Lack of Person-Centered Research Impedes Rural Access to OUD Meds

    Across the United States, people face many barriers to accessing medications for opioid use disorder (MOUD). This is often particularly pronounced in rural parts of the country, given a slew of hurdles such as limited health care provider knowledge, a dearth of services in harm reduction “deserts,” and stigma surrounding substance use.

    But new research, published in the International Journal of Drug Policy, also suggests that there are major knowledge gaps surrounding rural Americans’ access to lifesaving drugs like methadone and buprenorphine.

    According to the review, while some existing studies broadly compare access by rurality, there’s a lack of research into specific regions or localities—and critically, of research that centers patient experiences in those different places.

    “We know that patients in rural areas are even less likely to get on one of these medications.”

    “Getting on a medication for opioid use disorder can really be lifesaving. But it’s extremely difficult,” Tanner Bommersbach told Filter. A psychiatry fellow at the Mayo Clinic in Rochester, Minnesota, he is one of the authors of the new research. “And we know that patients in rural areas are even less likely to get on one of these medications.”

    Bommersbach and his team began considering this in 2021, and subsequently performed a “scoping review” of existing literature on access to MOUD in both rural and urban locales. Bommersbach explained that this process, which attempts to appraise the strengths and weaknesses of research on a particular topic, differs from a regular “systematic review,” which tries to answer a specific question.

    As they embarked on this review in 2022, the team searched online journals for peer-reviewed articles, and the broader internet for “gray” literature—things like reports and studies out of various professional or government organizations that may not necessarily be peer-reviewed like academic research. They also conferred with around 20 subject-matter experts to do a kind of quality check on their results, and asked them to provide any other papers they might have missed.

    At first, the team came up with 3,963 unique papers, but after removing those that didn’t fit the scope of their work, they ended up with 147.

    “This paper represents the most comprehensive overview of this topic thus far. That’s why we go to these great lengths of searching all these different ways to try to find every possible piece of information related to this topic,” Paul Joudrey, an assistant professor at the University of Pittsburgh’s School of Medicine and another of the paper’s authors, told Filter.

    According to Bommersbach, there were a few different (and not mutually exclusive) categories that the papers fell into: papers about MOUD access in rural or urban settings, and papers that looked at MOUD access through the lens of either personal factors or factors in the health care system.

    The overwhelming majority of the papers (96 percent) examined health care factors such as the existence of MOUD programs in an urban or rural area. Only 20 percent looked at patient factors—things like people’s physical ability to get to a clinic (which can be a challenge in some cities as well) using private or public transportation; people recognizing that they want to access MOUD; and whether or not people can afford the medications.

    In general, rural areas had fewer MOUD providers, the paper found, which is no surprise. But how these personal and health care factors vary from one rural community to the next, it noted, is still poorly understood.

    One of the patient-based factors impacting MOUD access is whether or not a potential patient knows or feels that they want to go on methadone or a similar medication. According to Joudrey, there’s little knowledge around how or why people decide to seek such treatment. Additionally, patients in any given small town or remote community may or may not be aware of the lengthy process involved in obtaining treatments.

    “In order for someone to really have meaningful access to treatment, you need to break down access into its smaller components,” Joudrey said. “Because any breakdown along this chain of events that’s needed to receive the medication can prevent someone from going into treatment.”

    “We don’t have a lot of data from the patient’s perspective, and that probably is hampering our efforts to meaningfully improve access.”

    The paper noted that this lack of research could hinder providers in meeting clients’ needs. Without understanding issues like transportation challenges, regional differences and others, policymakers and service providers can’t adequately tailor their approaches to their communities.

    “We don’t have a lot of data from the patient’s perspective, and that probably is hampering our efforts to really meaningfully improve access,” Bommersbach said.

    Going forward, the authors said that there needs to be more effort into reaching out to people who use drugs—particularly outside of cities—and talking to them about what personal factors influence their ability to get MOUD. And more research at a local or area level is needed to help policymakers better understand, serve and engage with people who use drugs in specific geographical settings.

    “I think for all of us in this field, this is a moment to pause and look for opportunities to really prioritize these approaches,” Bommersbach said, “and really center our measurement of access from the patient’s perspective.” 



    Photograph via Rawpixel/Public Domain

    • Doug is a writer, editor and journalist whose work has appeared in National Geographic, Undark Magazine, New Scientist and Hakai, among others. He lives in Alberta, Canada.

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