Overcoming barriers to opioid treatment: Challenges and innovations in methadone and buprenorphine
This Q&A with Sheeba Ibidunni, public health expert and the VP of operations at Sonara Health explores the socio-economic factors fuelling the epidemic, the barriers to accessing life-saving medications, promising government interventions, the impact of state laws, and innovative solutions like telehealth platforms.
Can you elaborate on the specific socio-economic factors that you believe are fueling the growth of the opioid crisis in the U.S.?
There are socio-economic factors that are common among people who use drugs (PWUD), including opioids. These factors include lack of employment, poverty, adverse childhood events, mental health issues and inadequate healthcare to address mental health issues, and systemic racism. Many of these socio-economic factors were highlighted during the COVID-19 pandemic, when the US experienced the highest rates of overdose fatalities.
What are some of the most prevalent systems and biases that hinder individuals from accessing life-saving methadone and buprenorphine treatments?
The system is not set up to help people when they are ready to seek treatment. Oftentimes, there are waitlists, provider shortages, and an insufficient number of beds at facilities that aid with withdrawal management (fka detox). For people who are in treatment for OUD and using other substances like stimulants, when they are ready to enter treatment, the rehab facilities often will not accept patients on methadone and will either turn them away or ask that they change to buprenorphine. Although this policy appears simple, it creates more barriers as those starting buprenorphine must be in a state of withdrawal, which is fear and anxiety inducing.
Many, providers included, are reluctant to embrace MOUD (medication for opioid use disorder) due to beliefs that methadone and buprenorphine simply substitute one drug for another drug. Thereby, further enabling drug use.
Concerning methadone specifically, this treatment is viewed as liquid handcuffs by patients and people who use drugs (PWUD), because of the daily, in-person dosing requirement. A patient may no longer be using, but they are still handcuffed to the medication. This hinders their ability to work, go to school, look after family, or even travel. This is an immense barrier that people often struggle to overcome.
There are prescribing and provider biases at play, supported by increasing research demonstrating racial discrimination affects access to MOUD. Buprenorphine, while more easily accessible and does not require daily, in-person dosing, is predominantly available to and accessed by patients who are white. Methadone, exclusively prescribed by opioid treatment programs (OTPs), is more likely to be located in communities with black and brown residents.
In your discussions with government officials, have you identified any promising strategies or interventions that could effectively address the opioid epidemic?
There are a number of promising strategies and interventions that include harm reduction and evidence-based treatment that can address the opioid epidemic. Included in these strategies and interventions is remote observation of take-home methadone, which is enabled by Sonara Health’s web-based application. The use of technology to remotely observe take-home methadone doses increases access, drives treatment retention, and minimizes diversion concerns. Remote observation is not new to public health and has long been employed successfully by tuberculosis treatment teams. Remote observation of take-home dosing provides the same level of direct supervision as in-person visits to an OTP.
How do you see state laws and policies influencing the landscape of opioid addiction treatment and prevention? Are there any particular policies that you believe have been particularly effective or ineffective?
Health policy is driven by state laws and regulations, which have the ability to influence the care that is available to people. Increasing access to health insurance through the Affordable Care Act has been an effective means to offer buprenorphine and methadone to people. Unfortunately, 10 states have chosen not to expand Medicaid coverage in the decade since expanded Medicaid coverage took effect for most states in Jan 2014.
Harm reduction is evolving and it is exciting to see states passing laws to authorize overdose prevention centers, which have been shown to reduce public drug use, reduce crime, and serve as a pathway to treatment and services.
Ineffective laws and policies include states that have chosen to implement laws that are more restrictive than federal regulations regarding how OTPs operate within the state. SAMHSA has ushered in a new era for methadone regulations to enable a more patient centered and low barrier care model, and it is imperative that states do not undermine this significance by restricting the ability of OTPs to follow federal regulations.
Lastly, reimbursement drives spread and adoption of new treatment modalities and innovation. We at Sonara urge policymakers to support the reimbursement of remote observation of take-home methadone. Such a policy will help increase access to treatment.
Could you share your insights on the role of Prescription Drug Monitoring Programs (PDMPs) in curbing opioid misuse and enhancing patient care?
Context: my experience with PDMPs was from my time working in Colorado in the early 2010s. I have not closely followed the changes to PDMPs and so my perspective may be outdated. With that said, I will say this: PDMPs serve a purpose when trying to understand the prescribing practices of opioids or identifying individuals who may be doctor shopping. However, as with any database, it is only useful when it is used - and used by all providers who have prescriptive authority. I doubt PDMPs are successful in enhancing patient care or curbing opioid misuse. PDMPs are not typically utilized in conjunction with outreach teams to assess whether someone has OUD or is ready for treatment. Rather, such systems probably push people to seek drugs from non-formal channels that do not need to be reported in the PDMP.
What challenges do you foresee in improving naloxone access and distribution efforts, and how can these obstacles be overcome?
A key challenge Naloxone suffers from is immense stigma. Harm reduction efforts have become quite divisive despite the evidence that it saves lives. There is a fundamental misunderstanding of addiction and drug use that contributes to the reluctance to save lives using simple measures like naloxone. To protect and maintain the health of the public, means we should ensure preventative and curative treatments are made available. Public health supports the spectrum of interventions from harm reduction to MOUD. Personal bias and beliefs about whose life is worth saving and whether drug use is being enabled must be confronted. We must use the measures we know that work - considering nearly one-third of US adults now know someone who’s died of drug overdose. These overdose fatalities continue to challenge the stereotype of who falls victim to overdose. It shouldn’t matter, but it does. And, we shouldn’t have to lose innocent lives, but we will. As more and more victims of overdose appear to be innocent like children, the easier the policy conversation concerning naloxone will become.
How do personalized solutions offered by telehealth platforms like Sonara Health contribute to the broader efforts to combat the opioid epidemic?
Treatments and interventions exist, but there are many reasons why people are reluctant to enter treatment and unable to stay in treatment. Sonara Health is one way to reduce known barriers to entering and staying in methadone treatment. Sonara was built to enable trust between providers and patients. A third of Sonara users are new to take-homes, which indicates Sonara helps increase access to take-home methadone. To further minimize barriers, Sonara’s web-based application was designed with health equity in mind, and we partner with Lifeline program partners to connect people, who qualify, to free, government smartphones. Solutions like Sonara should not be limited by tech or health literacy. Less time in the clinic means fewer opportunities to experience transportation challenges, privacy violations because patients are queued up outside the treatment center, or schedule disruptions; and, more time for people to spend doing what they need to do and love. Evolving the image of methadone treatment beyond liquid handcuffs can help people see treatment is doable and show providers that take-homes are safe and successful. Sonara empowers recovery and fosters trust.
