Miles Away From Help

Colorado continues to struggle with epidemic levels of opioid abuse and opioid overdose deaths, but a treatment method that has been shown to be especially effective is unavailable in nearly half of the state’s counties.

A new analysis by the Colorado Health Institute (CHI) finds that 31 of the state’s 64 counties do not have a location that provides medication-assisted treatment, or MAT, a clinically proven approach that combines medication and social support services. An additional 15 counties have just one site.

Ten of the 31 counties without a treatment location had overdose death rates well above the state rate.

The CHI analysis also shows that:

• About 304,000 people live in the 31 counties without a treatment location. Another 236,000 people live in the 15 counties with just one site.
• This means that 540,000 Coloradans, about one of 10 residents, live in places with little or no access to medication-assisted treatment.
• Measured another way, significant parts of northwest, southwest and southeast Colorado are farther than 30 miles from a treatment center, and most of these areas have seen rising drug overdose death rates.

There is hopeful news, however. Additional federal funding is coming to Colorado this year to help increase access to medication-assisted treatment. And the Colorado legislature passed several bills that would increase provider training and enhance the state’s behavioral health crisis response system.

This issue brief, the first in a series on the opioid epidemic in Colorado, analyzes the number of Coloradans struggling with addiction and the geographic variation in treatment availability.

The Opioid Epidemic: An Overview

Overdose deaths from all drugs more than tripled in the U.S., to more than 52,000, between 1999 and 2015.¹ Nationally, 63 percent of all drug overdose deaths in 2015 involved an opioid² — either prescription drugs such as codeine and oxycodone or illicit drugs such as heroin. Prescription overdose deaths rose steadily between 1999 and 2015. The percentage of deaths from heroin tripled between 2010 and 2015 alone.³

States have seen increases in drug abuse and dependence along with overdose deaths. Colorado is no exception. Between 2011 and 2014, an annual average of about 22,000 Coloradans (5.0 per 1,000 residents ages 12 and older) said they abused or had a dependence on opioids, including heroin. Overdose death rates for all drugs increased in each Colorado county except Mineral between 2002 and 2014, according to a previous analysis by CHI.

Prescription opioid addiction has begun to level off while heroin has become a more significant problem. Between 2011 and 2015, heroin-related overdose deaths increased 93 percent, from 1.5 deaths per 100,000 Colorado residents to 2.9 per 100,000.⁴ Colorado counted 472 opioid-related overdose deaths in 2015⁵ — more than quadruple the number in 1999.

What is Medication-Assisted Treatment?

There are treatment options for people addicted to opioids and at risk of an overdose.

Medication-assisted treatment is an evidence-based approach to treating opioid addiction with a combination of medication and psychosocial support services such as counseling. Respected scientific sources, including the Centers for Disease Control and Prevention, the National Institute on Drug Abuse and the Substance Abuse and Mental Health Services Administration (SAMHSA), all recommend medication-assisted treatment for opioid addiction.

Methadone, buprenorphine and naltrexone are the three types of medication approved for treating opioid addiction.

Medication-assisted treatment takes a holistic approach to treating the patient. Medication manages physical withdrawal or reduces cravings while counseling and other recovery support services address the psychological symptoms of addiction.

Medication-assisted treatment is effective at reducing the potential for relapse. It is proven to show better outcomes than programs without medication or medication alone. These outcomes include higher employment rates, reduced relapse rates and lower rates of overdoses and overdose-related deaths.^8,9

But medication-assisted treatment is not a short-term solution. It does not generally improve outcomes if delivered for less than 90 days. One study indicates people who receive treatment for less than three years are more likely to relapse than those who receive treatment for more than three years.¹⁰ Like other chronic conditions, opioid addiction typically requires lifetime management to sustain recovery.

Studies show that despite being effective, medication-assisted treatment is still significantly underutilized. There are many possible explanations for this. Patients and families may feel stigmatized by participating in a treatment program. The approach is not always widely available, and providers may not be aware of it or may lack proper training to administer medication-assisted treatment.

Opioid Use in Colorado

People can become addicted to opioids in a variety of ways. For example, some chronic pain sufferers who receive opioid prescriptions over long time periods can develop a tolerance, leading to a need for higher dosages and potentially addiction. Some people might use prescriptions written for friends or family members. And there are many other ways a person might abuse or become addicted to opioids.

An analysis by the federal Center for Behavioral Health Statistics and Quality found that an average of about 22,000 Coloradans reported dependence on opioids, including heroin, each year between 2011 and 2014.

Increased opioid prescribing is associated with increased dependence and overdose deaths. Table 1 shows higher rates of dependence on pain relievers in 2003-2006 period, at 7.9 per 1,000 Coloradans. The rate dropped by nearly half between 2007 and 2010, and it held steady at 4.5 per 1,000 between 2011 and 2014. Recent studies indicate that efforts to reduce overprescribing of opioids, such as provider education, have begun to show signs of success, which may help to explain the leveling off in Colorado.¹¹

However, heroin is stoking the opioid epidemic. Rates of dependence in Colorado tripled from 2007 to 2010 and nearly doubled again between 2011 and 2014.

Heroin-related hospitalization rates increased by 41 percent, and the rate of heroin-related emergency department visits more than doubled from 2011 to 2014.¹³

Treatment in Colorado

There is a successful evidence-based approach to treating opioid addiction. So why aren’t more people receiving help?

Approximately 304,000 Coloradans ages 12 and older live in 31 counties with no Opioid Treatment Program (OTP) or buprenorphine prescriber.¹⁴ An additional 15 of the state’s 64 counties, with a combined population of 236,000, have only one treatment provider. (See Map 1.)

However, not everyone seeks care in their own county, particularly if the closest provider is one county over. CHI mapped how much of the state was within 30 miles of an opioid treatment location, shown in Map 2, to account for this.

The northwest, southwest and southeastern corners of the state are all notably outside the radius. So are parts of Gunnison, Archuleta, Hinsdale, Ouray and Mineral counties. These may be sparsely populated areas, but all except Mineral have seen rising drug overdose death rates.

Additionally, 10 of the 31 counties with no treatment locations had overdose death rates well above the state rate (16.3 per 100,000) in 2014 (Table 2). Overdose deaths are not a perfect proxy for the number of people who might need treatment, but they do highlight the dangers of substance abuse and addiction.

In Colorado, 4,000 of the 22,000 people dependent on opioids — or about one of five — received treatment at a specialty facility such as a hospital, inpatient or outpatient drug or alcohol rehabilitation facility (including OTPs) or a mental health center. Some patients received treatment with either buprenorphine or naltrexone in an office-based setting, but there is no publicly available data on how many.

Barriers to and Opportunities for Providing Treatment

Nationally, an estimated 2.5 million people meet the criteria for opioid addiction and could benefit from medication-assisted treatment, but just under one million people are receiving it.¹⁶

The lack of providers willing or able to provide treatment is a significant barrier.

Barrier: Workforce

Between 44 and 66 percent of physicians trained and authorized to provide medication-assisted treatment do not prescribe it.¹⁷ Reasons vary, with the most common being not enough office and nursing support, reimbursement issues, insufficient staff knowledge and lack of available mental health services such as counseling.^18,19

It can be difficult or too costly for many primary care practices, especially in rural counties, to recruit and retain the appropriate staff, including counselors. Regulations also limit the type of practitioners who can provide medication-assisted treatment and the size of the patient population they can treat.

To prescribe buprenorphine, for example, physicians must take an eight-hour training course and apply to SAMHSA for approval. In year one, they can only treat up to 30 patients at a time. After the first year, they can apply to serve up to 100 patients at a time and more after that. At the lower patient limit, anecdotal evidence suggests doctors may not be willing to spend the time or money to hire additional staff that medication-assisted treatment requires.

Psychiatrists are most likely to be authorized to prescribe medication-assisted treatment, at 16 percent, compared with only three percent of primary care physicians nationwide. Rural residents typically rely on primary care providers²⁰ for their health care needs, so they may not have ready access to a doctor able to treat opioid addiction.

Methadone is available solely through an Opioid Treatment Program certified by SAMHSA. These are commonly referred to as methadone clinics. Colorado has 20 certified opioid treatment programs, about the same number as states with similar population sizes. They are mostly located in urban areas.

Opportunity: Insurance Coverage

Substance use treatment, including medication-assisted treatment, is a part of the essential health benefits package outlined by the Affordable Care Act (ACA) and covered by Medicaid. There is evidence that coverage gains under the ACA have improved outcomes for people with substance use disorders or mental health conditions.²¹

However, even though health insurance covers these services, there is still a shortage of available providers and other complications:

• Many substance use treatment providers do not accept Medicaid.
• Not all insurance plans cover all types of medication-assisted treatment.
• Many plans have limits on dosages or number of refills.²²
• Some plans have minimal counseling coverage or “fail first” criteria, which means a patient must have tried and failed a different type of treatment first before medication-assisted treatment is covered.²³

These limitations can lead to difficulty finding a treatment provider or paying for the appropriate services.

Opportunity: Regulations and Legislation

A regulation issued by SAMHSA in July 2016 allows approved providers to apply to treat up to 275 patients. This will allow physicians who are at or near the 100-patient limit to accept more patients. Many who are not prescribing or only prescribing to a few patients at a time might take advantage of the opportunity to scale up the treatment portion of their practice.

The Comprehensive Addiction and Recovery Act passed in July 2016 allows nurse practitioners and physician assistants to provide buprenorphine with additional training. This change could have a significant impact on Colorado’s shortage of medication-assisted treatment providers, as nurse practitioners and physician assistants are more likely to work in rural areas than physicians.²⁴

Recent Developments

The lack of access to opioid treatment in Colorado and nationwide has not gone unnoticed. Additional resources are coming to Colorado to help tackle the problem, and the General Assembly considered several pieces of legislation related to treatment this year.

Congress passed the 21st Century Cures Act in December 2016, which dedicated $1 billion over two years to combat the opioid epidemic. Colorado is set to receive $7.8 million each year for the next two years.²⁵ The funding will support medication-assisted treatment for uninsured and indigent patients, buprenorphine training for providers, family services and hospital emergency rooms starting people on buprenorphine.

The University of Colorado Denver received a grant from the federal Agency for Healthcare Research and Quality to expand access to medication-assisted treatment across 24 rural counties in eastern and southern Colorado. The project will provide primary care practices with face-to-face coaching and tele-training to deliver medication-assisted treatment.²⁶

The Colorado General Assembly passed Senate Bill 17-074, which creates a pilot program to expand access to medication-assisted treatment in Pueblo and Routt counties by providing grants to train nurse practitioners and physicians assistants.

Also passed was SB 17-207, which establishes a coordinated response system to keep people having a behavioral health crisis — including one arising from substance use — from ending up in jail or prison. SB 17-193 establishes a center for research into substance use disorder prevention, treatment and recovery strategies, and House Bill 17-1351 requires the Department of Health Care Policy and Financing in collaboration with the Department of Human Services to come up with options for residential and inpatient substance use disorder treatment under Colorado’s Medicaid program.

In April, the legislature also created an interim study committee to examine prevention, harm reduction, treatment and recovery support strategies for opioid and other substance dependence in Colorado.²⁷

Other work has been underway for several years. The Colorado Consortium for Prescription Drug Abuse Prevention was created in 2013 to establish a statewide response to the prescription drug epidemic. It also recently added a heroin work group in recognition of that rising problem.²⁸

The Consortium convened stakeholders to draft legislation aimed at increasing access to treatment. The group also produced a directory of opioid and heroin abuse coalitions and programs as well as a data dashboard to track the state’s progress in meeting goals outlined in the governor’s Colorado Plan to Reduce Prescription Drug Abuse.²⁹

Conclusion

Medication-assisted treatment is a proven, clinically effective treatment for opioid addiction. Even so, there is a shortage of medication-assisted treatment available in Colorado — especially in rural counties — and many Coloradans who need access to treatment for opioid addiction are not able to access it.

While there is significant activity underway to help address the epidemic, more work is needed to make sure everyone who wants treatment gets it.

End Notes

1 “Data Brief 273 Tables: Drug Overdose Deaths in the United States, 1999-2015.” National Center for Health Statistics, Centers for Disease Control and Prevention, February 2017.

2 Rose A. Rudd, MSPH; Puja Seth, PhD; Felicita David, MS; Lawrence Scholl, PhD. “Increases in Drug and Opioid-Involved Overdose Deaths – United States, 2010-2015.” Morbidity and Mortality Weekly Report, December 16, 2016.

3 Holly Hedegaard, MD, Margaret Warner, PhD, and Arialdi M. Miniño, MPH. “Drug Overdose Deaths in the United States, 1999–2015.” National Center for Health Statistics, Centers for Disease Control and Prevention, February 2017.

4 Heroin Response Work Group. “Heroin in Colorado: Preliminary Assessment.” April 2017.

5 “Poisoning deaths by selected categories: Colorado residents, 1999-2015.” Colorado Department of Public Health and Environment.

6 Christopher M. Jones, PharmD, MPH, Melinda Campopiano, MD, Grant Baldwin, PhD, MPH, and Elinore McCance-Katz, MD, PhD. “National and State Treatment Need and Capacity of Opioid Agonist Medication-Assisted Treatment.” American Journal of Public Health, June 11, 2015.

7 Lydia Aletraris, PhD, Mary Bond Edmond, PhD, and Paul M Roman, PhD. “Adoption of Injectable Naltrexone in U.S. Substance Use Disorder Treatment Programs.” Journal of Studies on Alcohol and Drugs, January 2015.

8 Nora D. Volkow, MD, Thomas R. Frieden, MD, MPH, Pamela S. Hyde, JD, and Stephen S. Cha, MD. “Medication-Assisted Therapies – Tackling the Opioid Overdose Epidemic.” New England Journal of Medicine, May 1, 2014.

9 Thomas F. Kresina and Robert Lubran. “Improving Public Health Through Access to and Utilization of Medication Assisted Treatment.” Int. J. Environ. Res. Public Health, October 24, 2011.

10 “Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health.” Office of the Surgeon General, U.S. Department of Health and Human Services, 2016.

11 Wilson M. Compton, MD, MPE, Christopher M. Jones, PharmD, MPH, and Grant T. Baldwin, PhD, MPH. “Relationship Between Nonmedical Prescription Opioid Use and Heroin Use.” New England Journal of Medicine, January 14, 2016.

12 Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, 2003- 2005, 2006-2008 (revised 3/12) and 2009-2010 (revised 3/12), 2011-2014.

13 Heroin Response Work Group. “Heroin in Colorado: Preliminary Assessment.” April 2017.

14 “Buprenorphine Treatment Physician Locator.” Substance Abuse and Mental Health Services Administration. Accessed April 25, 2017.

15 “Safety Alert: Health Risks Associated with Exposure to Clandestinely Produced Fentanyl.” Drug Enforcement Administration, March 2015.

16 Nora D. Volkow, MD, Thomas R. Frieden, MD, MPH, Pamela S. Hyde, JD, and Stephanie S. Cha, MD. “Medication-Assisted Therapies – Tackling the Opioid Overdose Epidemic.” New England Journal of Medicine, May 1, 2014.

17 Christopher M. Jones, PharmD, MPH, Melinda Campopiano, MD, Grant Baldwin, PhD, MPH, and Elinore McCance-Katz, MD, PhD. “National and State Treatment Need and Capacity of Opioid Agonist Medication-Assisted Treatment.” American Journal of Public Health, June 11, 2015.

18 Alexander Y. Walley, MD, MSc, Julie K. Alperen, DrPH, Debbie M. Cheng, ScD, Michael Botticelli, Carolyn Castro-Donlan, Jeffrey H. Samet, MD, MA, MPH, and Daniel P. Alford, MD, MPH. “Office-Based Management of Opioid Dependence with Buprenorphine: Clinical Practices and Barriers.” Journal of Internal Medicine, September 2008.

19 Eliza Hutchinson, BA, Mary Catlin, BSN, MPH, C. Holly A. Andrilla, MS, Laura-Mae Baldwin, MD, MPH, and Roger A. Rosenblatt, MD, MPH, MFR. “Barriers to Primary Care Physicians Prescribing Buprenorphine.” Annals of Family Medicine, March 2014.

20 Roger A. Rosenblatt, MD, MPH, MFR, C. Holly A. Andrilla, MS, Mary Catlin, BSN, MPH, Eric H. Larson, PhD. “Geographic and Specialty Distribution of US Physicians Trained to Treat Opioid Use Disorder.” Annals of Family Medicine, January/February 2015.

21 “Continuing Progress on the Opioid Epidemic: The Role of the Affordable Care Act.” Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, January 11, 2017.

22 “Insurance and Payments.” Substance Abuse and Mental Health Services Administration. Accessed April 4, 2017.

23 Nora D. Volkow, MD, Thomas R. Frieden, MD, MPH, Pamela S. Hyde, JD, and Stephen S. Cha, MD. “Medication-Assisted Therapies – Tackling the Opioid Overdose Epidemic.” New England Journal of Medicine, May 1, 2014.

24 Prevention and Chronic Care Program. “Primary Care Workforce Facts and Stats No. 3.” Agency for Healthcare Research and Quality, January 2012.

25 “Trump Administration awards grants to states to combat opioid crisis.” U.S. Department of Health and Human Services. April 19, 2017.

26 “Increasing Access to Medication-Assisted Treatment of Opioid Abuse in Rural Primary Care Practices.” Agency for Healthcare Research and Quality. Accessed April 3, 2017.

27 “Legislative Request For Interim Study Committee.” State of Colorado, April, 2017.

28 “Colorado Consortium for Prescription Drug Abuse Prevention.”

29 “Colorado Plan to Reduce Prescription Drug Abuse.” Office of Governor John Hickenlooper, September 2013.

A version of this report with additional material is available in PDF form by clicking the link at the bottom of this page.