On an average day, 130 people in the U.S. will die of an opioid-related overdose. Despite the urgency of that situation, access to and use of opioid-use disorder (OUD) treatment is low and beset by racial, geographic, ethnic and economic barriers.
There are efforts underway in New York City, however, that are aimed at getting more people into treatment and reducing overdoses, while lowering racial inequities in the process.
Learn with the AMA about the six key steps states should take to combat the opioid epidemic, and discover the AMA Opioid Task Force’s key recommendations for physicians and for policymakers.
Wide treatment gap
A report on veterans with OUD reflects both the low use of treatment and disparities between urban and rural access.
The U.S. Department of Veterans Affairs provided medications for addiction treatment (MAT, commonly referred to as medication-assisted treatment) to nearly 24,000 veterans in fiscal 2018, but that was only 33.6% of those diagnosed with OUD, according to “Services for Substance Use Disorders, and Efforts to Address Access Issues in Rural Areas,” a Government Accountability Office report issued in December. Veterans diagnosed with an OUD in rural areas had less access to MAT, with only 27% receiving treatment.
The Food and Drug Administration has approved three medications for MAT: Naltrexone, buprenorphine —which physicians must obtain a waiver for from the Drug Enforcement Administration (DEA) to prescribe for opioid-use disorder—and methadone, which is also highly regulated by federal and state governments.
A JAMA research letter describes how buprenorphine treatments grew almost 125% between 2009 and 2018, but are still at a rate “below national estimates of the combined rates of prescription opioid-use disorder and heroin use.” Meanwhile, a study published in JAMA Pediatrics finds that only one in 54 (1.9%) Medicaid-enrolled youths, aged 13 to 22, who had a nonfatal opioid-related overdose received MAT.
Big Apple recognizes big problems
Offering technical assistance to implement buprenorphine initiation in emergency departments (EDs) is one of the interventions used by the New York City Department of Health and Mental Hygiene (DOHMH) to connect patients with the MAT they need.
This includes offering ED providers mentorship from experienced buprenorphine prescribers and holding quarterly citywide learning collective webinars for New York City providers on best practices to address OUD. To date, 13 EDs around the city are offering buprenorphine initiation, said Hillary Kunins, MD, MPH, the DOHMH’s executive deputy commissioner or mental hygiene.
DOHMH is also helping to finance staffing at 27 clinics, mostly federally qualified health centers, in which a nurse care manager supports primary care physicians and other clinicians to offer buprenorphine treatment to patients with OUD.
“Because we now have a network of primary care sites, we can help the emergency departments identify referral sources for the patients that they initiate on buprenorphine,” Dr. Kunins said.
The city has sponsored DEA-waiver training for buprenorphine prescribing, partnered with practices and institutions to recruit new buprenorphine prescribers, and offered one-on-one “public health detailing” to follow up with providers who took the waiver-training course.
The city’s efforts have shown some success. The number of physician and nonphysician prescribers who wrote at least one prescription for buprenorphine rose15%, from 1,861 in 2016 to 2,721 in 2019.
City funding has also gone toward instituting buprenorphine treatment at syringe-exchange facilities, which Dr. Kunins said is an effort to meet patients “where they’re at” and to offer care where they are already engaged.
“We specifically funded primary care and syringe exchange programs that care for people who are uninsured, underinsured of have public insurance to create meaningful access for people of color and people who might be poor,” she explained.
“The big-picture goals are increasing the number of people who are on effective treatment for opioid addiction and reducing risk of overdose,” Dr. Kunins said. “There is also the additional goal of reducing racial inequities and types of care that people are offered by increasing access to buprenorphine in all of these ways and particularly focused on neighborhoods with those high rates of opioid overdose and also neighborhoods with high proportion of people of color.”
Learn more about how ED innovation boosts access for patients with opioid-use disorder and find more resources at the AMA End the Epidemic website.