The opioid epidemic has touched nearly every corner of the United States. Public health officials, lawmakers, and others have recommended a vast scale-up in the capacity of substance abuse treatment in response, especially evidence-backed medication-assisted treatment (MAT).

There are currently three drugs used for the treatment of opioid use disorder (OUD): methadone, buprenorphine, and naltrexone. While all three are demonstrated to be effective in treating OUD, not all drugs are appropriate for all patients. For instance, naltrexone requires patients to undergo a minimum seven- to 10-day detoxification before initiation, which may not be right for patients who need to begin treatment immediately. Similarly, some patients are averse to taking opioid agonist drugs as part of treatment and may therefore prefer the use of naltrexone, an opioid antagonist.

As such, it is not only imperative that treatment facilities and providers offer MAT, but also that multiple treatment options be made available to increase treatment uptake and success. Clinical guidelines from the Substance Abuse and Mental Health Services Administration (SAMHSA) highlight the benefits of OUD treatment programs that offer multiple forms of MAT, and the President’s Commission on Combating Drug Addiction and the Opioid Crisis similarly recommended a requirement that “all modes of MAT are offered at every licensed MAT facility.”

Currently, facilities may choose to offer only one or two modes of MAT due to uncertainty about the effectiveness of the different modes of MAT, regulatory barriers to providing methadone or buprenorphine, or any number of other reasons.

Current MAT Accessibility

Previous analyses have documented how many facilities offer any form of MAT as part of OUD programs, but there doesn’t seem to be any previous tracking of how many facilities offer multiple forms of MAT for patients—an area where we’ve found serious shortcomings.

We use data from the SAMHSA’s National Survey of Substance Abuse Treatment Services (N-SSATS), for this analysis. It includes treatment facilities that “(1) are licensed, certified, or otherwise approved for inclusion in the Directory by their State Substance Abuse Agencies, and (2) responded to the 2016 N-SSATS.” The 2016 N-SSATS had a response rate of 91.4 percent and is the most complete publicly available survey of substance abuse facilities in the United States. No attempt was made to impute responses for nonresponding facilities, so our results may undercount the number of facilities. Facilities were categorized according to whether they reported offering any form of MAT, two forms of MAT, or all three forms of MAT and whether they reported accepting Medicaid. For further detail on how the key codes were used, see here.

For 2016, 12,029 facilities (Exhibit 1) report as providing substance abuse treatment, of which 7,466 (62.1 percent) report accepting Medicaid. Of the 4,950 (41.2 percent) that report offering at least one form of MAT (Exhibit 2), 3,346 (67.6 percent) report accepting Medicaid. Twenty-three percent (2,761) of facilities report offering two or more forms of MAT (mostly naltrexone and buprenorphine). However, just 319 (2.7 percent) facilities (Exhibit 3) report offering all three forms of MAT, of which 234 (73.4 percent) report accepting Medicaid. Eight states do not have any facilities that report offering all three forms of MAT, and 14 states do not have a facility offering all three forms of MAT that also accepts Medicaid.

Exhibit 1: All Substance Abuse Facilities, 2016

Source: Substance Abuse and Mental Health Services Administration’s National Survey of Substance Abuse Treatment Services. Note: Interactive version is available here.

Exhibit 2: Substance Abuse Facilities Offering Medication-Assisted Treatment, 2016

Source: Substance Abuse and Mental Health Services Administration’s National Survey of Substance Abuse Treatment Services. Note: Interactive version is available here.

Exhibit 3: Substance Abuse Facilities Offering All Three Forms Of Medication-Assisted Treatment, 2016

Source: Substance Abuse and Mental Health Services Administration’s National Survey of Substance Abuse Treatment Services. Note: Interactive version is available here.

Implications For The Opioid Epidemic

This analysis reveals significant gaps in access to MAT and in particular extremely low availability of all-MAT facilities in most of the country. The facilities that do provide all three forms of MAT are densely clustered in the Southwest and Northeast, while the rest of the country has virtually no access. When filtered further by all-MAT facilities that accept Medicaid, access is more limited still. In the heart of Appalachia, a region heavily affected by the opioid epidemic, Kentucky and Tennessee have no facilities that provide all three forms of MAT and accept Medicaid. (Interactive versions of these maps and county-level data are available here).

While “all-MAT” is the President’s Commission’s recommended standard, the picture isn’t substantially improved when sorting facilities into those that provide at least two forms. Kentucky and Tennessee combined have 61 facilities of which only 31 accept Medicaid, while New York alone has 416, of which 377 accept Medicaid. MAT can reduce mortality and morbidity from opioid use, and providing multiple forms can increase the likelihood of treatment success. Without access for those who need it most, the epidemic is unlikely to improve.

The Way Forward

This analysis highlights the gulf between the current state of access to treatment and the services required to successfully address the opioid epidemic. Policy makers should use every available tool at their disposal to ensure that the hardest hit communities have access to these interventions.

First, due to the federal Institutes for Mental Diseases exclusion, federal Medicaid funds are prohibited from reimbursing services provided in inpatient facilities with more than 16 beds, except for the minority of states that have been granted waivers from this requirement. The President’s Commission has recommended granting waivers to all states to increase treatment access.

Second, as of 2013, Medicaid programs in 17 states didn’t cover methadone in their programs, and one didn’t cover naltrexone. State Medicaid programs should be brought into alignment with the recommendation that OUD programs offer all three forms of MAT.

Finally, policy makers should also make full use of strategies that are not dependent on substance abuse facilities. Physicians, as well as nurse practitioners and physician assistants, can receive waivers to prescribe buprenorphine outside of substance abuse facilities. Steps should be taken to both expand the number of waivered practitioners and remove monetary and capacity barriers that prevent them from actually prescribing. Other innovative strategies include the “hub and spoke” model being used in Vermont to support buprenorphine prescribers.

If “all-MAT” is to be the standard of care for opioid use disorder, we have a long way to go. The scarce availability of these programs highlights the need for a massive effort to increase treatment access. We can and must act quickly to improve the lives of people with substance use disorders and to turn the tide on preventable drug-related overdoses.