New research shows just how difficult it is to access opioid treatment in rural areas in Kentucky, Indiana and surrounding states.
The study from Yale University analyzed drive times to methadone treatment in every county in Kentucky, Indiana, Ohio, West Virginia and Virginia, which have the nation’s highest rates of opioid-related overdose deaths. The study was published in the Journal of the American Medical Association on Tuesday.
Patients usually have to receive methadone in person six days a week. The findings show that the average drive time to a clinic from a rural county’s population center is about 49 minutes. That’s compared to a drive time of about eight minutes in large metro areas. And for a patient trying to get methadone treatment, time spent getting to appointments acts as a barrier to treatment.
“If you need methadone and you live in a rural county, you're in trouble in many places, that's the issue,” said study author Paul Joudrey, a researcher and doctor at the Yale School of Medicine. ”For most health care, you might go to your doctor once a month, even less. In the case of methadone, it's uniquely burdensome.”
Methadone isn’t the only medication-assisted treatment option for people who want to get help for opioid addiction; others include buprenorphine and vivitrol. But Joudrey said access to methadone is important because some of the other options don’t work for everyone. That’s despite the fact that methadone is more difficult to obtain. When it’s used to treat addiction, it has to be dispensed in liquid form at a treatment center. An overdose can occur from misusing methadone, but that's rare when taken as prescribed.
The JAMA study used data from 2017. Since then, Kentucky has added three additional treatment centers and satellite clinics where only methadone is dispensed, but there are still only 28 locations across the state’s 120 countries. Holly Broce, the vice president of opioid treatment programs at provider Pinnacle Treatment Centers, said the company has opened several full-service clinics and satellite locations in the last few years.
“We had lots of patients waiting for a treatment provider to come to their community,” Broce said. “And we realized we had patients driving an hour and a half each way to get to our program.”
Solutions
Across the five states included in the study there are several regions that stand out with the longest drive times. That includes much of the western side of Indiana, a wide swath of eastern West Virginia and some counties in eastern Kentucky.
Study author Joudrey says one potential solution is for federally-qualified health centers to offer methadone treatment. These centers often provide primary care to low-income patients. Joudrey said Canada and Australia allow primary care clinics to prescribe methadone, but the process is more difficult in the United States.
“For many primary care clinics, those rules and restrictions are burdensome, and it limits the number of opiate treatment programs and methadone clinics,” Joudrey said.
He said if these clinics offered methadone treatment, it would make the treatment easier to access for rural residents. When he analyzed drive times to these clinics, he found the drive for many rural patients to the clinic would be about 17 minutes, compared to the 49 minutes to a methadone treatment center.
In addition to the drive time issue, Joudrey also pointed to stigma as a reason why methadone treatment should be included within primary care settings. Allen Brenzel, the medical director for the Kentucky Department for Behavioral Health and Developmental and Intellectual Disabilities, said he’s often told by people in recovery that certain physical elements of the clinics can turn people away from methadone treatment.
“What people tell me is, ‘I have to get in line outside on the sidewalk at six in the morning, and everybody is driving by and they see me out front, and they know why I'm there,’” Brenzel said. “And then a lot of our communities fight these methadone clinics. They don't want, quote, unquote, those people in the shopping mall, so they don't want clinics to be there.”
Brenzel said it’d be up to the federal government to ease rules for federally-quality health centers and primary care clinics. Meanwhile, the state is working toward easing licensing requirements for providers.
“There's an attempt to simplify and streamline and decrease the number of programs that have to have dual licensure,” Brenzel said. “It's been complicated.”
Insurance Coverage
Though the study is new, what’s not new is the awareness that drive times and transportation to Kentucky’s methadone clinic are burdensome for some. In 2014, when Kentucky expanded Medicaid, the state also expanded substance abuse treatment coverage — but excluded methadone in part because of access issues.
“If someone is a Medicaid client, they're entitled to transportation to a medical appointment,” Brenzel said. “And so Medicaid would have been responsible for covering transportation on a daily basis to each of the methadone clinics wherever they might be. And so I think there was some concern that we were adding a very expensive benefit in general.”
But that changed in July; now, Kentucky’s Medicaid program covers the drug. Broce with Pinnacle said this has been a big win for some patients.
“Before Medicaid coverage came, the main reason for patients leaving was because they weren't able to afford it, or provide transportation to get there,” Broce said.
Under Medicaid’s new coverage, however, transportation to appointments is not included.
Data from the state shows that since Medicaid started covering methadone, about 6,000 people are using the benefit.
Research Details
The research in JAMA was based off data from 487 counties in Kentucky, Indiana, West Virginia, Ohio and Virginia. Authors used population centers — where the most people in a county live — as the starting point to the nearest methadone clinic. Data about the methadone clinics are from 2017.
Kentuckians struggling with a substance use disorder, either themselves or within their families, can call 1-833-8KY-HELP (1-833-859-4357) toll-free to speak with a specialist about treatment options and available resources.
Correction: An original version of this post misspelled the name of Holly Broce; her company, Pinnacle Treatment Centers was incorrectly identified as Pinnacle Health.
