Barriers to accessing treatment for pregnant women with opioid use disorder in Appalachian states

Abstract

Background and aims: Opioid agonist therapies (OATs) are highly effective treatments for opioid use disorders (OUDs), especially for pregnant women; thus, improving access to OAT is an urgent public policy goal. Our objective was to determine if insurance and pregnancy status were barriers to obtaining access to OAT in 4 Appalachian states disproportionately impacted by the opioid epidemic. Methods: Between April and May 2017, we conducted phone surveys of OAT providers, opioid treatment programs (OTPs), and outpatient buprenorphine providers, in Kentucky, North Carolina, Tennessee, and West Virginia. Survey response rates were 59%. Logistic models for dichotomous outcomes (e.g., patient acceptance) and negative binomial models were created for count variables (e.g., wait time), overall and for pregnant women. Results: The majority of OAT providers were accepting new patients; however, providers were less likely to treat pregnant women (91% vs. 75%; p < .01). OTPs were more likely to accept new patients than waivered buprenorphine providers (97% vs. 83%; p = .01); rates of accepting pregnant patients were lower in both (91% and 53%; p < .01). OTPs and buprenorphine providers accepted cash payments for services at high rates (OTP: 100%; buprenorphine: 89.4%; p < .01); Medicaid and private insurance were accepted at lower rates. In adjusted models, providers were less likely to accept pregnant women if they took any insurance (adjusted odds ratio [aOR] = 0.15, 95% confidence interval [CI]: 0.03–0.68) or were a buprenorphine provider (aOR = 0.09, 95% CI: 0.02–0.37). Conclusions: We found that OAT providers frequently did not accept any insurance and frequently did not treat pregnant women in an area of the country disproportionately affected by the opioid epidemic. Policymakers could prioritize improvements in provider training (e.g., training of obstetricians to become buprenorphine prescribers) as a means to enhance access to pregnant women or enhancing reimbursement rates as a means of improving insurance acceptance for OAT.

Keywords:

• Appalachia
• buprenorphine
• insurance
• Opioid agonist therapies (OAT)
• opioid use disorder (OUD)
• opioid treatment programs (OTPs)
• pregnant women

Acknowledgments

The authors would like to acknowledge Brad Stein, MD, the University of Chicago Survey Lab, and Mary White, MPH, for their contributions to this paper.

Additional information

Funding

Research reported in this publication was supported by the National Institute on Drug Abuse of the National Institutes of Health under award number K23DA038720. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The sponsor had no role in the design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript or the decision to submit.

Notes on contributors

Stephen W. Patrick

Dr. Patrick had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. S.W.P and W.O.C contributed to the study concept and design. S.W.P, M.B.B, T.A.S and W.O.C contributed to the acquisition, analysis, or interpretation of data. S.W.P contributed to the drafting of the manuscript. S.W.P, M.B.B, P.R.M, T.A.S, W.D, M.R and W.O.C contributed to the critical revision of the manuscript for important intellectual content. T.A.S and S.W.P contributed to the statistical analysis. S.W.P, M.B.B and W.O.C contributed to study supervision.

Melinda B. Buntin

Dr. Patrick had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. S.W.P and W.O.C contributed to the study concept and design. S.W.P, M.B.B, T.A.S and W.O.C contributed to the acquisition, analysis, or interpretation of data. S.W.P contributed to the drafting of the manuscript. S.W.P, M.B.B, P.R.M, T.A.S, W.D, M.R and W.O.C contributed to the critical revision of the manuscript for important intellectual content. T.A.S and S.W.P contributed to the statistical analysis. S.W.P, M.B.B and W.O.C contributed to study supervision.

Peter R. Martin

Dr. Patrick had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. S.W.P and W.O.C contributed to the study concept and design. S.W.P, M.B.B, T.A.S and W.O.C contributed to the acquisition, analysis, or interpretation of data. S.W.P contributed to the drafting of the manuscript. S.W.P, M.B.B, P.R.M, T.A.S, W.D, M.R and W.O.C contributed to the critical revision of the manuscript for important intellectual content. T.A.S and S.W.P contributed to the statistical analysis. S.W.P, M.B.B and W.O.C contributed to study supervision.

Theresa A. Scott

Dr. Patrick had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. S.W.P and W.O.C contributed to the study concept and design. S.W.P, M.B.B, T.A.S and W.O.C contributed to the acquisition, analysis, or interpretation of data. S.W.P contributed to the drafting of the manuscript. S.W.P, M.B.B, P.R.M, T.A.S, W.D, M.R and W.O.C contributed to the critical revision of the manuscript for important intellectual content. T.A.S and S.W.P contributed to the statistical analysis. S.W.P, M.B.B and W.O.C contributed to study supervision.

William Dupont

Dr. Patrick had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. S.W.P and W.O.C contributed to the study concept and design. S.W.P, M.B.B, T.A.S and W.O.C contributed to the acquisition, analysis, or interpretation of data. S.W.P contributed to the drafting of the manuscript. S.W.P, M.B.B, P.R.M, T.A.S, W.D, M.R and W.O.C contributed to the critical revision of the manuscript for important intellectual content. T.A.S and S.W.P contributed to the statistical analysis. S.W.P, M.B.B and W.O.C contributed to study supervision.

Michael Richards

Dr. Patrick had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. S.W.P and W.O.C contributed to the study concept and design. S.W.P, M.B.B, T.A.S and W.O.C contributed to the acquisition, analysis, or interpretation of data. S.W.P contributed to the drafting of the manuscript. S.W.P, M.B.B, P.R.M, T.A.S, W.D, M.R and W.O.C contributed to the critical revision of the manuscript for important intellectual content. T.A.S and S.W.P contributed to the statistical analysis. S.W.P, M.B.B and W.O.C contributed to study supervision.

William O. Cooper

Dr. Patrick had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. S.W.P and W.O.C contributed to the study concept and design. S.W.P, M.B.B, T.A.S and W.O.C contributed to the acquisition, analysis, or interpretation of data. S.W.P contributed to the drafting of the manuscript. S.W.P, M.B.B, P.R.M, T.A.S, W.D, M.R and W.O.C contributed to the critical revision of the manuscript for important intellectual content. T.A.S and S.W.P contributed to the statistical analysis. S.W.P, M.B.B and W.O.C contributed to study supervision.