PROVIDENCE — Treatment with medication is helping to prevent opioid overdoses in Rhode Island, but the state could make a bigger impact by boosting access in low-income ZIP codes to a prescription drug that’s more convenient to use than methadone, a new study found.
Rhode Island has been among the states hardest hit by the opioid crisis, and it remains on track to set a record for accidental drug overdose deaths in 2020.
In 2015, Governor Gina M. Raimondo created the Overdose Prevention and Intervention Task Force, placing an emphasis on medication-assisted treatment. To monitor progress, the state Department of Health shared a database on medical claims with the Federal Reserve Bank of Boston’s New England Public Policy Center.
On Tuesday, the Boston Fed released a 47-page report that found that, among patients who had an initial nonfatal overdose, those who had received medication-assisted treatment in the preceding three months were less likely to experience a second overdose.
“The great thing about Rhode Island is they understand the value of medication-assisted treatment,” said Mary A. Burke, a senior economist and policy adviser for the New England Public Policy Center.
But researchers did find “significant disparities” in access to medication-assisted treatment across different groups within Rhode Island. For example, the report said that among those with opioid dependence, people living in high-poverty ZIP codes are less likely to receive buprenorphine while also somewhat more likely to receive methadone.
“So there was almost this class system where methadone clinics tend to be in poorer areas,” Burke said.
She explained that methadone can be more effective for some people, but it is a lot less convenient to use because people have to take it at clinics while buprenorphine is available by prescription and can be taken at home. Also, researchers say buprenorphine has less potential for misuse than methadone, especially when mixed with naloxone in the brand-name formulation Suboxone.
“To get methadone, you have to show up in person every day and have people watch you take the medications,” Burke said. “Imagine if you had diabetes and you had to show up to get insulin every day – people would often miss doses and have health problems. So it’s a huge barrier.”
Ideally, patients should have similar access to both methadone and buprenorphine, researchers said. But since buprenorphine is available by prescription only, those who don’t have health insurance or a primary care physician may not be able to get it -- and doctors who are able to prescribe it aren’t always doing so.
According to the report, “the median active buprenorphine provider in our sample in 2017 served only about half as many patients in a given month as they could have,” the report said. “Even more concerning, beginning in 2016, an increasing number of providers in our sample appear to have stopped prescribing buprenorphine altogether, despite continuing to prescribe other medications.”
Rhode Island officials should take a closer look at where buprenorphine prescribers are located, and figure out what might be keeping them from treating more people with buprenorphine, Burke said.
“One surprise is that some practitioners have said they treat zero patients with buprenorphine,” she said. “What is going on with them? Why did they burn out? We need to see if the regulatory oversight needs more work. We need to get to the bottom of this, and it’s not just in Rhode Island.”
A change in federal policy has allowed physician assistants and other mid-level practitioners to prescribe buprenorphine, the report said, and that did lead some mid-level practitioners to start prescribing the drug in high-poverty ZIP codes in Rhode Island.
But those mid-level practitioners might need more support, Burke said. Patients living in poverty often have complicated medical histories and can be difficult to treat, she said, so mid-level practitioners might need help from addiction specialists.
The research also found that women are “somewhat less likely” than men to receive either methadone or buprenorphine.
“It could be a perception that child-bearing-age women shouldn’t take these medications, but there are safe ways where pregnant women can take these drugs,” Burke said. Or it could be that women are more likely to take anti-anxiety medications that can be dangerous to mix with those drugs, she said.
The researchers said some policies that could promote greater access to medication-assisted treatment include allowing pharmacists to prescribe buprenorphine.
“Every neighborhood has a pharmacy,” Burke said. “Some don’t want to stock these medications because they fear people will break in, but many already stock opioid pain relievers. So why don’t they stock this?”
Researchers also mentioned the possibility of relaxing restrictions obtaining buprenorphine prescriptions via telehealth, and allowing take-home doses of methadone.
More research is needed before enacting any of those proposals, and many require changes on the federal level, they said. “But consideration of further policy adjustments is critically important given the ongoing scourge of opioid abuse and the proven ability of medication-assisted treatment to help those suffering from opioid use disorder,” they wrote.
Burke, who wrote the report along with Riley Sullivan, explained that the Boston Fed studies high-priority public policy issues in New England. “There are fiscal and economic implications to the opioid epidemic and people’s individual lives,” she said. And next year, the Boston Fed is planning to study whether receiving medication-assisted treatment raises the chances of employment, she said.
In response to Tuesday’s report, Department of Health spokesman Joseph Wendelken said treatment has been a major focus on the Overdose Prevention and Intervention Task Force.
“We have spent years massively increasing the treatment infrastructure in Rhode Island,” he said. “Our whole vision behind overdose prevention is that addiction is a disease, recovery is possible, and treatment works. We have done an enormous amount of work to reduce barriers to treatment.”