Rehab Care for Opioid Addiction Often Tough to Find: Study
The United States is in the middle of an opioid crisis, yet new research shows that only about 7% of Americans on Medicaid who have opioid use disorder receive residential treatment.
This means that many people who could potentially benefit from what is more commonly known as "rehab" aren't getting the care they need to help them with their addiction.
“We know residential care is important when it's done right … and when it's evidence-based. We know it's incredibly important to engaging people in their recovery from opioid use disorder,” said study corresponding author Lindsay Allen. She is a health economist and assistant professor of emergency medicine at Northwestern University Feinberg School of Medicine, in Chicago.
“And Medicaid is a major payer. It's the biggest payer of opioid use disorder treatment nationally because so many individuals with OUD [opioid use disorder] are covered by Medicaid,” Allen continued.
Making direct comparisons of access to residential OUD treatment can be difficult because states code or define programs differently.
But the researchers used a research network that standardized data for nine states that represent about 14.9 million people, including 20% of all Medicaid enrollees.
Using an apples-to-apples comparisons of data, the investigators discovered that usage of residential treatment for OUD varied widely, depending on the state.
While some states provided residential treatment for up to 14.6% of Medicaid enrollees with OUD, others only allowed 0.3% to access rehab.
Allen said the differences were disconcerting.
Among the benefits of having standardized data is providing information about where and what policies need to be targeted, she said.
The states that were part of the study were Delaware, Kentucky, Maryland, Michigan, North Carolina, Ohio, Pennsylvania, Virginia and West Virginia.
While residential treatment is effective, it's not all equal, Allen noted. Those that Allen considers most effective offer 24-hour live-in care with structured support, including individual and group therapy, as well as medication for OUD, such as buprenorphine or methadone.
“We know that if you take these medications, you are going to do so much better than if you don't take these medications,” Allen said. But about 60% of residential facilities don't yet offer this medication, and some may even prohibit it, she noted.
Other issues include how states reimburse for treatment. Medicaid is state-run, so any plans to increase residential treatment rates are up to the states. There are several federal mechanisms the states can use to get federal financial assistance for care.
The issue of OUD is itself a big problem, with millions of American adults addicted to opioids, the researchers noted.
Stigma and other issues exist for certain groups who need residential treatment, Allen said. Among them are pregnant women and mothers who are worried about who will care for their children if they go to treatment, and are also concerned about losing their kids.
Solutions could include helping certain groups who are experiencing disparities in access to residential treatment.
“I think we need a shift in understanding that it is a medical clinical disease. It's a chronic condition and we need to treat it just like we do diabetes, just like we do heart disease. We need to prevent it the way we prevent heart disease and diabetes,” Allen said.
Intervening early, as with other physical health issues, is a must, she stressed.
The findings were published April 12 in the Journal of Substance Use and Addiction Treatment. The U.S. National Institute on Drug Abuse provided funding for the study.
One reason people may look toward residential treatment is because there's a housing crisis in addition to an opioid crisis, said Dr. Sarah Wakeman, medical director for substance use disorder at Mass General Brigham, in Boston.
Yet, there isn't convincing evidence that residential treatment is best for treating OUD, she said, noting that many residential programs don't offer medication to treat OUD, or even prohibit them.
What is best is treating a patient with an opioid agonist, such as methadone and buprenorphine, Wakeman said, comparing this to providing insulin to someone with diabetes. The medications are misunderstood and deeply stigmatized, she said.
“They restore normal functioning. They allow a person to feel well again, to not experience cravings or an urge to want to use opioids, to not experience withdrawal and to just get on with their life,” Wakeman said. “And they've been shown in literally hundreds of studies over decades to reduce the recurrence of opioid use disorder and reduce both overdose-specific mortality and all-cause mortality.”
Residential treatment may be helpful for someone who has experienced significant consequences from their opioid disorder, who has not successfully stabilized in an outpatient treatment setting or who is also addicted to other substances, said Dr. Larissa Mooney, director in the division of addiction psychiatry at UCLA's David Geffen School of Medicine in Los Angeles.
However, even in residential treatment, medication for OUD needs to be offered, Mooney said.
“The most robust treatments for opioid use disorder are FDA-approved medications, which include buprenorphine, methadone and extended-release naltrexone,” Mooney said.
Managing co-occurring psychiatric disorders, such as depression or anxiety, is also an important part of addiction recovery, she said.
“With support and access to medication treatment, many people can achieve remission from opioid use disorder. Individual paths to recovery vary widely, so we need to ensure access to as many treatment options as possible,” Mooney said.
The U.S. Department of Health and Human Services has more on the opioid crisis in the United States.
SOURCES: Lindsay Allen, PhD, health economist and assistant professor of emergency medicine, Northwestern University Feinberg School of Medicine, Chicago; Sarah Wakeman, MD, medical director, substance use disorder, Mass General Brigham, Boston; Larissa Mooney, MD, professor, clinical psychiatry and director, division of addiction psychiatry, department of psychiatry & biobehavioral sciences, David Geffen School of Medicine, University of California, Los Angeles; Journal of Substance Use and Addiction Treatment, April 12, 2023