Running Head: MAT -BARRIERS AND ACCESS 1 Barriers to access Medication Assisted Treatment and
Recommendations to increase the access to Medication Assisted Treatment. Sini Eapen
Marymount University
MSN-FNP MAT: BARRIERS AND ACCESS 2
Introduction Substance abuse disorder has been one of the major issues in our health care system.
This problem has contributed to the unintentional death of people, resulting from overdose
secondary to the use of prescription drugs. Subsequently the substance abuse has increased the
rate of emergency room visits and hospital admissions (readmissions secondary to substance
abuse treatment programs), in the last 10 years. Neither the use of behavioral therapy nor the
abstinence alone has not yielded any good results. Medication assisted treatment (MAT)make use
of medication as well as behavioral therapy provide treatment options for people who are
addicted to Heroin and individuals diagnosed with opioid use disorder. Results indicate that
maintenance medication provides the best opportunity for patients to achieve recovery from
opiate addiction. Extensive literature and systematic reviews show that maintenance treatment
with either methadone or buprenorphine is associated with retention in treatment, reduction in
illicit opiate use, decreased craving, and improved social function. Because of lack of adequately
trained medical professionals, the negative attitude among public, providers and patients towards
use of MAT, the effectiveness of the treatment is questionable. This paper aims to present the
barriers of MAT and how to increase the outreach of the MAT.
. MAT: BARRIERS AND ACCESS 3
Background of the problem “In this global economy of ours, the most important thing we can do is to reduce demand for
drugs. And the only way that we reduce demand is if we’re providing treatment and thinking
about [substance use] as a public health problem, and not just a criminal problem… there are
steps that can be taken that will help people battle through addiction and get on to the other side,
and right now that’s under-resourced.” Barack Obama. The former U. S. President is referring to
the Medication Assisted Treatment program which involves a combination of behavioral therapy,
counselling and use of medications in a controlled manner
The morbidity and mortality associated with opioid use has increased to its max from its
overdose. The amount spent on prescription opioids by insurance companies has sky rocketed. It
was estimated that about 72.5 billion was spent on opioids by insurance companies in 2007
(which are like the amount spent on treating diseases like asthma or HIV). Too much money
spent on mental and social rehabilitation of these people with OUD. By means of federal law
people who are enrolled in MAT program are entitled for medical counseling, vocational,
educational, and other assessment and treatment services, in addition to prescribed medication.
But the chances of going back treatment of opioid overuse is refractory
Federal law has increased the provision for rehab services are available in a wide variety
of settings like hospitals, correctional facilities, offices, and remote clinics. But previous studies
on MAT and its effectiveness has shown that Medication assisted therapy outreach is not that
effective because of lack of adequately trained medical professionals,( a considerable shortage of
physicians because of lack of expertise in MAT and geographic reason), legislative barriers on
non-physician providers to participate in MAT (APRNS and physician assistants were not
allowed to prescribe buprenorphine for MAT initially , only physicians were allowed ),a negative MAT: BARRIERS AND ACCESS 4 attitude among public, providers and patients towards use of MAT, plays an important role in
limited use of it. Use of MAT will increase the retention of patients in the treatment of opioid
overuse, reduce antisocial activities.
Scope and Severity of the problem: Significance of the problem and Literature review
(-Problem assessment, Need for Analysis, Problem definition)
Studies done by various governmental agencies has shown that the opioid addiction has
grown into a social issue, increased the healthcare costs, increased the death rates and has created
a social problem. According to Substance Abuse and Mental Health Services Administration
(SAMHSA), in 2013,1.9 million Americans were dependent on pain relievers, and 517,000 were
dependent on heroin (SAMHSA,2014). With individuals who were on active opioid prescriptions who may also have been addicted, the number rose closer to five million (Kolodny,
Courtwright, Hwang, et al., 2015). The increase use of heroin has added to increased mortality,
which is increasing nationally (Department of Health and Human Services, 2015). Total number
of deaths resulted from heroin overdoses were 3036 in 2010 and that from opioid pain reliever
overdoses were 16.651. In 2013, deaths from heroin overdose more than doubled to 8257 while
those from opioid pain reliever dropped slightly to 16,235 (National Institute on Drug Abuse,
2015). There is more evidence that associates nonmedical use of pain relievers with subsequent
heroin use (Muhuri, Gfroerer, & Davies, 2013), highlighting the link between licit and illicit drug
use and the need to address both as a continuum of the same epidemic.
Assessment of the problem
The combination of increasing overdose deaths, increased crime rate, opiate exposed newborns,
and demand for treatment services constituted a public health emergency. U.S. Department of
Health and Human Services' Center for Substance Abuse Treatment defined MAT as “the use of
medications, in combination with counseling and behavioral therapies to provide a whole patient MAT: BARRIERS AND ACCESS 5 approach to the treatment of substance use disorders” (Substance Abuse and Mental Health
Services Administration (SAMHSA), 2016). MAT involves long-term use of medications in
addition to behavioral therapy. MAT is more effective at treatment retention and reduction of
heroin and prescription opiate abuse than using time-limited medication (i.e., opioid
detoxification or tapering) or psychosocial and abstinence interventions; the latter approaches are
associated with higher rates of relapse (Fullerton, Kim, Thomas, et al., 2014; Thomas, Fullerton,
Kim, et al., 2014). Both Fullerton et al. and Thomas et al. found mixed results on whether MAT
affected the use of other illicit drugs, criminal behavior, and risk factors for human
immunodeficiency virus (HIV) or hepatitis C virus (HCV). Studies, however, do indicate there is
an association between MAT and reduced overall mortality and while in prison, recidivism, and
treatment engagement among those recently released from prison (Degenhardt, Larney, Kimber,
et al., 2014;) Farrell MacDonald, MacSwain, Cheverie, Tiesmaki, & Fischer, 2014)
So far only two studies has done to compare the costs of health care for those participating in
MAT and those who are not participating in MAT(this is based on commercial health insurance
costs(Baser, Chalk, Fiellien &Gastfriend 2011),McCarty et al 2010.It was found that that the
total annual healthcare costs was 50% lower than those without MAT, a reduction in annual
healthcare cost was found in one study conducted by Baser et al as evidenced by ,reduced
number of inpatient services, on opioid related outpatient services for the those in MAT(Baser et
al.,2011). For instance, in the state of Maine, the amount of money spent to implement MAT is
high. Statistics show that 866 million dollars were spent on it in 2009 ,93% of which was spent
on Buprenorphine. (one of the medications used in MAT). The state Department of Health and
Human Services added another $2.4 million in existing funds to support the medication-assisted
treatment for opiate addiction. The administration also supports creation of 359 new slots for MAT: BARRIERS AND ACCESS 6 uninsured Mainers is the latest effort to combat the state’s worsening drug crisis. Records show
that the state witnessed a record number of overdose deaths – 286 for the first nine months of
2016.
Another study evidenced that all the healthcare costs tripled for those Medicaid beneficiaries
because of opioid overdose and its sequelae when matched with a group of same age and gender
with no opioid misuse. The study also revealed that the opioid misuse group are crippled with
other comorbidities like obesity, diabetes HIV, Hepatitis B & Hepatitis C, and other psychiatric
disorders. (McAdam-Marx et al.,2010) Need for analysis.
Opioid analgesics are important pain medications that provide significant benefits for
patients when used properly for their approved indications. But it is always associated with a risk
of abuse, misuse and death. More than 15,500 people died in the United States in 2009 after
overdosing on narcotic pain relievers. That’s a 300 percent increase over the last 20 years. And
for each death, there are an additional ten treatment admissions, 32 emergency department visits
and 825 nonmedical users of these drugs. FDA is extremely concerned about the inappropriate
use of opioids, which has become a major public health challenge for our nation.
The Medicaid beneficiaries are higher risk for developing substance abuse, more chances
for relapse, for getting psychiatric disorders in addition to opioid overdose and death. According
to U.S Center for Disease control and Prevention, about 45.5 % of the cases involved in
prescription overdoses of opioids was among those with Medicaid. (Coolen, Best, Lima, Sabel
&Paulozzi ,2009) Reports from SAMHSA 2013 shows that the expenditure on all opioid related
treatments supported by Medicaid has gone up from 9% to 21% between 1989 and 2009. MAT: BARRIERS AND ACCESS 7 Definition of the problem.
Opioid use has become such a chronic brain disorder that it has become one of the
leading causes of antisocial or criminal activities, fatal overdose requiring ER admissions,
increasing overall health care costs, It causes dependency and tolerance for the medication,
overdose and death. It has been estimated that in every 16minutes an opioid overdose death
occurs in U.S. From 2000 to 2015 more than half a million-people died from drug overdoses. 92
Americans die every day from an opioid overdose. More than 78 billion dollars are wasted by
U.S government in healthcare, criminal justice and lost productivity by dealing with prescription
drug overdose and ,misuse and dependency .This opioid overdose and related problems can be
treated using Medication assisted Treatment which combines medication and behavioral therapy.
MAT helps to decrease overdose deaths and improve other health outcomes, such as reduction in
transmission HIV and hepatitis, reduce crime rates and improve social lives. Even though MAT
has given promising results in reducing opioid overdose, patients has very limited access to it.
Major factors limiting access to Mat: Issue with Funding
Each state has a unique system for allocating public funds to substance abuse treatment, so it is
unlikely that a single strategy can overcome barriers related to access to medical staff and
funding in all states (Heinrich & Hill, 2008; Levit et al., 2008; McAuliffe & Dunn, 2004).
A promising initiative is the Advancing Recovery project, which has brought together state
officials and treatment providers in 12 states to promote the implementation of evidence-based
treatment practices, including Substance use disorder medications (Evans et al., 2007; McCarty
et al., 2009; ). As state-provider partnerships attempted to implement SUD medications,
numerous funding barriers were revealed, including lack of Medicaid coverage for medications
as well as state contracts that did not include reimbursement for the costs of purchasing
medications and related services (e.g., physician time, lab tests). State officials and providers
worked together to redirect existing state funds to assist with the costs of medications, expand
state contracts to include MAT, develop billing mechanisms for physician time and medications,
and formalize relationships with the state pharmacy to receive SUD medications. Providers also
worked with state Medicaid officials to change the Medicaid formulary to include medications.
(Action) MAT: BARRIERS AND ACCESS 8 Practitioner Capacity, Perceived Value among patients, practitioners, institutions towards MAT,
and Insurance Coverage, Geographic restriction can affect patients access to MAT.
Practitioner Capacity
There is definitely a problem with the availability of medical professionals, especially
physicians who have trained in MAT. In addition to the expertise there is limitations imposed on
the number of patients that MAST trained physician can see in each year. So, most MAT trained
physicians are practicing to their fullest extent. Only those physicians who have the waiver from
Drug Addiction Treatment Act 2000 can prescribe Buprenorphine for opioid addiction treatment
and that too only to a limited number of patients in an outpatient setting, such as a doctor’s
office. Only physicians were considered eligible for DATA 2000 waiver till July 2016. Qualified
nurse practitioners and physicians’ assistants were permitted to receive a DATA 2000 waiver
from the date of the act’s enactment until October 1, 2021. (it was granted on July 22, 2016). But
again, there are certain other limitations imposed on these Nurse practitioners and Physician
assistant practice. The practitioners must be appropriately licensed under state law and must have
proven expertise in MAT as evidenced by certain certification, training, or experience. Also, they
must have the capacity to refer patients for appropriate counselling. Practitioners who receive a
DATA 2000 waiver may treat only 30 patients in their first year under the waiver and may
increase to 100 patients after one year upon submission of a notice to the Secretary of Health and
Human Services. As of August 8, 2016, certain practitioners may be approved to treat up to 275
patients after one year. So, the limitation on the number of qualified practitioners—specifically
in OTPs (Opioid Treatment Programs) and physicians with waivers who can prescribe
buprenorphine for opioid addiction may affect patients’ access to this treatment. According to
SAMHSA report in March 2016, there are only 1400 OTPs exists. Another factor that limit the
access to these practitioners is their geographic distribution. Most of the OTPs are in urban areas MAT: BARRIERS AND ACCESS 9 limiting the access to individuals in rural areas, (they may have to travel hours daily to be at the
OTP to take methadone and may not be willing to do that). which in turn risk them going back
into addiction.
Perception of MAT: Many of our physicians still believe in the traditional abstinence based
program for treating SUD, they still don’t believe in MAT -using another medication to substitute
addiction. even though research indicates that abstinence fails a large proportion of the time and
is generally less effective than MAT. (SAMHSA 2014) There exists a perceived stigma about
MAT and its use among patients, physicians and other social institutions especially about
methadone- one of the medicines used in MAT. This perceived stigma among patients make them
reluctant to seek treatment, leading to social isolation and undermining the chances of long-term
recovery. Discrimination against OTPs such as community opposition, because they give onsite
medical care to opioid dependents. Some patients try to avoid OTPs because of this stigma and
to limit interactions with others who may be drug users and to avoid daily attendance
requirements. This perception makes buprenorphine (a MAT medication that can be prescribed in
various office-based settings including in an office, community hospital, health department, or
correctional facility) a more attractive treatment option to many patients.
MAT and Criminal Justice system. The 2011 Legal Action Center report and the 2014
SAMHSA brief, Reports show that drug courts and other sentencing officials deny access to
MAT for varying reasons. This is because of a false notion about the nature of addiction and
MAT, that MAT is substituting one addiction for another. Court officials including some judges
view opioid addiction more of a crime and a social problem that is best addressed through
abstinence. Institutions within the criminal justice system have policies that limit MAT, some MAT: BARRIERS AND ACCESS 10 drug courts have policies that prohibit participants from using any controlled substances, which
would include MAT. (SAMHSA 2014brief)
Availability and limits of insurance coverage. According to several articles reviewed, financing
of treatment is a key factor that can affect patients’ access to MAT. The availability and limits of
insurance coverage for MAT in terms of accessing it possess a challenge for patients who have
insurance and for those who lack insurance. For example, for those who don’t have any
insurance coverage for MAT may face prohibitive out-of-pocket costs that may limit their access
to it. According to Mohlman 2016, a month’s supply of a daily dose of sublingual buprenorphine
may cost such patients between $200 and $450 per month. ( Bonhomme, J 2012). Another article
that reviewed available literature on MAT found that the monthly cost of injectable naltrexone is
significantly higher than that of the other MAT medications— buprenorphine and methadone.
(www.gao.gov,Sep 2016) So, one of the factors that practitioners consider when determining
whether to prescribe naltrexone to a patient is its cost. For those who have insurance, the benefit
coverage for MAT-related services can vary by insurance plan and by state. Some private health
insurance plans do not cover buprenorphine treatment, or they impose limits on the length of
treatment with buprenorphine. limits on lifetime coverage for buprenorphine which can range
from 12 months to 36 months, even though some patients may need it for the rest of their lives to
prevent relapse. Similarly, a 2014 SAMHSA report found that although state Medicaid programs
reimburse for at least one of the three MAT medications, most states did not reimburse for all
three. In some cases, state Medicaid programs also limit the length of time that the medications
can be used. The specific coverage offered by Medicaid for substance abuse treatment allowed
under the Patient Protection and Affordable Care Act can vary by state MAT: BARRIERS AND ACCESS 11 Major stakeholders.
Practitioner Capacity, Perceived Value among patients, practitioners, and institutions towards
MAT, and Insurance Companies and their coverage, various governmental and non-governmental
agencies, health care facilities, health education institutions and the public can affect patients’
access to MAT for Opioid Addiction.
Measures of effectiveness. In the state of Massachusetts, a noticeable reduction in the amount of
Medicaid money spent for SUD treatment compared to that on diagnosed untreated SUD.
Treatment included ambulatory detoxification and medication-assisted treatment services
whereas Washington state witnessed a reduction in Medicaid expenditure through Screening,
Brief Intervention and Referral to Treatment (SBIRT) services. Use of SBIRT resulted in savings
of $250 per member per month for inpatient hospitalization from emergency department
admissions from opioid overdose. As a result, ED visits decreased by 9.9 percent; the number of
people with frequent ED use dropped by 10.7 percent; and the number of visits resulting in
narcotic prescription dropped by 24 percent. The state attributed savings of about $34 million.
For individuals in managed care with alcohol dependence, total healthcare costs were 30 percent
less for individuals receiving medication-assisted treatment than for individuals not receiving
medication-assisted treatment. Medical costs for Medicaid patients in California decreased by
one-third over three years following engagement in medication-assisted treatment. (Department
of Health and Human services, Centers for Medicare & Medicaid Services July 2015)
Maintenance MAT combined with prenatal home visits is associated with improved birth
outcomes when given to opioid-addicted pregnant women, although neonatal abstinence
syndrome remains a concern (Fullerton et al., 2014; Thomas et al., 2014).
Increasing Access To MAT: Implementation
The ultimate aim is to increase access to MAT, prevent relapse, increase retention in the
treatment. This includes linking patients and their families prior to and following treatment
discharge to primary care physicians for long-term care. It also includes long-term monitoring of
substance use with random drug and alcohol tests either by the primary care physicians and/or by
external monitoring service This will include increasing MAT in rural areas, continuous
assessment of patients and their family’s satisfaction with the MAT therapy. For instance: Hub
and Spoke model of Vermont (blueprintforhealth.vermont.gov 2012). Coordination and
integration of care must be between the hub and spoke as well as within each spoke site, and
should be typically carried out by a registered nurse, clinician case manager, or other “care
connector” (e.g., via peer-to-peer support or behavioral health workers). social workers,
counseling services, and community health teams provide psychosocial services. State of
Vermont supported this model by allocating funding for online training for physicians to get
buprenorphine waivers. It also increased the outreach of MAT to the community by increasing MAT: BARRIERS AND ACCESS 12 the number of buprenorphine waivered physicians (do). Disadvantage found was the lack of
sufficient number of hubs with adequate expertise in MAT(Study). Increasing the number of
hubs with the appropriate expertise and resources in all settings that wish to implement a MAT
model of care. Provisions for adequate funding and training the staff must be initiated by the
appropriate authorities. (Action)
Minimize delay in intake and continue ongoing MAT(PLAN): Involving Nurse care manager
along with primary physicians so that the nurse care manager can performs initial screening,
intake, and education, she can provide ongoing management of Opioid Use Disorder and other
medical issues, including drop-in or same day visits, management of acute issues, coordination
of prior authorization requests, communication with pharmacists, and perioperative care
coordination.(Do) The diagnosis of OUD and appropriateness of MAT are confirmed by the
prescribing physician, who comanages the patient with the nurse care manager. Another
adaptation of this model at a community-based health care system in Massachusetts in which a
“care partner” (usually a master’s level individual who is not a nurse care manager) performs this
role. This model uses a training program to get more primary care physicians involved in
prescribing buprenorphine. Advantage: make use of nonphysician to offload some of the burden
from prescribing physicians, which in turn enables the prescribing physicians to manage more
patients. Disadvantage: dependency on the availability of a nurse care manager or a person
equivalent to do the initial screening and intake. (study). Increase the number of number of nurse
care managers or equivalent position by providing adequate training on MAT. Or Using
Advanced Practice Nurses like NPs or Physician assistants who have been trained in MAT
(Action).
Integrate MAT and behavioral health therapies with primary care. (Plan) Provider and
community education is emphasized to increase uptake (by clinicians and patients) and to
decrease stigma. (DO)By doing so, minimized delay in intake, Increased care coordination and
availability of core psychosocial services. This model is highly flexible that the service delivery
can be modified to meet the needs and resources of a particular setting. (Study) Provision for
increasing the MAT training in more primary care centers. (Action).
Use of Internet-based audiovisual network for linking primary care clinics in rural areas
with a university health system for the purpose of mentoring and education regarding a number
of medical conditions including MAT. (Plan) Effective utilization of advanced practice nurses
like nurse practitioner- or physician assistant-based screening with referral to a collaborating
physician prior to initiation of MAT and for ongoing treatment, typically with
buprenorphine/naloxone. Counseling and behavioral therapies are offered from a team members.
Referral services for complex patients for further assessment and/or evaluation at an OTP,
recruitment of physicians for buprenorphine waiver training and provision of continuing medical
education in OUD. (Do) A potential disadvantage that due to the geographic distance between MAT: BARRIERS AND ACCESS 13 the primary care sites and th...

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