By Clarissa Donnelly-DeRoven
About a month before 18-year-old Madison Workman died of a fentanyl overdose, she told her mom, Amber DelVechio, she wanted to get into a substance use treatment program that used suboxone. This sort of program, called medication-assisted treatment (MAT), was new to the family. Workman had been in a recovery program before, but it was abstinence-only and it hadn’t helped the teenager stop using drugs for very long.
Her mom was skeptical.
“I felt like it was taking one drug and replacing it with something else,” DelVechio remembered. Still, she told her daughter she’d look into it. DelVechio began researching. She read up and spoke with her daughter’s counselors from the other program.
Eventually, she revised her position. This treatment sounded like a good idea.
DelVechio said, “I told her, whenever you’re ready, I’m ready.”
MAT programs use medications, such as suboxone, methadone and buprenorphine, to help the brain find a new equilibrium after its chemistry has been altered by habitual drug use. These drugs act on the same brain structures that opioids do, but they have different effects. Methadone, for example, stays in the body much longer than heroin or oxycodone, reducing cravings, without altering consciousness the way oxycodone does.
DelVechio arranged for her daughter to start a year-long MAT program in Louisiana. But Madi, as her mom called her, didn’t get the chance to start. She died early in the morning on July 28, 2017 after ingesting 9.6 nanograms of cyclopropyl fentanyl, about the size of a grain of salt.
Her intake appointment for the program was scheduled for later that day.
“I’d forgotten all about the appointment, obviously,” DelVechio said, until the clinic called to reschedule. “As you can imagine, it was bad. There was, like, this dead silence on the phone.”
Structural barriers to accessing MAT
Between April 2020 and April 2021, a year soaked in pandemic-related malaise, 3,332 North Carolinians died of drug overdoses, according to data from the Centers for Disease Control and Prevention. That number is nearly 40 percent higher than the 2,422 people reported to have died from overdoses in 2020. It’s also higher than the overall nationwide increase of 27 percent, and higher than the rate increases of overdose deaths in more than 30 other states.
North Carolina’s state data shows slightly different numbers: the state reports 3,278 overdose deaths from January through October 2021, compared to 2,576 between the same period in 2020, a rise of 27 percent.
Regardless of which numbers are used, the rise has been steep. On the list of reasons why, those who work in the field say there are many causes.
One big reason: newer restrictions on prescription opioids meant prescribers started pulling back.
“That’s when the heroin moved in, and that just raised the stakes considerably,” said Jana Burson, an addiction medicine doctor in North Wilkesboro.
Beyond heroin, much – if not most – of the illicit drug supply is now tainted by fentanyl. There have been long-standing cuts to mental health services in the state, and COVID-19 has wrought havoc on nearly everyone’s well-being.
Some factors impacting the rising deaths run even deeper, though. They’re structural. Limited access to MAT sits high on this list, despite robust scientific evidence supporting the treatment’s effectiveness.
Barriers to treatment
“We have two really highly effective medications for opioid use disorder with the medications buprenorphine and methadone,” said Jamie Carter, a primary care and addiction medicine doctor in Durham, at the North Carolina Institute of Medicine’s annual meeting at the end of October. “These are medications that reduce overdose and all-cause mortality by up to 50 percent.”
“Very few patients are actually accessing these medications who have opioid use disorder. About 20 percent of patients, in most estimates, are getting any type of treatment, and very small numbers are actually getting effective medication treatments,” Carter said.
The federal government’s historic approach to MAT is largely to blame for the treatment’s limited uptake, providers say.
“It was illegal from, what, the 1930s up until 2000 when the DATA 2000 Act passed,” explained Burson. “Doctors were actually forbidden to prescribe a medication to treat opioid use disorder. So, you have 70 years where it was prohibited and all of a sudden, they’re like, ‘Okay, the laws changed. Now you can prescribe buprenorphine.’
“It just takes time for that to change, and this nation has had such a strong abstinence-only approach. That stuff doesn’t change overnight.”
Carter said some North Carolina clinics erect high barriers that limit people’s access to MAT. Many programs, she said, which receive state funding through the state’s regional mental health management organizations (known as LME/MCOs), will discharge patients for things such as missing appointments and group therapy sessions, or continuing to use certain drugs.
“Practically, what this means is that most programs are really selecting for the most stable patients and discharging or refusing or declining to treat patients who are less stable and at highest risk for overdose,” Carter said. “We should be spending our state opioid funding on high-quality treatment and right now we’re not doing that.”
A reason for these strict rules, Carter said, are state Medicaid guidelines, which were updated in 2021.
“Unfortunately, they’re still bad,” she said.
“I think one reason why providers across the state may be confused about transitioning to low-barrier care, or conflicted about it, is because they’re looking at the state Medicaid guidelines and saying, ‘Well, this is what the state is recommending for me to do,’” she said.
How to motivate providers
Whether because of a general stigma against those who use drugs, or the complicated legal history surrounding MAT, there’s a dearth of MAT services in many areas.
Marisa Domino, a health economist at the UNC Gillings School of Global Public Health, works with a UNC program aimed at increasing the number of health care providers in the state offering MAT, called Project ECHO. Domino and her colleagues struggled to recruit for the program.
“It was hard to get providers to commit to participating for one to two hours a week for about six months,” she said. So, they decided to do what researchers do best: a study.
They wanted to figure out how they could motivate health care providers — physicians, physician assistants, and nurse practitioners — to participate. They sent out four different versions of a letter to more than 15,000 primary care providers in North Carolina.
All the letters invited the workers to participate in Project ECHO and become MAT providers. One version explained that the providers would be reimbursed for time spent participating in the project, another included “pro-social messaging” that explained how the particular community the provider works in has been impacted by substance use disorder and how their training could help the community, a third letter included both messages, and the fourth, control group, letter contained neither.
Both forms of “nudges,” as the researchers referred to them, increased responses compared to the control group. Talk of financial incentives increased the response rate by 6 percent, while the pro-social messaging increased responses by 27 percent.
“As an economist, it was very surprising to me,” Domino said. Most surprising, though, was the response to both messages.
“Based on other people’s research, having both of those approaches — social messages and reimbursement together — we really thought that they were going to kind of crowd each other out,” Domino said. Instead, the providers who received letters including both messages responded at a rate nearly 50 percent higher than those who received the control letter.
“We got much more of a response from providers who are in counties with proportionately higher overdose death rate,” she said. “If that’s the marker for the unmet need in those counties, then providers in those counties are stepping up to the plate even more.”
The findings show the possibility that through very little effort, the provider network for MAT could grow exponentially.
“If the market isn’t bringing enough providers who are willing to provide treatment, then some kind of government intervention seems in order. And so maybe it’s the state Medicaid agency, maybe it’s some other branch of the state Department of Health and Human Services,” Domino said. “Government is charged with trying to correct for market failures like this.”
An attempt to increase access to MAT
At the beginning of the pandemic, the federal Department of Health and Human Services implemented policy changes to MAT prescribing rules. Before, people needed to go to the clinic most days to get their medication. After the change, providers were permitted to prescribe “stable” patients with a 28-day supply of buprenorphine, methadone or naltrexone; less stable patients could receive a two-week supply.
“The point was to reduce the number of clinic visits to prevent the spread of SARS-CoV-2,” said Nabarus Dasgupta, a physician scientist at the UNC Gillings School of Global Public Health, at the same NCIOM meeting.
Dasgupta heard early on from colleagues in syringe service programs that while the policy sounded good on paper, it was not playing out on the ground.
“They said, ‘Let’s do a study,” Dasgupta recounted. The scientists randomly selected three methadone programs in central North Carolina and surveyed 104 participants about their access to medication during the summer of 2020.
They found that take-home doses increased substantially after the policy change, but the supply patients received varied.
In one clinic where all enrollees received a take-home, only 13 percent received medication for a week or longer. In another clinic, of so-called “stable” patients who’d been receiving treatment for longer than a year, just a third of them received enough for 7 days or more. Under the policy change, all of them should have received a month’s worth.
“Despite all the efforts, what’s happening on the ground is really heterogeneous,” he said.
Another complicating factor for expanding MAT access is the huge number of uninsured people in the state, upward of 13 percent, according to 2019 U.S. Census statistics. Elyse Powell, the state opioid coordinator at NCDHHS, argues that Medicaid expansion is “the most important tool” to prevent overdose deaths in North Carolina.
“Just for people who overdose and show up in an emergency department, of those people, 40 percent have no health insurance at all,” Powell said. “They overdose, they come to the emergency department, [and] they’re saddled with a potentially quite large emergency department bill.”
Without insurance, these people often leave the ER without being connected to services.
“Access to evidence-based treatment is what works to prevent overdoses, period,” Powell said. “If you have health insurance, you can access basic mental health care that prevents you from going down the road of really getting into the depths of a problematic addiction in the first place.”
Powell added that because North Carolina hasn’t expanded Medicaid, a good chunk of federal grants received by the state go toward paying for MAT for 20,000 uninsured people each year.
“The need is much, much, much larger than that,” Powell said. ”Not having Medicaid expansion both means that we are using a huge chunk of our federal grant dollars that we could use toward other things, like funding post-overdose response teams, and more naloxone and justice involved programs.”
Carter, the Durham addiction medicine doctor, explained that this federal money for opioid treatment primarily goes to the LME/MCOs, while almost none goes to local community health clinics, also known as federally qualified health care centers (FQHCs), even though these clinics are a major source of care for uninsured people.
“There’s just no pathway right now for that funding to go directly to FQHCs. No FQHC, or very few to my knowledge, has been successfully able to contract with their local LME/MCO,” Carter said. ”What that means in practice is that an uninsured patient who seeks care from an LME/MCO-funded program has been able to get care for free, with no cost barrier for the appointment or for the medication, while a patient who seeks treatment at an FQHC has a sliding scale copay that’s based on their income, which is often somewhat burdensome.”
Would Medicaid expansion help?
This sort of block grant funding adds a complicating factor to the role Medicaid expansion might play in reducing overdose deaths, explained Domino, the health economist. Prior to two years ago, she said, she assumed expansion would have a “huge” impact on reducing overdose deaths in the state.
“If patients have reimbursement or coverage for services, you would think they would demand more services and providers can get reimbursed and therefore, it increases the statistical argument for participating in treatment,” Domino said. One of her doctoral students studied what was happening in expansion states.
The results were surprising.
“He really didn’t find much of an effect,” Domino said. ”We thought that it was because substance use is a little bit different because there are state block grant funds that can be used to pay for substance use services.”
Other studies have shown similar results. While many people experiencing substance use disorder gain insurance coverage in expansion states, they don’t necessarily access more substance use treatment services.
Many working in harm reduction argue that this result demonstrates how expansion is still critical to those with substance use disorder. Even if people experiencing addiction aren’t getting treatment specific to their disorder, it can help improve their overall health.
“In a state that doesn’t have Medicaid expansion, people are suffering from lack of health care coverage,” said Michelle Mathis, the executive director of the harm reduction organization Olive Branch Ministry. “They can’t even go to the pharmacy and buy Narcan or naloxone,” the overdose reversal drugs that are in short supply recently due to manufacturing issues.
Instead, they must rely on organizations like Olive Branch for their naloxone, which often have to rely on donations or a buyers club in order to obtain the drug.
“Our infrastructure for naloxone distribution in the United States is teetering on this network of sharing,” said Dasgupta. “This critical piece of our response to overdose deaths can’t be teetering on GoFundMe pages and bake sales.”
Access to naloxone and MAT can save lives for those experiencing substance use disorder. Still, for many in the field, the highest level goal is to help people from becoming addicted in the first place. This requires going “way upstream,” said Marcus Plescia, the chief medical officer at the Association of State and Territorial Health Officials, at the NCIOM meeting in October.
Looking upstream means looking at the role social determinants of health and adverse early childhood experiences play in the development of substance use disorder and implementing policies that help break that cycle.