2019 Series • No. 19–2
Current Policy Perspectives
Access to Medication-Assisted Treatment for Opioid Use Disorder: Is Rhode Island Different, and Why?
The opioid epidemic is a national public health emergency that has hit Rhode Island especially hard. As of 2017, the state’s opioid-related overdose death rate was the 10th highest in the United States (among the 36 states that were ranked). Since 1999, over 2,600 Rhode Islanders have died of opioid-involved overdoses, and 277 of those deaths occurred in 2017. In August of 2015, Rhode Island Governor Gina Raimondo signed an executive order establishing the Governor’s Overdose and Prevention Task Force to combat the state’s opioid crisis. Consistent with this executive order, the Raimondo administration has prioritized the expansion of access to medication-assisted treatment (MAT) as part of a comprehensive approach to treating opioid use disorder (OUD).
Rhode Island is not the only New England state which has suffered disproportionately from the opioid crisis, nor is it the only state in the region to have taken concerted measures to address the opioid crisis. As of 2017, five of the six New England states were ranked among the top ten in the nation for deaths related to opioid overdoses. The only exception, Vermont, nonetheless in 2017 also experienced an opioid overdose rate that was above the national average. Vermont has attracted national attention for its innovative policies to expand access to high-quality treatment for OUD, including MAT. Massachusetts has also taken strong actions in recent years to promote access to MAT. In contrast, until recently New Hampshire devoted few public resources to the treatment of OUD (Manchester and Sullivan 2019), and according to some reports the state now faces an uphill battle in attempting to expand its treatment capacity rapidly enough to meet the growing demand fueled by this public health emergency.
MAT refers to a class of treatments for OUD involving three FDA-approved medications used either alone or in combination: methadone, buprenorphine, and naltrexone. The World Health Organization and the US Department of Health and Human Services both strongly endorse the use of MAT—in conjunction with psychological counseling---for combating opioid dependence, based on the method’s proven effectiveness in reducing opioid abuse, the risk of fatal overdose, and all-cause mortality. Nonetheless, the vast majority of OUD patients in the United States do not receive MAT; it is estimated that between 2004 and 2013, only 20 percent of individuals suffering from OUD received treatment of any kind, with or without MAT.
This paper assesses the prevalence of MAT among treatment episodes for OUD in Rhode Island during the period from 2000 through 2017 as compared with the five remaining New England states and with the United States as a whole. The analysis makes use of the Treatment Episode Data Set (TEDS), which tracks individual treatment episodes for all forms of substance abuse. (An episode is defined as the period between a patient’s initial entry into treatment and their subsequent discharge.) This paper contains the preliminary findings from what will be a multiyear project by the Federal Reserve Bank of Boston to recommend better policies to combat the opioid crisis, and is the precursor to a larger study using the Rhode Island All-Payer Claims Database. Since Rhode Island has been one of the more innovative states in formulating policies to deal with the opioid crisis, it makes a particularly good case study.
- Between 2000 and 2017, Rhode Island exhibited a consistently greater tendency to use MAT as part of OUD treatment when compared with the average tendency among all US states or the average tendency among the five other New England states.
- The MAT share of OUD treatment episodes in Rhode Island increased from 35 percent in 2000 to just under 50 percent in 2017, though in most years the average MAT share was around 40 percent. Over this 17-year period, the MAT share in the five other New England states doubled to 28 percent by 2017, while the United States as a whole had about a 32 percent MAT share at the end of 2017.
- When controlling for the size of the Rhode Island population, between 2006 and 2017 the state had relatively fewer total treatment episodes for OUD (with or without MAT) compared with the average for other US states and the combined average among the other five New England states.
- The observed factors that might contribute to these higher incidence of MAT in Rhode Island include a higher share of patients with government-sponsored health insurance, patients that tend to be older (over 29 years of age), married, and a higher percentage of intravenous drug users.
- Over half of the difference in the MAT rate between Rhode Island and the rest of the United States is due to differences in factors not observed in the TEDS. These include the state’s high number of methadone clinics per capita, its high federal funding to combat substance abuse, and concerted policy initiatives to promote MAT for combating OUD.
The analysis finds that Rhode Island exhibits both a high MAT rate among OUD treatment episodes and a higher opioid-related death rate compared to the respective US averages. These facts do not necessarily imply that MAT is ineffective in Rhode Island. Instead, these two outcomes may indicate that the state has a large number of OUD sufferers who do not receive any treatment for this illness. Given this possibility, policymakers and researchers need to learn more about the barriers to OUD treatment in general, besides engaging in further efforts to understand and alleviate the barriers to receiving MAT. Other findings from the paper suggest that adequate coverage for substance abuse treatment may still be lacking in many private US health plans. Furthermore, to the extent that Rhode Island’s favorable policy environment played a role in its higher tendency to treat OUD with MAT, the paper’s findings suggest that other states that have not already done so could adopt similar strategies to help increase access to MAT.
This paper assesses the prevalence of medication-assisted treatment (MAT) among treatment episodes for opioid use disorder (OUD) in Rhode Island, as compared with the remaining New England states and the United States as a whole. Based on the Treatment Episode Data Set (TEDS-A), a national census of admissions into publicly funded treatment facilities for substance use disorders, we find that during the period beginning in 2000 through 2017, Rhode Island exhibited a greater tendency to use MAT as part of OUD treatment compared with the average state in the United States and compared with the average combined tendency among the five other New England states. Logistic regression analysis reveals that the higher incidence of MAT among OUD treatment episodes in Rhode Island compared with the US average can be partly accounted for by Rhode Island’s having (1) a higher share of patients with government-sponsored health insurance plans, (2) an older age profile of patients, (3) a higher share of married patients, and (4) a higher percentage of intravenous drug users. However, well over half of the difference in the MAT rate between Rhode Island and rest of the United States is due to differences in factors not observed in the TEDS-A but which are known to prevail in the state, such as Rhode Island’s high number of methadone clinics per capita, its high federal funding rate per capital to combat substance abuse, and state policies promoting the use of MAT.