Overcoming Barriers to Medication-Assisted Treatment (MAT) in Rural Areas

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In 2020, the opioid crisis in the United States entered its fourth decade.

That’s not an exaggeration.

Many people in the U.S. think the crisis began when former President Trump announced an action plan in 2017 to address increasing fatal overdose rates.

Others think it began around 2010, when regulators changed prescribing rules and a large number of people with prescriptions for opioids were denied refills, and instead turned to illicit opioids – which increased risk of overdose and led to an increase in heroin use and heroin overdose.

In fact, the opioid crisis began in 1990, when physicians increased the number of prescriptions for opioid pain-relievers. This increase in prescriptions followed the release of new formulations of opioid pain medication. The new class of pills were stronger, and some were designed as extended-release medications, which increased risk of misuse. This increase in opioid prescriptions resulted in a spike in fatal opioid overdose nationwide, which continued until around 2010.

To learn more about the relationship between chronic pain, opioid use disorder, and opioid medication, please read this article on our blog:

Study Shows Chronic Pain Linked to Opioid Use Disorder

Now, back to our topic: how the opioid crisis unfolded.

That period from 1990 to 2010 is known as the first wave of the opioid crisis, as defined by the Centers for Disease Control (CDC).

The second wave began in 2010. The driving force behind the second wave was the prescription-to-addiction pathway we describe above. In the absence of access to legal opioids, many people turned to illicit opioids and heroin, which led to a surge in fatal heroin overdose nationwide. The third wave began around 2012, driven by an influx of illicit fentanyl coordinated by international drug smugglers. The CDC indicates that fentanyl is fifty times stronger than heroin and a hundred times stronger than morphine and dramatically increases risk of overdose.

Fentanyl is also at the root of the fourth wave of the opioid crisis, which is happening right now. This wave is characterized by the increased stress and isolation of the COVID-19 pandemic, the presence of fentanyl in non-opioid drugs like methamphetamine and cocaine, and an increase in the prevalence of co-occurring mental health disorders alongside substance use disorders.

This fourth wave affects us all, and increases risk for us all. However, one demographic group experienced elevated risk during the pandemic, and the underlying causes of that risks persists today. IN this article, we’ll discuss the risk of opioid overdose in rural areas, and the barriers to treatment that exist for the most effective treatment for OUD we have access to: medication assisted treatment, or MAT.

Elevated Risk of Opioid Use Disorder and Fatal Opioid Overdose in Rural Communities

A study published in early 2022 examined the impact of the coronavirus pandemic on individual with OUD in rural areas. The identified the following risk factors for both OUD and fatal opioid overdose:

  • Geographic and social isolation
  • Poverty
  • Insufficient access to critical resources, including:
    • Health insurance
    • Reliable transportation
    • Support and understanding from family
    • Support and understanding from community
  • Chronic housing insecurity, chronic unemployment, and chronic food insecurity
  • Few options for evidence-based SUD treatment
  • Few options for evidence-based mental health treatment

Those factors increased risk of OUD and fatal overdose across the board for people living in rural areas. When we combine this knowledge with the latest data on overdose fatality in the U.S. overall, we understand that while on crisis is winding down – the pandemic – the crisis that was here before, and never went away, needs our attention immediately.

Here are the latest facts and figures from the CDC.

Fatal Overdose: Opioids, 2019-2021:

  • 2019: 50,178
  • 2020: 69,061
  • 2021: 73,453

Fatal Overdose: All Substances, 2019-2021

  • 2019: 67,697
  • 2020: 78,056
  • 2021: 107,306

One thing about the opioid use disorder crisis and the opioid overdose crisis that is simultaneously encouraging and heartbreaking is this: an effective treatment is available that can decrease overdose and increase successful recovery.

It’s called medication-assisted treatment (MAT). According to the Substance Abuse and Mental Health Services Administration (SAMHSA):

“MAT is the use of medications in combination with counseling and behavioral therapies to treat substance use disorders… Research shows that a combination of medication and therapy can successfully treat these disorders, and for some people struggling with addiction, MAT can help sustain recovery. MAT is also used to prevent or reduce opioid overdose.”

For people with OUD, evidence shows MAT can:

  • Decrease patient mortality (death)
  • Increase time in treatment
    • Time in treatment is associated with improved treatment outcomes
  • Increase participation in therapy and counseling for OUD
  • Reduce use of illicit opiates use
  • Reduce criminal activity associated with illicit opioids
  • Increase ability to seek and find employment
  • Increase ability to participate in family life
  • Improve ability to participate in school or ongoing vocational training
  • Improve birth outcomes for pregnant women with OUD

The three most common medications used in MAT programs are buprenorphine, naltrexone, and methadone. These medications are safe, FDA-approved, and perform the following functions:

  • Stabilize the chemical balance in the brain
  • Prevent the rewarding effects of opioids
  • Relieve physical and psychological cravings for opioids
  • Stabilize physical and psychological reactions to withdrawal
  • Mitigate the negative effect of withdrawal
  • Reverse overdose and prevent overdose death

The benefits of MAT are clear.

The statistics demonstrate a clear need for MAT in rural communities.

However, significant barriers to care remain. In the remainder of this article, we’ll identify those barriers and offer a list of expert suggestions to reduce these barriers and increase access to MAT for people in rural areas.

MAT in the Rural U.S.: What are the Barriers to Care?

Evidence from a wide range of credible sources, including the article we link to above, identify barriers to care that are specific to individuals in rural areas diagnosed with OUD. We collected the information below from four evidence-base articles published by reputable sources:

Factors that Influence Access to Medication-Assisted Treatment

Opioid Use Disorder: Challenges and Opportunities in Rural Communities

Improving Access to Evidence-Based Medical Treatment for Opioid Use Disorder: Strategies to Address Key Barriers Within the Treatment System

Medication-Assisted Treatment for Opioid Use Disorder in a Rural Family Medicine Practice

If you’re interested in taking a deep dive into the research, we encourage you to read these articles: the data is real and the content is informative. If source research is not for you, we understand. Read on, and we’ll summarize the content for you.

Each of these articles identifies a host of barrier to care that fall into three general categories: structural barriers, provider barriers, and personal barriers.

Structural Barriers to Rural MAT

  • Insufficient access to evidence-based treatment for any type of SUD
    • Including MAT
    • Most MAT programs are in urban areas
  • Insufficient access to evidence-based treatment for co-occurring disorders
    • Wave Four of the opioid crisis includes an increase in co-occurring disorders among people with OUD
  • Limited training for SUD/OUD/MAT treatment providers in the primary care setting
  • Limited training for MAT among the SUD and OUD counselors who do work in rural areas
  • Inconsistent reimbursement from public and private payers for SUD treatment
  • Inconsistent reimbursement from public and private payers for MAT programs
  • Resources for people with OUD in MAT are fragmented:
    • Medication may be available at one location
    • Counseling may be available at another location
    • Vocational, food, and housing support may be available at another
    • Standard medical care may be available at yet another location
  • Long wait times for care and medication
    • Gaps in care and medication can lead to relapse and/or fatal or non-fatal overdose

Those are the structural/organizational barriers to care in rural areas. Now let’s look at the barriers related to care providers.

Provider-Related Barriers to Rural MAT

  • There is unresolved tension between abstinence-only providers and proponents of MAT and harm reduction
    • These tensions may exist within treatment centers that offer MAT
    • This creates stigma that people with OUD on MAT experience directly
  • While may physicians in primary care settings are trained and educated about the benefits of MAT, primary care physicians show reluctance to initiate MAT care for rural patients
  • Providers who receive authorization to dispense buprenorphine report reluctance of other providers to coordinate care and lack of reciprocity and support for patients on MAT
  • Patients with OUD on MAT report lack of knowledge and awareness about pain management and evidence-based treatment

Those are the provider-related barriers reported by people with OUD who seek MAT in rural areas. It’s important to note here that stigma and conflict among providers with regards to MAT is almost always one hundred percent obvious to people in treatment.

Personal Barriers to Rural MAT

  • Lack of knowledge about the benefits of MAT
  • Misunderstanding of MAT
  • Stigma against SUD treatment in general
    • Includes fear of stigma from others
  • Stigma against MAT specifically
    • Includes fear of stigma from:
      • Family
      • Peers
      • Providers
    • Lack of insurance
    • Lack of reliable transportation
    • Absence of family support
    • Absence of peer support

People in rural areas face obstacles to medical care by default. This is true for people with all types of medical conditions, from cancer to diabetes to hypertension to chronic arthritis. However, these people rarely experience significant misunderstanding about the nature of their condition or reluctance to initiate evidence-based treatment for those conditions.

That’s what people in rural areas on MAT for OUD face: structural barriers due to simple geography compounded by stigma related to both their medical condition – OUD – and the best available treatment, which is medication-assisted treatment.

In the face of these barriers, experts in rural SUD care identify several steps we can take to offer support and care to people in rural areas.

Action Steps: Removing Barriers to Access for Rural MAT

The fact barriers to care exist is a problem.

However, it’s a problem with practical solutions that are well within reach.

Let’s take a look at a list of these solutions, as indicated in the four article we cite and link to above. These solutions address the structural barriers to MAT, the provider-related barrier to MAT, and the personal barriers to MAT. They’re often linked, and the most important barrier to care we need to address is education: providers, payers, and patients all need to learn as much as they can about MAT, so they can make an informed decision about its application.

Removing Barriers to MAT in Rural Areas: What We Can Do

Structural Remedies:

    • Expand access to all modes of SUD treatment, including:
      • Medication-assisted treatment for OUD
        • Buprenorphine
        • Naltrexone
        • Methadone
      • Counseling
      • Therapy
      • Education
      • Community support
    • Expand training programs for providers in MAT
    • Expand training for and access to the lifesaving overdose reversal drug, Naloxone
    • Restructure reimbursement practices for payers

Provider-Related Remedies:

    • Emphasize compassionate care
    • Prioritize harm reduction
    • Increase provider education and training on MAT, SUD, and OUD
    • Perform comprehensive biopsychosocial assessments
    • Implement brief intervention, treatment and referral programs – known as SBIRT – in order to identify and offer support to those most in need
    • Offer integrated, whole-person treatment and support
    • Increase coordination of care between settings and types of support:
      • Medical
      • Psychological
      • Social
    • Expand MAT to primary care office settings, office-based settings, and telehealth/virtual settings
    • Expand support for providers during the entire MAT licensing and waver process
    • Create incentives for coordinating care between providers
    • Create incentives for coordinating care between public and private entities

Individual/Personal Remedies:

    • Reduce self-stigma by providing community education about SUD
    • Reduce treatment stigma by providing community education about SUD treatment
    • Decrease MAT stigma providing community education about MAT
    • Increase support for people in rural areas who lack:
      • Insurance
      • Reliable transportation
      • Support from family and friends
    • Increase access to peer support groups such as Narcotics Anonymous (NA) and Alcoholics Anonymous (AA)
      • Expand telehealth programs for local community support groups

There’s one simple thing that unites the remedies listed above: they’re achievable. We have the technology, the knowledges, and the resources to implement all these action steps.

How do we know?

New Round of Funding Targets Opioid Crisis

Federal funding to increase access for SUD treatment in rural areas – specifically for MAT – appears in the latest federal budget related to COVID relief. In addition, on September 24th, 2022, the White House announced 1.5 billion dollars in funding for the opioid crisis.

Here’s the announcement:

Today, as part of National Recovery Month, the Biden-Harris administration announced a series of actions, including the distribution of $1.5 billion in funds to all states and territories, to address the overdose epidemic and support the tens of millions of Americans in recovery. Funding will support life-saving programs and policies, such as increasing access to treatment for substance use disorder, removing barriers to medications like naloxone, and expanding access to recovery support services.”

What this announcement tells us is that the tireless work of local, grassroots activists has been effective. Policymakers at the highest level now understand the scope of the problem. This announcement also tells us those policymakers have been listening: local providers in both urban and rural areas have indicated the need for expanded access to medication – including naloxone and other MAT medications – and recovery support services.

That’s exactly what this funding provides.

Now it’s on all of us – treatment providers and community members alike – to use this funding to support the people who need it most, and help our nation mitigate the serious, ongoing harm caused by the opioid crisis.