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In states with most overdose deaths, poor patients struggle to find treatment

Poor people with opioid use disorders may struggle to find doctors to prescribe the anti-addiction drug buprenorphine in U.S. states with the highest overdose death rates, a new study suggests.

In 2018, researchers posing as patients called to schedule appointments for a buprenorphine prescription at 1,092 clinics with 546 clinicians who could offer the drug. The clinics were located in the places with high rates of opioid overdose deaths in 2016: Massachusetts; Maryland; New Hampshire; Ohio; West Virginia; and Washington, D.C.

These “secret shoppers” said they were uninsured or had coverage through Medicaid, the U.S. health program for the poor. When callers got through to appointment schedulers, clinicians offered appointments to just 54 percent of Medicaid “patients” and 62 percent of uninsured “patients.”

And “patients” were told they could get buprenorphine prescriptions at their first visit just 27 percent of the time with Medicaid and 41 percent of the time when they were uninsured.

“It can be hard to find the doctor that accepts your insurance and has openings, but there are doctors out there who can offer quick access,” said senior study author Dr. Michael Barnett of the Harvard T. H. Chan School of Public Health in Boston.

“The tough part is finding them,” Barnett said by email.

Buprenorphine is considered among the best options for treating opioid use disorder because it reduces cravings for heroin and other opioids by binding to the same receptors in the brain that respond to opioids. Buprenorphine can be dispensed in outpatient clinics, making it more convenient than rehab options that require an overnight stay. And the medication rapidly relieves withdrawal symptoms without causing a euphoric high.

“Because users have much less need to seek dangerous opioids like heroin or fentanyl while on buprenorphine, their risk for overdose is much lower,” Barnett said. “Getting quick access to treatment can be very important because data shows that treatment delays are a high risk period for repeated overdose.”

Wait times for buprenorphine appointments in the study were similar regardless of the type of clinician or the type of insurance.

Half of the “patients” couldn’t get an initial appointment for buprenorphine for at least six days with Medicaid coverage and five days without insurance.

And, half of the patients couldn’t start taking buprenorphine for at least eight days after their initial office visit with Medicaid and at least seven days without insurance.

However, some “patients” would have waited almost two weeks to start treatment.

Without insurance, half of the patients would pay at least $250 to start taking buprenorphine. And 19 providers, or 5 percent, said the cost would be at least twice that high. Half of the clinicians who discussed pricing also said there could be additional fees for urine drug testing or other lab work before patients could start taking buprenorphine.

The study wasn’t a controlled experiment designed to prove whether or how appointment availability or treatment timing might directly impact outcomes for patients seeking buprenorphine.

One limitation of the study is that it excluded most U.S. states, researchers note in the Annals of Internal Medicine. Another drawback is that the states that were included all expanded Medicaid eligibility under Obamacare, which might impact both access and affordability of buprenorphine treatment – but the study couldn’t account for that.

It’s also not clear from the study why it’s harder to get seen with Medicaid, said Dr. Pooja Lagisetty of the University of Michigan in Ann Arbor, an author of an accompanying editorial.

Doctors might not accept Medicaid because of legal or “red tape” conerns like excessive paperwork, or because of low reimbursement rates, or some combinations of these issues, Lagisetty said by email.

“Willing clinicians are often available for same-day or appointments within a week, demonstrating that they do have availability, and many said yes and had short wait times,” Lagisetty said.

“However, there was a very large proportion of clinicians who couldn’t even be reached,” Lagisetty added. “It is unclear whether these clinicians are saying no because they are at capacity versus they are just not providing treatment at all — I suspect many may fall into the latter category.”

SOURCE: Annals of Internal Medicine, online June 3, 2019.

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