Rhode Island has been among the states hardest hit by the opioid abuse crisis, and evidence suggests that after experiencing a brief period of stability in opioid-related-death rates, the state saw a resurgence in 2020 due in part to the COVID-19 pandemic. Since at least 2015, Rhode Island officials have made it a priority to expand access to medication-assisted treatment, known as MAT, for opioid use disorder. MAT is strongly supported by scientific evidence and endorsed by U.S. public health officials, and yet it fails to reach many opioid use disorder patients.

“Medication-assisted Treatment for Opioid Use Disorder in Rhode Island: Who Gets Treatment, and Does Treatment Improve Health Outcomes?” is a new report from the Federal Reserve Bank of Boston’s New England Public Policy Center, or NEPPC. It considers MAT’s efficacy in preventing opioid overdoses in Rhode Island and sheds light on the barriers to receiving MAT. The report, coauthored by senior economist and policy advisor Mary A. Burke and senior policy analyst Riley Sullivan, offers guidance to state and federal policymakers concerning measures to further expand access to MAT and to enhance the effectiveness of treatments for opioid use disorder. Here, Burke discusses the report’s findings:

What is medication-assisted treatment, and how does it help those who are suffering from opioid use disorder?

It involves using any of three FDA-approved medications – methadone, buprenorphine or naltrexone – together with behavioral therapy to treat opioid use disorder. It’s important to stress that opioid use disorder is a brain disease. MAT treats the condition of the brain, binding to opioid receptors to alleviate difficult withdrawal symptoms and, over time, to suppress the cravings for opioids. In this way, patients can stabilize and attend behavioral therapy to address the broader factors contributing to their condition.

Why did you focus your research on Rhode Island?

Rhode Island started experiencing a severe opioid crisis earlier than many other states and has been grappling with the crisis for more than 20 years. In 2018, the state was ranked 10th in the nation in terms of mortality rate due to opioid overdose.

A main reason why we chose to focus on Rhode Island was because its state leaders expressed an interest in partnering with the NEPPC to foster our research. Most importantly, they were willing to share a large administrative data set, the state’s All-Payer Claims Database, or HealthFacts RI, to enable this work. The data include medical treatments and health outcomes for more than three-quarters of the Rhode Islanders covered by health insurance from mid-2011 through mid-2019.

Rhode Island also has been innovative in how it has responded to the crisis. The state was the first to allow the use of MAT in correctional facilities. It also created a training program for medical students that enables them to prescribe medications for opioid use disorder immediately upon graduation.

Do patients who receive MAT have better health outcomes?

We found that people who were on either methadone or buprenorphine had a reduced risk of overdose. Specifically, we show that among patients who had at least one non-fatal overdose, those that were taking MAT recently – during the three months preceding our observation – were less likely to have a second opioid overdose.

I want to stress that we found it is not enough to just initiate treatment; patients need the support of their providers and families to stay on the medication longer term. It is this longer-term treatment – 12 months or more – that helps a patient stabilize their life situation. One of the big takeaways of our research is that, although promoting broader access to MAT is very important, policy discussions have perhaps not focused enough on helping patients stay in treatment over the longer term.

Are there segments of the population in Rhode Island that lack access to MAT?

The profile of Rhode Islanders receiving MAT is quite diverse in terms of age range and type of insurance coverage, and the chance that an opioid use disorder sufferer gets MAT is well above the national average. However, there are still some disparities. Patients in high-poverty ZIP codes seem to have less access to buprenorphine, which is concerning because that medication offers greater convenience than methadone. We also find that older patients and women seem to be getting MAT at lower rates than other patients. We are still trying to understand the underlying reasons for these patterns. Patients who also have been diagnosed with alcohol use disorder – and such individuals are more likely to suffer an opioid overdose – are less likely to get methadone.

Our research suggests that Medicaid expansion can increase access to MAT and provide more complete coverage than may be afforded by alternative state funding mechanisms for MAT, such as state block grants for public health. Medicaid patients have a high rate of accessing MAT, especially methadone, in large part because Medicaid provides full coverage for the treatment. We have learned that some buprenorphine providers do not accept Medicaid patients because reimbursement rates are lower, and some do not accept any insurance whatsoever. Still, the good news is that it does appear that being on Medicaid insurance is helping low-income populations in Rhode Island gain and maintain access to MAT.

Does your research suggest ways that more people can access MAT?

One way is for hospitals to initiate MAT treatment for a patient suffering from an opioid overdose in the emergency room. Expanding the set of providers who can prescribe buprenorphine would also increase access. Federal policies that increased the number of patients per prescriber and gave prescribing privileges to nurse practitioners did expand access to buprenorphine in Rhode Island. Providing additional support to existing prescribers – many of whom are serving fewer patients than they are allowed to prescribe to – could increase access by increasing the number of patients they serve.

Other nations have sought to increase access to MAT through granting pharmacists buprenorphine prescribing licenses. This policy bears consideration given the prevalence of pharmacies across community types. The COVID-19 pandemic has provided an experiment for the role that telehealth can play in increasing access to MAT. During the pandemic, rules requiring in-person or on-site prescribing of buprenorphine and methadone have been relaxed. While there is certainly a benefit to in-person evaluation and confirmation that medications are being taken, permanently relaxing in-person prescribing requirements could further expand access to MAT, although care would have to be taken to minimize any abuses of such a policy.

This interview was conducted by Darcy Saas, deputy director at the New England Public Policy Center.