Patient Barriers in Getting Treatment for Opioid Use Disorder

RESEARCH ANALYSIS

Patient Barriers in Getting Treatment for Opioid Use Disorder

YACHANA PANCHAL, MPH

Philadelphia College of Osteopathic Medicine

SUMMARY POINTS

-        The barriers that patients face in getting treatment for Opioid Use Disorder (OUD) can be broken down into five categories: treatment cost/insurance barriers, access to care/flexibility, stigma, negative patient perceptions about treatment, and lack of social support.

-        Many of the barriers that patients face in getting treatment for OUD are interrelated through stigma and access, so these are the most important barriers to focus on.

-        Education for patients and their communities, prioritizing social support, and reducing restrictions for patients are ways to reduce the barriers that patients face in getting treatment for OUD.

ANALYSIS

Background

Opioid Use Disorder (OUD) is a public health problem. The number of opioid-related deaths have been rising since 1999, with a recent surge in 2013 due to synthetic opioids such as fentanyl (1). In 2022, over 75% of the drug overdose related deaths were due to opioids (1). OUD is characterized in the DSM-5 by 12 criteria shown in Table 1 below.

Table 1: Strain, E. & Peavy, M.K. (2024). Opioid Use Disorder: Treatment Overview. UpToDate.

Patients exhibiting 2–3 of these symptoms are considered to have mild disease, 4–5 symptoms indicate moderate disease, and 6 or more symptoms indicate severe disease (2). Treatment for opioid use disorder (OUD) includes both medications for opioid use disorder (MOUD) and psychotherapy (2). There are three FDA-approved MOUD: buprenorphine, methadone, and naltrexone (2). According to the 2022 National Survey on Drug Use and Health, among the 8.1 million people with OUD, only 18.3% received MOUD (3). This low percentage highlights the presence of significant barriers to treatment. The barriers that patients face in getting treatment can be broken down into five different categories: treatment cost/insurance barriers, problems with access/flexibility, stigma, negative patient perceptions of treatment, and lack of social support.

Findings

A major barrier to OUD treatment is cost and lack of insurance coverage. Approximately half of OUD treatment providers charge fees, meaning that patients must pay out of pocket or rely on insurance coverage (4). This creates significant challenges for individuals who are low-income, homeless, or unemployed. A study analyzing Reddit posts found that patients frequently expressed concerns about lacking insurance, insurance not fully covering treatment, losing coverage, and being forced to switch treatment due to insurance limitations (5). These financial burdens can isolate patients and discourage them from seeking or continuing treatment.

Another major barrier is limited access and flexibility in treatment. To get MOUD, patients must join a waitlist, which is oftentimes long and requires the patient to attend immediately if a spot becomes available (4,6). This system is not practical for patients who have work or other responsibilities, such as childcare. Long wait times significantly reduce the likelihood that a patient will enter a treatment program (4). Access barriers are particularly acute for methadone treatment, which can only be dispensed through certified opioid treatment programs. These programs are highly regulated and often require frequent clinic visits, urinalysis, and counseling, limiting flexibility and making patients feel a lack of control (4, 7). Accessibility issues are even more pronounced in rural areas, where such programs are scarce, and access to psychotherapy is also limited (6, 7).

Stigma was also reported as a barrier by patients in many different studies. Figure 1 shows the different levels of stigma that patients with OUD face.

Figure 1: Cheetham A, Picco L, Barnett A, Lubman DI, Nielsen S. The Impact of Stigma on People with Opioid Use Disorder, Opioid Treatment, and Policy. Subst Abuse Rehabil. 2022 Jan 25;13:1-12. doi: 10.2147/SAR.S304566. PMID: 35115860; PMCID: PMC8800858.

One type of stigma patients expressed concern over was from healthcare providers. Within healthcare, there is a lack of understanding and awareness about treatment options (5). This can affect the quality of care that patients with OUD receive and deter patients from seeking care in the future. Healthcare providers may experience personal stigma towards patients with OUD seeking treatment, which could affect the quality of care patients receive (4). Patients also reported stigma from their friends, family, and community in many studies. There is a misconception that MOUD is an alternate form of addiction among patients and their communities, which further perpetuates this stigma (4). Internalized stigma among patients is also a persistent issue, as it can cause a delay in seeking care (8). Additionally, patients with OUD often have co-morbidities and other mental health disorders, which may further stigmas and discourage timely treatment (4).

Stigma contributes to patients’ negative perceptions of treatment. Many fear they are simply replacing one addiction with another (4). Misconceptions—such as methadone "rotting" teeth or bones—persist due to a lack of accurate information (4). These concerns, when unaddressed, can delay or prevent treatment engagement. Racial and ethnic minority groups, in particular, report more negative attitudes and misconceptions toward MOUD compared to non-Hispanic white individuals (9), highlighting the need for targeted education. Chronic pain patients may also hesitate to pursue OUD treatment due to fears that it will exacerbate their pain, emphasizing the need for integrated pain management strategies (10).

A lack of social support is another significant barrier. Strong social support is associated with fewer barriers to methadone treatment and better outcomes overall (7). However, stigma often prevents patients from building supportive networks. While support groups like Narcotics Anonymous exist, many do not accept MOUD and may stigmatize its use, creating further isolation (6). This problem is especially pronounced in rural communities, where support systems are limited despite the high prevalence of OUD (6).

Discussion:

In summary, many of the barriers to OUD treatment are interconnected, with stigma and limited access emerging as central issues. Education for patients, families, friends, and communities is a way to reduce the stigma and negative perceptions of OUD treatment. Given the importance of social support, strategies to incorporate support systems into treatment should be explored. During the COVID-19 pandemic, methadone regulations were temporarily relaxed, improving access and reducing treatment barriers (7). Continuing these relaxed regulations could help sustain improvements in care. Finally, because OUD frequently co-occurs with other mental health conditions, integrated treatment approaches should be prioritized.

REFERENCES:

1.     Understanding the opioid overdose epidemic. Centers for Disease Control and Prevention. Accessed June 17, 2024. https://www.cdc.gov/overdose-prevention/about/understanding-the-opioid-overdose-epidemic.html?CDC_AAref_Val=https%3A%2F%2Fwww.cdc.gov%2Fopioids%2Fbasics%2Fepidemic.html.

2.     Strain, E. & Peavy, M.K. (2024). Opioid Use Disorder: Treatment Overview. UpToDate. Retrieved June 14, 2024, from https://www.uptodate.com/contents/opioid-use-disorder-treatment-overview

3.     Key substance use and mental health indicators in the ... Accessed June 17, 2024. https://www.samhsa.gov/data/sites/default/files/reports/rpt42731/2022-nsduh-nnr.pdf.

4.     Hall NY, Le L, Majmudar I, Mihalopoulos C. Barriers to accessing opioid substitution treatment for opioid use disorder: A systematic review from the client perspective. Drug Alcohol Depend. 2021 Apr 1;221:108651. doi: 10.1016/j.drugalcdep.2021.108651. Epub 2021 Feb 26. PMID: 33667783.

5.     Bremer W, Plaisance K, Walker D, Bonn M, Love JS, Perrone J, Sarker A. Barriers to opioid use disorder treatment: A comparison of self-reported information from social media with barriers found in literature. Front Public Health. 2023 Apr 20;11:1141093. doi: 10.3389/fpubh.2023.1141093. PMID: 37151596; PMCID: PMC10158842.

6.     Scorsone KL, Haozous EA, Hayes L, Cox KJ. Overcoming Barriers: Individual Experiences Obtaining Medication-Assisted Treatment for Opioid Use Disorder. Qual Health Res. 2020 Nov;30(13):2103-2117. doi: 10.1177/1049732320938689. Epub 2020 Jul 21. PMID: 32691670.

7.     Pasman E, Kollin R, Broman M, Lee G, Agius E, Lister JJ, Brown S, Resko SM. Cumulative barriers to retention in methadone treatment among adults from rural and small urban communities. Addict Sci Clin Pract. 2022 Jul 15;17(1):35. doi: 10.1186/s13722-022-00316-3. PMID: 35841076; PMCID: PMC9284487.

8.     Cheetham A, Picco L, Barnett A, Lubman DI, Nielsen S. The Impact of Stigma on People with Opioid Use Disorder, Opioid Treatment, and Policy. Subst Abuse Rehabil. 2022 Jan 25;13:1-12. doi: 10.2147/SAR.S304566. PMID: 35115860; PMCID: PMC8800858.

9.     Husain JM, Cromartie D, Fitzelle-Jones E, Brochier A, Borba CPC, Montalvo C. A qualitative analysis of barriers to opioid agonist treatment for racial/ethnic minoritized populations. J Subst Abuse Treat. 2023 Jan;144:108918. doi: 10.1016/j.jsat.2022.108918. Epub 2022 Oct 26. PMID: 36403456.

10.  Stumbo SP, Yarborough BJ, McCarty D, Weisner C, Green CA. Patient-reported pathways to opioid use disorders and pain-related barriers to treatment engagement. J Subst Abuse Treat. 2017 Feb;73:47-54. doi: 10.1016/j.jsat.2016.11.003. Epub 2016 Nov 15. PMID: 28017184; PMCID: PMC5193128.