Opioids continue to drive the nation’s overdose crisis. In 2023, of the 107,543 total overdose deaths, 81,083 were related to opioids. More than 92% of those opioid-related overdose deaths involved synthetic opioids like fentanyl.1 Yet only 18% of individuals who could benefit from treatment with Food and Drug Administration (FDA)-approved medications for opioid use disorder (MOUD) receive it.2 Stigma around opioid use disorder (OUD), among other challenges to access, stands in the way of patients’ and providers’ use of these medications.3 In rural communities, persons with OUD may be concerned about a lack of anonymity in seeking care. Further challenges to rural communities include limited resources, a limited number of OUD treatment providers, and travel hardships.4
Buprenorphine, naltrexone, and methadone all have been shown to reduce or eliminate opioid cravings and blunt or block the effects of illicit opioids. Access to all three medications is important because none can be said to work best for all patients. “There is no ‘one size fits all’ approach to OUD treatment,” the Substance Abuse and Mental Health Services Administration (SAMHSA) explains.5
Pharmacology: Medications for Opioid Use Disorder6
Buprenorphine | Methadone | Naltrexone (XR-NTX) |
Opioid receptor partial agonist Reduces opioid withdrawal and craving; blunts or blocks euphoric effects of self-administered illicit opioids through cross-tolerance and opioid receptor occupancy | Opioid receptor agonist Reduces opioid withdrawal and craving; blunts or blocks euphoric effects of self-administered illicit opioids through cross-tolerance and opioid receptor occupancy | Opioid receptor antagonist Blocks euphoric effects of self-administered illicit opioids through opioid receptor occupancy; causes no opioid effects; reduces opioid craving |
Methadone, which has the longest history among the medications, has demonstrated wide-ranging benefits for individuals and communities, including reduced risk of overdose-related deaths, HIV and hepatitis C infection, and illegal activity.7 Research also indicates methadone is effective and safe during pregnancy.8
Studies show that treatment with methadone or buprenorphine is more cost-effective than treatment without MOUD. But unlike buprenorphine and naltrexone, methadone can only be dispensed by specialty clinics known as opioid treatment programs (OTPs) as required by the Controlled Substances Act.9 In addition to federal regulations, most states have rules governing how OTPs are established and operated and how they provide care. These regulations have not always been evidence-based and have tended to limit access and have a negative effect on patient experience.10 Methadone treatment in OTPs can lower costs in health care and the criminal legal system.11 However, many rural residents face long drive times to reach the closest OTP, which may impact their ability to access treatment consistently.12
During the COVID-19 pandemic, OTPs were able to successfully pilot expanded use of take-home medication. Greater flexibility allowed patients to reduce the number of visits to the clinic per week, enabling them to focus on other areas of their lives. SAMHSA has proposed codifying the expanded flexibility in methadone dispensing for OTPs, but flexibility alone will not increase access if stigma remains a significant barrier.13 To better understand the impact stigma has on access to MOUD in rural communities, we need to hear from the people living and working in those communities.
Our team
Gloria Baciewicz, MD: Professor of clinical psychiatry specializing in the treatment of addiction
Itza Morales, MSB, CASAC: Director of the opioid treatment program at the University of Rochester Medical Center
Michele Herrmann, BS: Project Manager
References
[1] Centers for Disease Control and Prevention (CDC). (2024, May 15). U.S. overdose deaths decrease in 2023, first time since 2018 [Press release]. Data are provisional.
[2] Volkow, N. (2024, February 1). 50 years after founding, NIDA urges following science to move beyond stigma. National Institute on Drug Abuse; Substance Abuse and Mental Health Services Administration (SAMHSA). (2023). Key substance use and mental health indicators in the United States: Results from the 2022 National Survey on Drug Use and Health, p. 53. Data are provisional.
[3] Bourne, D., Peterson, K., Anderson, J., Mackey, K., & Veazie, S. (2020). Barriers and facilitators to the use of medications for opioid use disorder: A rapid review. Journal of General Internal Medicine, 35(12), 954–963.
[4] Lister, J. J., Weaver, A., Ellis, J. D., Himle, J. A., & Ledgerwood, D. M. (2020). A systematic review of rural-specific barriers to medication treatment for opioid use disorder in the United States. American Journal of Drug and Alcohol Abuse, 46(3), 273–288.
[5] SAMHSA. (2021). TIP 63: Medications for opioid use disorder, part 1, p. 3; part 4, p. 4; Executive Summary, p. 2.
[6] Adapted from SAMHSA. (2021), Exhibit 3A.1, part 3, pp. 6-7.
[7] SAMHSA. (2021), part 1, p. 5; part 3, p. 17.
[8] National Academies of Sciences, Engineering, and Medicine. (2019). Medications for opioid use disorder save lives. National Academies Press, p. 70.
[9] SAMHSA. (2021), part 1, p. 7.
[10] Pew Charitable Trusts. (2022, September 19). Overview of opioid treatment program regulations by state [Issue brief].
[11] SAMHSA. (2021), part 1, p. 7.
[12] Joudrey, P. J., Edelman, E. J., & Wang, E. A. (2019). Drive times to opioid treatment programs in urban and rural counties in 5 US states.JAMA, 322(13), 1310.
[13] Samhet, J. H., Boticelli, M., & Bharel M. (2018). Methadone in primary care—One small step for Congress, one giant leap for addiction treatment. New England Journal of Medicine, 379(1), 7-8.