Methadone Treatment for Opioid Use Disorder Improving Access Through Regulatory and Legal Change: Proceedings of a Workshop (2022) / Chapter Skim
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3 The History of Methadone and Barriers to Access for Different Populations
3 The History of Methadone and Barriers to Access for Different Populations
Pages 13-28
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From page 13... ...
. • Social barriers to methadone access include affordability, stigma, discrimination in health care settings, lack of culturally responsive care, and inequalities in the criminal justice system (Cerdá)
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. • Treatment attrition caused by a lack of, or non-continuation of health insurance or Medicare is associated with increased maternal deaths, particularly in the postpartum period (Terplan)
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Moreover, she said, "Understanding how that happened helps us to see that our current regulations could be otherwise." THE EARLY YEARS OF METHADONE MAINTENANCE REGULATION AND THE POLITICS OF STIGMA AND RACIALIZATION According to Samuel Kelton Roberts, associate professor of history, sociomedical sciences, and African American and African diaspora studies at Columbia University, methadone maintenance1 is one of the most closely regulated medical protocols. "Perhaps not entirely by coincidence, it is also one of the most stigmatized, controversial, and misunderstood," he said.
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CURRENT BARRIERS TO ACCESS, INITIATION, AND RETENTION IN METHADONE TREATMENT With an understanding of the historical backdrop to methadone regulations in the United States, several workshop participants discussed the effects of those regulations on health inequities, including social barriers to treatment, and considerations for special populations. Those populations include minoritized groups; people with low income; elderly individuals; people involved in the criminal justice system; pregnant women; lesbian, gay, bisexual, transgender, queer, intersex, asexual and all sexual and gender minority (LGBTQIA+)
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FIGURE 3-1 Opioid overdose death rates by race/ethnicity January–December 2020 versus January–December 2019. All demographic groups experienced more overdose deaths during 2020, with the steepest rise among Black Americans.
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. Indeed, one study showed that White patients are more likely to be referred to a medical professional and receive medication as part of their treatment plan, and less likely to leave against medical advice or be terminated by the facility than are racially minoritized patients (Entress, 2021)
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Finally, Cerdá suggesting making permanent the federal requirement that Medicaid cover all medications for OUD; enacting policies to reduce copays and prior authorization requirements by commercial insurance; and expanding the possibility of using community settings to dispense methadone, including mobile units and harm reduction programs. 2 Outpatient treatment services provided outside of licensed OTPs by primary care or general health prescribers with a Drug Addiction Treatment Act (DATA)
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Substance use is also the primary driver of increased foster care placements in the United States, added Terplan, noting that there are marked racial inequities in the child welfare system, driven in large part by primary health care providers. Terplan's research has shown that the rate of
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At the federal level, he noted that the Child Abuse Prevention and Treatment Act (CAPTA) 6 is currently undergoing reauthorization, providing an opportunity for states to decouple substance use disorder from child abuse; to roll back punitive policies; and to implement legislation grounded in basic bioethical principles.
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"We're increasingly having conversations with public health officials and policy makers to try to mitigate the adverse public health impact of exposure." Keuroghlian said the health inequities experienced by LGBTQIA+ people must be understood in the context of a minority stress framework. From 7 To learn more about the National LGBTQIA+ Health Education Center, go to https://www.
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He advocated incorporating behavioral health approaches such as cognitive behavioral therapy, delivered in a culturally responsive manner grounded in the minority stress framework and tailored for LGBTQIA+ people. Such care would focus on minority stress-specific triggers for cravings, such as identity-related discrimination and victimization, expectations of rejection, identity concealment, and internalized homophobia/transphobia (Girouard et al., 2019)
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Since 2016, the Bureau of Primary Healthcare9 has required all Federally Qualified Health Centers (FQHCs) , nearly 1,400,10 to report sexual orientation and gender identity data (Keuroghlian, 2021)
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Older adults are at increased risk of having musculoskeletal pain as well as co-occurring conditions that limit their ability to safely receive methadone treatment under current guidelines or those that make receiving methadone treatment prohibitively challenging, said Levander. For example, these co-occurring conditions may result in reduced mobility or cognitive impairment, making it difficult to get to an appointment even if they remember it, she said.
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Levander advocated including methadone as a preferred drug by Medicare Part D to promote reforms such as providing methadone through pharmacies, doctors' offices, and hospitals for older adults. Training in addiction treatment across all population groups is also critical, said Levander.
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. • Decoupling substance use from child abuse, roll back punitive policies, and ensure legislation reflects basic bioethical principles during the reauthoriza tion of the Child Abuse Prevention and Treatment Act (Terplan)
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