Rural Pennsylvania Medicaid enrollees diagnosed with opioid use disorder are driving an average of four times as far as their nearest prescriber to receive medication-assisted treatment, according to an analysis led by University of Pittsburgh Graduate School of Public Health researchers.
The study, published in the Journal of General Internal Medicine, also found that the farther people have to travel, the less likely they are to adhere to medication-assisted treatment, which is the standard of care for opioid use disorder.
“While people in rural areas with opioid use disorder face challenges obtaining medication-assisted treatment, another important finding from our research is that these same people have substantial contact with their primary care physician, averaging four visits per year,” said lead author Dr. Evan Cole, research assistant professor in Pitt Public Health’s Department of Health Policy and Management. “By providing training and support to primary care physicians to provide medication-assisted treatment to their patients, policymakers might stimulate increases in treatment access in local communities.”
Medication-assisted treatment is the use of medications, such as buprenorphine, naltrexone or methadone, often with counseling, to treat opioid use disorder. The medications relieve opioid cravings and withdrawal symptoms. Providers must complete training and be approved to prescribe buprenorphine, and methadone can be dispensed only by licensed clinics for opioid use disorder.
Through a grant from the Agency for Healthcare Research & Quality to the Pennsylvania Department of Human Services, Cole and his colleagues reviewed Pennsylvania Medicaid claims data from 2014 to 2015 for 7,930 enrollees with a diagnosis of opioid use disorder living in 23 rural Pennsylvania counties heavily impacted by the opioid crisis. Pennsylvania is the seventh–largest Medicaid program by enrollment, the fourth–largest by expenditure and has the third–largest rural population, compared to other states.
The team mapped availability of providers of medication-assisted treatment and the actual location of where each enrollee was receiving treatment. The average distance to the nearest possible provider of medication-assisted treatment was 4.2 miles among rural enrollees with opioid use disorder. When the researchers limited it to only physicians with a high likelihood of taking new Medicaid recipients, the average distance was 12.6 miles. However, despite closer options, the Medicaid enrollees in the study were traveling an average of 48.8 miles for treatment.
“We can’t say for sure why the enrollees were traveling so much farther than necessary for treatment. We couldn’t measure things like wait times for appointments or patient preferences for particular providers,” Cole said. “But we do know that only 20 percent of those with opioid use disorder were diagnosed by their primary care physician. More frequently, they were diagnosed by a behavioral health provider, who then likely referred them to treatment.”
Getting someone with opioid use disorder into treatment is only the beginning, Cole said. His team took their analysis further and found that enrollees who travelled more than 45 miles to treatment had 29% lower odds of remaining adherent to medication-assisted treatment. There is strong evidence that adherence to medication-assisted treatment is related to a lower risk of relapse and improved outcomes.
“Primary care physicians don’t get a lot of training in addiction, so they may be reluctant to treat it due to concerns about administrative burdens on their practice or stigma about taking on new patients with opioid addiction,” Cole said. “But what we found is that the people in rural communities with opioid use disorder are already being seen by these primary care physicians for other reasons. If we can equip these physicians with training and administrative and clinical support to offer such treatment, and show them that they’ll be treating the patients they already have, they could be in the right place at the right time to address important gaps in access to addiction treatment.”
Cole said that future research will need to examine whether patients who are traveling great distances for medication-assisted treatment eventually switch to closer providers, and whether that change is associated with improved outcomes.
The research was funded by Agency for Healthcare Research & Quality grant 1R18HS025072-01. Ellen DiDomenico, M.S., of the Pennsylvania Department of Drug and Alcohol Programs is the principal investigator of the AHRQ grant, and is a co-author of the study.