By Amanda Gomez

Stigma toward people who use drugs often obscures valuable information on harm reduction and mischaracterizes treatment options for this community. Medications for opioid use disorder (MOUDs), formerly known as medication-assisted treatment (MAT), are critical tools for the treatment of opioid use disorder. As North Carolina counties begin allocating opioid settlement funds, it is imperative that local leaders understand how MOUDs can support a patient’s treatment plan and recovery goals.

The ADA and OUD

The Americans with Disabilities Act (ADA) prohibits discrimination on the basis of disability in several areas, including employment, transportation, public accommodations, communications, and access to government programs and services. Under this law, a disability is defined as “1) a physical or mental impairment that substantially limits one or more major life activities, including major bodily functions; 2) a record of such an impairment; or 3) being regarded as having such an impairment.” People with opioid use disorder (OUD) typically have a disability because addiction limits major life activities and is considered a physical or mental impairment. Additionally, the ADA protects individuals who are in recovery and would be limited in a major life activity in the absence of treatment and/or services that support their recovery. For example, a health facility that refuses to admit a patient because they take a prescribed medication for opioid use disorder and prohibits all patients from taking these medications would be in violation of the ADA.

However, it is important to note that the ADA does not protect individuals engaged in the current illegal use of substances. For example, an employer may refuse to hire an applicant because of a drug test indicating current or recent substance use and would not be in violation of the ADA.

What are MOUDs?

Three medications for opioid use disorder (MOUDs) are approved by the U.S. Food and Drug Administration for the treatment of OUD: methadone, buprenorphine, and naltrexone. These medications reduce withdrawal symptoms and opioid cravings. MOUDs are considered the gold standard treatment for OUD, with or without concurrent counseling and behavioral interventions. Increasing access to MOUDs is consistent with the harm reduction framework. Harm reduction is a way of preventing disease and promoting health that “meets people where they are” rather than making judgments about where they should be in terms of their personal health and lifestyle.

Methadone

Methadone (e.g., Methadose, Dolophine) is a full opioid agonist, meaning it generates a full opioid effect. It is a Schedule II medication that has been used as a maintenance therapy for OUD since the 1950s. Methadone can only be dispensed through a certified Opioid Treatment Program (OTP). The Substance Abuse and Mental Health Services Administration (SAMHSA) accredits and certifies OTPs, allowing them to dispense all FDA-approved MOUDs and provide counseling to their patients.

Buprenorphine

Buprenorphine is a partial agonist and generates a partial opioid effect. It is a Schedule III medication and has been approved by the FDA to treat OUD since 2002. Two common buprenorphine medications are Subutex and Suboxone. Physicians, physician assistants, and nurse practitioners obtain a special waiver from SAMHSA in order to prescribe and dispense buprenorphine. This medication is administered as an office-based opioid treatment (OBOT), which also includes a chronic disease visit and other medical and psychosocial interventions.

Naltrexone

Naltrexone (e.g., Vivitrol, ReVia) is an opioid antagonist and blocks activation of opioid receptors. It is not a controlled substance and has been used to treat OUD since 1984. Any health care provider who can prescribe medications can prescribe naltrexone in any health setting.

There are a few issues with the use of naltrexone for OUD. First, a patient must be abstinent from opioids for 7-10 days before beginning naltrexone. Additionally, opioid tolerance fades within naltrexone patients, leading to a risk of overdose and death among those who return to use at levels used previously. Finally, both methadone and buprenorphine may be more effective in preventing overdose and death among people with opioid use disorder.

What about MAT?

Medication-assisted treatment (MAT) refers to the use of the medications listed above for OUD. This term can imply that medication’s role in treatment for OUD is only supplemental or temporary. However, the use of MOUD more closely aligns with the way other medications are understood to be used in the treatment and management of ongoing chronic conditions (e.g., antidepressants, antihypertensives).

Implications for North Carolina

Since the launch of North Carolina’s Opioid Action Plan (OAP) in 2017, over 21,000 people without insurance have received OUD treatment through federally funded programs. The OAP also established four jail-based treatment programs and launched medical residency training projects that have provided buprenorphine waiver training to over 1,000 prescribers in the state. Early studies of state data show that buprenorphine prescription rates are associated with reductions in opioid mortality at the county level.

In July 2021, Attorney General Josh Stein announced a historic $26 billion national settlement with three drug distributers and one manufacturer. Approximately $750 million is available to address the opioid epidemic in North Carolina. As counties begin to make decisions about opioid settlement fund allocations, it is important that local leaders are equipped with information on evidence-based strategies and an adequate understanding of relevant public health targets and policies. The North Carolina Institute of Medicine’s Healthy North Carolina 2030 report set a goal to reduce the state drug overdose death rate from 20.4 to 18.0 (per 100,000 population) by 2030. Between 2000 and 2020, over 28,000 North Carolinians died from drug overdose, and deaths grew during the COVID-19 pandemic. Additionally, the most recent OAP (3.0) has built upon previous objectives to include centering equity and lived experience of people who use drugs, addressing trauma and its relationship to OUD, reducing harm among people who use multiple substances, and connecting more people to care (e.g., justice-involved persons). The NCIOM will continue supporting these efforts by convening county-level stakeholders, conducting key perspective interviews and focus groups, and otherwise supporting local planning for substance use disorder and overdose prevention strategies. To learn more about this collaborative process, click here.