Among the many public health problems exacerbated by the COVID-19 crisis, opioid-related overdose deaths have increased sharply since the pandemic began. Provisional data from the Centers for Disease Control and Prevention indicate that more than 93,000 deaths resulted from drug overdose in the US in 2020, reflecting an increase of 30% compared with the previous year.1
One factor likely contributing to this trend is the reduction in access to mental health and substance abuse treatment during the pandemic, including access to medications for opioid use disorder (MOUD), previously referred to as medication-assisted therapy (MAT).2 The concept of MAT is “now considered out of date because it implies that medication is not treatment itself, although in reality, research from the past 5 years has shown that medications alone can treat addiction for many individuals,” explained Ashish P. Thakrar, MD, fellow in the National Clinician Scholars Program at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia.3
Compared with nonpharmacologic approaches, research consistently supports the benefits of MOUD, including fewer deaths, higher rates of sustained recovery, and greater cost-effectiveness.4-6 In a recent cohort study of 40,885 insured individuals, Sarah Wakeman, MD, assistant professor of medicine at Harvard Medical School and medical director for the Massachusetts General Hospital Substance Use Disorder Initiative, and colleagues observed drastic reductions in overdoses at 3 and 12 months (76% and 59%, respectively) in those receiving treatment with buprenorphine or methadone.4
In addition, these therapies were linked to substantial reductions in use of opioid-related acute care at 3 and 12 months (32% and 26%, respectively) vs no treatment. The other treatment options examined — including inpatient detoxification, residential treatment, naltrexone, and intensive and nonintensive behavioral health services — were not associated with reductions in overdose or opioid-related acute care use.4
Despite its demonstrated benefits, however, MOUD has been vastly underutilized since before the pandemic. In the study by Wakeman et al, only 12.5% of the sample received MOUD with buprenorphine or methadone, and 2.4% received the generally less-effective naltrexone.4
In research published in June 2021 in the Journal of Hospital Medicine while Dr Thakrar was a fellow in the division of addiction medicine at Johns Hopkins Bayview Medical Center in Baltimore, he and colleagues reported that resident internal medicine teams started only 10% of eligible patients on MOUD at their site (only buprenorphine was examined).5 After a comprehensive, resident-led training program for providers, prescriptions of buprenorphine at discharge increased to 24%.
Updates in MOUD and solutions to increase utilization were discussed in extended interviews with Dr Thakrar and Dr Wakeman.
What is the current state of MOUD in the US, and what was the impact of the COVID-19 pandemic on this essential resource?
Dr Thakrar: These medications are the standard of care and should be available to all individuals with opioid addiction. However, the reality is that, in any given year, less than one-quarter of patients with opioid addiction are actively in treatment with 1 of the 3 medications approved by the US Food and Drug Administration (FDA) for OUD: buprenorphine, methadone, and extended-release naltrexone. Access to these treatments is highly variable depending on geographic location, insurance coverage, and treatment setting.
During the COVID-19 pandemic, federal agencies made 2 important regulatory changes regarding MOUD. First, they allowed prescribers to start buprenorphine via telemedicine, whereas they were previously required to have an in-person appointment with patients to prescribe this drug.7
Second, they allowed methadone clinics to provide more take-home medications to patients earlier in recovery. Research is ongoing to determine the impact of these changes, but early reports indicate that they were crucial in giving patients flexibility and increasing access to these life-saving medications.
Dr Wakeman: Despite decades of evidence demonstrating that medication treatment with buprenorphine and methadone are far and away the most effective treatment we have, most people with OUD are not treated with these lifesaving medications, and most providers don’t provide these treatments. These situations occur in part because of how we have chosen to regulate these medications, as methadone and buprenorphine treatment requires additional licensure, which has created this opt-in system whereby most providers aren’t able to offer these therapies.
Practically, this means that there are vast treatment deserts and counties without a single buprenorphine prescriber, resulting in people having to travel far distances to find an opioid treatment program for methadone treatment. Recent changes that allow for prescribers to get an X waiver without taking the 8 to 24 hours of previously required training is a step in the right direction, but this is far from the sweeping changes that are needed to ensure these medications are available to all who need them.8
What are believed to be the reasons why MOUD is so vastly underutilized?
Dr Thakrar: There are 3 major barriers to increasing the use of MOUD: stigma, misunderstanding of these medications, and restrictive regulations. Too many clinicians and providers attribute addiction to poor willpower or a moral failing instead of to a chronic medical condition. As a result, they fail to realize that addiction is treatable.
Many providers are unfamiliar with these medications and do not feel comfortable starting them; others fail to realize that these are long-term medications that benefit patients for years. Last, restrictive and confusing regulations around these medications make it difficult to know when providers are legally permitted to start them.
Dr Wakeman: There are several barriers. First, policies regulating these treatments have created a system that makes these lifesaving medications a scarce resource while we are in the midst of an overdose epidemic, which is exactly the opposite of what we should be doing. We should be creating a system where it is easy for both providers to offer the most effective treatments and patients to access these medications. Instead, it is far easier to access illicit opioids than it is to access medication treatment.
The next barrier, which policies help enshrine, is stigma. Stigma exists among providers, many of whom haven’t received any education in addiction and therefore carry the same biased beliefs as the general public. Rather than seeing addiction as a health condition, many providers and the public see this as an issue of bad behavior or, even worse, a criminal legal issue.
We may say that this is a health issue now, but our policies and treatment models still reflect a deep and abiding belief that people who use drugs are untrustworthy, bad, and different. Therefore, our systems reflect a general punitive model full of the tropes that many have heard in the mainstream media and society: that we should be practicing “tough love,” that we shouldn’t be “enabling” people, or that they need to “hit bottom.” All of that is completely false, yet these notions continue to permeate the addiction treatment system and general medical providers’ beliefs about addiction.
The other way stigma plays out is in antipathy toward medications specifically. In part because of a misunderstanding of what addiction is, people erroneously believe that treatment with medications like methadone or buprenorphine is “addictive.” This confuses physical dependence with addiction. Addiction is defined as compulsively using a substance despite harm. Taking a daily medication that allows you to be healthy, to work and parent, and not die from overdose does not meet this definition. If needing a medication every day were the same as addiction, then anyone who takes thyroid medication, insulin, or antidepressants would be “addicted.”
On a related note, what is needed to ensure that more people in recovery and those close to them receive naloxone kits and training?
Dr Wakeman: First, we could make naloxone available over the counter. Second, we could ensure that prices stay low and that price gouging by the pharmaceutical companies is prohibited. Lastly, we could make it standard practice that naloxone is prescribed to any person with OUD and their family and friends, as well as available in community-based settings, similar to defibrillators.
In addition to MOUD, what other types of treatment and support are important to increase the odds of long-term recovery in these individuals?
Dr Thakrar: Care for OUD needs to be personalized. Some patients transition to recovery with medications alone, but many need or benefit from psychotherapy, case management, housing assistance, peer support, or some combination of these services.
It is also important to remember that even patients who do not desire abstinence deserve compassionate, evidence-based care to reduce the harms of using drugs. This includes harm reduction services such as syringe exchanges, distribution of naloxone to reverse overdose, overdose-prevention sites (also known as safe consumption sites), and housing-first provisions that do not mandate abstinence as a requirement for housing.
Dr Wakeman: Medication is by far the most effective treatment for OUD. Additional psychosocial treatments should be available but never required. Recovery supports like recovery coaching or community-based options like recovery community centers and mutual help can be helpful but also should be voluntary.
Nontreatment supports that address social determinants of health are absolutely vital and under-resourced. Housing is crucial. It is incredibly difficult to engage in treatment for any chronic condition if you are dealing with daily trauma, poverty, racism, and being unhoused. Addressing those broader barriers must be a part of comprehensive solutions to the overdose crisis.
Disclosure: As noted in her paper, Dr Wakeman received personal fees from OptumLabs during the study described herein.
1. Steenhuysen J, Trotta D. US drug overdose deaths rise 30% to record during pandemic. Reuters. July 14, 2021. Accessed online July 26, 2021.
2. World Health Organization. COVID-19 disrupting mental health services in most countries, WHO survey. October 5, 2020. Accessed online July 26, 2021.
3. Capurso N. Toward accurate terminology for opioid use disorder treatment. Comment on [Fairley M, Humphreys K, Joyce VR, et al. Cost-effectiveness of treatments for opioid use disorder. JAMA Psychiatry. 2021;78(7):767-777. doi:10.1001/jamapsychiatry.2021.0247]
4. Wakeman SE, Larochelle MR, Ameli O, et al. Comparative effectiveness of different treatment pathways for opioid use disorder. JAMA Netw Open. 2020;3(2):e1920622. doi:10.1001/jamanetworkopen.2019.20622
5. Thakrar AP, Furfaro D, Keller S, Graddy R, Buresh M, Feldman L. A resident-led intervention to increase initiation of buprenorphine maintenance for hospitalized patients with opioid use disorder. J Hosp Med. 2021;16(6):339-344. doi:10.12788/jhm.3544
7. Kosten TR, Petrakis IL. The hidden epidemic of opioid overdoses during the coronavirus disease 2019 pandemic. JAMA Psychiatry. 2021;78(6):585-586. doi:10.1001/jamapsychiatry.2020.4148
8. Substance Abuse and Mental Health Services Administration. FAQs about the new buprenorphine practice guidelines. Accessed online July 26, 2021.