Opioid treatment programs are inaccessible for many rural Americans, and many don't offer the full range of treatment

Percentage of opioid treatment programs than accept Medicaid coverage, by state
Map by The Pew Charitable Trusts; click the image to enlarge it.

Opioid overdose deaths have shot up during the pandemic, topping a record-setting 100,000 in the 2021 fiscal year. But only 11 percent of the 2.7 million Americans with opioid-use disorder received medication-assisted treatment in 2020, and opioid treatment programs remain out of reach for many Americans with opioid-use disorder, including those in rural areas, Sheri Doyle and Vanessa Baaklini report for The Pew Charitable Trusts. Not only are OTPs scarcer in rural areas—Wyoming, one of the most rural states, had none at all as of 2020—but rural programs may not do much good if they don't accept Medicaid, offer buprenorphine, or have mental-health care that goes beyond drug treatment,

Pew found significant disparities among the states. OTPs are the only health-care facilities that may offer patients all three types of medication-assisted therapy for opioid addiction, but 60.5% didn't offer injectable naltrexone and 24.2% didn't offer buprenorphine.

Buprenorphine availability may have been hampered because medical providers once had to obtain special training and a waiver to prescribe it, but in April 2021 the Department of Health and Human Services largely did away with the waiver. However, the treatment still may be hard to get because the Drug Enforcement Administration also began cracking down on pharmacies suspected of improperly dispensing it, so many pharmacies subsequently refused to dispense it all.

Medicaid acceptance among OTPs also varied widely, from 100% in several states to none in Mississippi and South Dakota; 83.2% of OTPs overall accept Medicaid, Doyle and Baaklini report. When Medicaid is not accepted, the poor must pay out of pocket or seek charity.

Mental-health issues are common among those with opioid-use disorder, and treating such problems—which are often at the heart of opioid misuse—can help make drug treatment stick. But only 46.1% of OTPs offer mental-health treatment, Doyle and Baaklini report.

The study found wide disparities in the availability of OTPs that cater to specific populations: 64.1% offer treatment in other languages, 56.9% offer treatment specially for pregnant people, 24% for LGBTQ Americans, 24% for veterans, and 4.7% for adolescents.

Pew has recommendations for improving access, including a re-conception of the programs. OTPs have "punitive rules that reflect a distrust of patients—such as observed daily dosing, regular urine drug screens, and limits on access to take- home medication—rather than encouraging a collaborative setting in which the provider and patient work in partnership," says a Pew brief published with the study.

Also, state laws "prevent or discourage new OTPs, such as prohibiting OTPs near schools, requiring new OTPs to obtain a certificate of need (a legal document demonstrating public need for new facility services), or requiring licensure by the state board of pharmacy, a level of oversight not required by the federal government," Pew reports. "West Virginia law even prohibits new clinics from opening at all."

To increase access, Pew recommends that all OTPs accept Medicaid, that states should encourage mobile methadone clinics, and that more OTPs in general should be opened.