measures (i.e., drug overdose mortality, nonmedical use of pain relievers, and opioid prescribing) included in our analysis, thereby meeting OIG’s definition of ‘high need.’…More than half (61 percent) of these high-need counties are in rural areas.”).

But 20 million Americans live in a county without a physician who has federal approval to prescribe buprenorphine for opioid use disorder.

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Nat’l Inst. of Health (“NIH”), Physician-pharmacist collaboration may increase adherence to opioid addiction treatment (Jan. 11, 2021), https://www.nih.gov/news-events/news-releases/physician-pharmacist-collaboration-may-increase-adherence-opioid-addiction-treatment (“In the United States, fewer than 10% of primary care providers are authorized to prescribe buprenorphine, and more than 20 million people in the United States live in a county without a buprenorphine-waivered physician. This lack of access is a significant barrier to treatment, especially to people in underserved communities.”); HHS, Geographic Disparities (2020), at 9 (“In total, 72 percent of counties with low-to-no patient capacity are in rural areas (for comparison purposes, 63 percent of counties nation-wide are rural). The lack of waivered providers in rural areas may reflect a wider problem with shortages and maldistribution of primary care and other providers.”).

This shortage of providers discourages rural Americans from accessing treatment due to long wait times that may last weeks or months.

¹⁵

U.S. Government Accountability Office, Report to the Majority Leader, U.S. Senate, Opioid Addiction: Laws, Regulations, and Other Factors Can Affect Medication-Assisted Treatment Access, at 15 (Sept. 2016) https://www.gao.gov/assets/690/680050.pdf (“[B]ecause there are many areas of the country that have an insufficient number of physicians, the result is that many people needing treatment may remain on waitlists for weeks or months. It added that prolonged waitlists are associated with reduced likelihood of treatment entry.”).

Solution

The Mainstreaming Addiction Treatment Act will remove structural health barriers that fuel the risk of overdose death for women, persons of color, veterans, and rural Americans.

A person’s sex, racial and ethnic background, military service, and where they live should not determine whether they can access lifesaving, affordable treatment.

By allowing all medical providers with a standard controlled medication license to prescribe buprenorphine for opioid use disorder, the Mainstreaming Addiction Treatment Act will help ensure all Americans can achieve long-term recovery.