Medications for opioid use disorder among American Indians and Alaska natives: Availability and use across a national sample
Introduction
Over the past two decades, American Indians and Alaska Natives (AI/ANs) have experienced a fivefold increase in opioid overdose deaths (Tipps et al., 2018), a faster growth rate than the national average. AI/ANs continue to have the highest rate of prescription opioid misuse and overdoses, and rising deaths involving heroin, synthetic opioids, and stimulants(Kariisa et al., 2019; Scholl et al., 2019; Substance Abuse and Mental Health Administation, 2018). AI/ANs often use alcohol and other drugs at higher rates, begin using substances at earlier ages(Whitesell et al., 2012) and have elevated rates of chronic disease and mental health conditions that exacerbate addiction risk (Barnes et al., 2010; Skewes and Blume, 2019). Still, this group has received little attention in national discussions of the opioid epidemic and in research and public health responses to address it.
One essential opioid response strategy is expanding access to medications for opioid use disorder (MOUD) - especially the agonist medications methadone and buprenorphine - which effectively reduce overdose and other opioid-related harms(Leshner and Mancher, 2019; Sordo et al., 2017). Expanding MOUD has also been a focus of overdose prevention efforts within AI/AN communities, through initiatives such as the federally-funded Tribal Opioid Response Grants and other tribe-initiated and government programs(Tipps et al., 2018; Venner et al., 2018; Zeledon et al., 2019). Unfortunately, regulatory hurdles and stigma against medications have made access to MOUD a challenge nationwide (Leshner and Dzau, 2019). Efforts to expand MOUD treatment in AI/AN communities have also encountered unique barriers such as limited resources of tribe and Indian Health Service (IHS)-run behavioral health services, a lack of trained providers near reservations, and the perception that medication treatments are incongruent with traditional values and healing practices (Rieckmann et al., 2017; Tipps et al., 2018; Venner et al., 2018; Zeledon et al., 2019). Given AI/ANs already have low rates of treatment for substance use compared to other groups (Substance Abuse and Mental Health Administation, 2018), MOUD-specific barriers only exacerbate the gap in receipt of effective care.
Despite recognition of a need to expand MOUD access in behavioral health settings, the extent to which MOUD are currently available and used among AI/ANs seeking OUD treatment is not well-documented. One study surveyed 192 substance use treatment programs that serve AI/ANs, and found that only 28 % offered MOUD (Rieckmann et al., 2017). More information is needed about how MOUD among AI/ANs compares to other race groups, and the settings where the largest gaps remain. Additionally, more information is needed about individual, clinical, and structural factors impacting MOUD use among this group. This study aims to fill some of these gaps by using publicly-available data to characterize the landscape of MOUD treatment availability and utilization among AI/ANs across the U.S. We do this by exploring the extent to which MOUD are offered in substance use treatment facilities that explicitly serve AN clients compared to other facilities, and then assessing use of MOUD among AI/AN clients admitted to specialty treatment for OUD relative to clients of other races. We hypothesized that AI/ANs would have lower access to MOUD at the facility and client level.
Section snippets
Data
We used two databases operated by the Substance Abuse and Mental Health Services Administration (SAMHSA). The first is the 2018 National Survey on Substance Abuse Treatment Services (N-SSATS), an annual census of characteristics of public and private substance use treatment facilities in the U.S., including information on types of medications offered (Batts et al., 2014). In 2018, the N-SSATS collected information from 14,809 treatment facilities, with a response rate of 94.8 % among invited
Availability of MOUD across treatment facilities
Of the 14,809 facilities that were surveyed in N-SSATS in 2018, 1,532 (10.3 %) explicitly served AI/AN clients. Of these, the majority (1,470) accepted IHS funds as a source of payment, 262 were operated directly by tribal governments, 81 had staff that spoke Native languages, and 23 were operated by the IHS. Table 1 displays the proportion of facilities within each of these categories that 1) offered any MOUD for any purpose, or 2) offered agonist maintenance with methadone or buprenorphine.
Discussion
To our knowledge, this is the first study to examine MOUD use among American Indians and Alaska Natives in a national sample. While some literature has compared MOUD utilization across racial/ethnic groups, studies often exclude AI/ANs because of their relatively small representation in the general population or due to insufficient information on race/ethnicity (Hansen et al., 2016; Krawczyk et al., 2017a; Lagisetty et al., 2019). Our findings suggest that, similar to other racial/ethnic groups
Conclusions
MOUD are critical for addressing the opioid epidemic, and yet they continue to be underutilized across the U.S.(Leshner and Mancher, 2019). This study shows that AI/AN populations are no exception to this trend, and that this group experiences overall low uptake of MOUD with vast variation in access across different regions of the U.S. AI/ANs experience similar or even somewhat greater use of MOUD relative to other race groups, but may be less likely to use MOUD for maintenance rather than
Role of Funding Source
This Study was funded by a Bloomberg Philantropies grant.
Contributors
NK conducted the analyses and drafted the manuscript; BG, EAS and BS helped conceptualize the studyand EAS and BS oversaw the overall project; NJA, EP and KS significantly revised and helped frame the manuscript in the context of the literature.
Availability of data and material
Data used for this study is publicly available from the Substance Abuse and Mental Health Services Administration
Code availability
Not Applicable
Declaration of Competing Interest
No conflict declared.
Acknowledgments
This work was funded by a grant from Bloomberg Philanthropies. Authors would like to thank colleagues at Bloomberg Philanthropies, Vital Strategies, Pew Charitable Trusts, CDC Foundation, and Johns Hopkins Bloomberg School of Public health for their valuable contributions to and review of this work.
References (35)
- et al.
Buprenorphine and methadone treatment for opioid dependence by income, ethnicity and race of neighborhoods in New York City
Drug Alcohol Depend.
(2016) - et al.
Racial and ethnic differences in opioid agonist treatment for opioid use disorder in a U.S. national sample
Drug Alcohol Depend.
(2017) - et al.
Future directions for medication assisted treatment for opioid use disorder with American Indian/Alaska Natives
Addict. Behav.
(2018) - et al.
Health Coverage and Care for American Indians and Alaska Natives
(2013) - et al.
Health characteristics of the American Indian or Alaska native adult population: United States, 2004–2008
Natl. Health Stat. Rep.
(2010) - et al.
Comparing and evaluating substance use treatment utilization estimates from the National Survey on Drug Use and Health and other data sources
CBHSQ Data Rev.
(2014) - et al.
Primary care–based buprenorphine taper vs maintenance therapy for prescription opioid dependence: a randomized clinical trial
JAMA Intern. Med.
(2014) - et al.
American Indian methamphetamine and other drug use in the Southwestern United States
Cult. Divers. Ethn. Minor. Psychol.
(2011) - et al.
Misclassification of race/ethnicity in a population-based cancer registry (United States)
Cancer Causes Control
(2006) Gender and use of substance abuse treatment services
Alcohol Res. Health
(2006)
Extended-release injectable naltrexone for opioid use disorder: a systematic review
Addiction
Increases in methamphetamine use among heroin treatment admissions in the United States, 2008–2017
Addiction
Drug overdose deaths involving cocaine and psychostimulants with abuse potential — United States, 2003–2017
MMWR Morb. Mortal. Wkly. Rep.
Pharmacologic treatments for opioid dependence: detoxification and maintenance options
Dialogues Clin. Neurosci.
Only one in twenty justice-referred adults in specialty treatment for opioid use receive methadone or buprenorphine
Health Aff. (Millwood)
Buprenorphine treatment divide by race/ethnicity and payment
JAMA Psychiatry
Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: a cohort study
Ann. Intern. Med.
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