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5th District Footprint provides a spatial analysis of data relevant to community development in the Fifth District. The publication is available online quarterly.

5th District Footprint

November 2018

5th District Footprint logo

This issue of 5th District Footprint explores the question: To what extent do Fifth District residents have access to opioid treatment programs that help those with opioid use disorder?

Opioid Treatment Access in the Fifth District

From 1999 to 2017, more than 399,000 individuals in the U.S. died from a fatal opioid overdose.1 Although the total number of nonfatal opioid overdoses is unknown, the Centers for Disease Control and Prevention (CDC) reported that from July 2016 to September 2017, the number of nonfatal opioid overdoses treated in emergency rooms rose 30 percent.2 The ongoing opioid epidemic is of particular concern in the Fifth District – which includes the District of Columbia, Maryland, North Carolina, South Carolina, Virginia and most of West Virginia – because of the relatively high fatal and nonfatal overdose rates experienced in Fifth District localities.3 This issue of 5th District Footprint explores the question: To what extent do Fifth District residents have access to opioid treatment programs (OTPs) that help those with opioid use disorder?

A growing body of research exists on the economic costs of the opioid epidemic.4 While this continues to be an important research focus, this piece explores a component of the opioid epidemic that has received less attention from researchers: access to treatment. Opioid use disorder treatment can be a complex and harrowing process. Research from Harvard University suggests that it takes the average opioid use disorder patient eight years and five to six treatment attempts to achieve one year of sobriety and information from the National Institute on Drug Abuse indicates that one round of treatment costs, on average, $5,980 to $14,112 per year.5

OTPs vary in the strategies used to help patients recover with a key differentiating factor being the use of prescription medicines. Medication-assisted treatment (MAT) programs use federally-regulated prescription medications to address patients’ withdrawal symptoms while also offering counseling and behavioral therapy.6 Conversely, abstinence-only OTPs do not use prescription medicines and generally require patients to maintain sobriety for the duration of the program. This piece looks at proximity to MAT programs because the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) maintains a comprehensive directory of these OTPs, but not abstinence-only OTPs.7 OTPs run by the U.S. Department of Veterans Affairs (VA) have also been excluded because they cannot be accessed by the general population.

In 2017, the national drug overdose mortality rate was 21.7 individuals per 100,000, or 70,237 drug overdose deaths nationwide.8 This is a 9.6 percent increase from 2016 when the overdose mortality rate was 19.8 individuals per 100,000.9 While not all fatal overdoses are opioid overdoses, prescription and illicit opioids are currently the main drivers of the increasing national overdose mortality rate with opioid overdose deaths accounting for 67.8 percent of all drug overdose deaths in 2017 (47,600 deaths).10 As of 2017, West Virginia, Ohio, Pennsylvania and the District of Columbia had the highest overdose mortality rates in the country.11 All Fifth District states and the District of Columbia had an increase in overdose mortality rates from 2016 to 2017.12 At the same time, OTPs are reaching a relatively small percentage of individuals with opioid use disorder. In 2016, 579,528 of the estimated 2.1 million individuals with opioid use disorder nationwide (27.0 percent) were admitted to an OTP.13

The map displays proximity to an OTP in terms of distance, with the darkest green indicating areas that are within ten miles of an OTP and the lightest green indicating areas that are more than 60 miles from an OTP. As of August 2018, there are 225 OTPs in the Fifth District. State-level OTP counts range from five OTPs in the District of Columbia to 86 OTPs in Maryland.14 Thirty of Maryland’s OTPs are located in the city of Baltimore, making it the Fifth District locality with the highest concentration of OTPs. The city of Richmond, Virginia has the second highest concentration with seven OTPs.

The relative absence of OTPs in eastern West Virginia and northwestern Virginia may be explained by the location of the Monongahela, George Washington and Jefferson National Forests. Accordingly, a number of counties in this area have relatively low drug overdose mortality rates at fewer than 20 individuals per 100,000. However, Webster and Pocahontas Counties, West Virginia are outliers in this area as both counties have an overdose mortality rate of more than 30 individuals per 100,000. Similar explanatory factors do not necessarily exist for other parts of the Fifth District that are up to or more than 60 miles from the nearest OTP although low-OTP density areas in southern South Carolina, the western tips of Maryland and Virginia, and northern West Virginia may be covered by OTPs located in adjacent states.

Proximity to Opioid Treatment Programs by County, 2018

SOURCE: SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION OPIOID TREATMENT PROGRAM DIRECTORY, JULY 2018.

Note: By federal regulation, Opioid Treatment Programs (OTPs) must have valid accreditation status, certification from the Substance Abuse and Mental Health Services Administration (SAMHSA) and Drug Enforcement Administration (DEA) registration.The treatment centers dispense opioid drugs for the treatment of opioid addiction, which currently include methadone and pharmaceutical products containing buprenorphine. OTPs may dispense additional pharmaceutical products, such as naltrexone, in accordance with regulation and best medical practices. This map does not capture abstinence-only, faith-based or telehealth treatment programs or treatment programs run by the U.S. Department of Veterans Affairs.

When looking at the map, it is important to consider that OTP proximity captures just one dimension of access to treatment. Financial affordability, insurance coverage, access to transportation, mountainous terrain, program waiting lists and the need for additional services may also impact the degree to which individuals with opioid use disorder can access treatment. Although OTPs run by the VA are excluded from the map, veteran access to OTPs in the City of Fayetteville in Cumberland County, North Carolina provides a good example of further limitations to treatment access. Fayetteville borders Fort Bragg, the largest military base in the world, and is home to a large veteran population, but there is only one VA OTP in the immediate area. If that OTP is not accepting new patients, veterans must drive nearly sixty miles to the next-closest VA OTP.15

 
1

Opioid overdose deaths include those caused by prescription and illicit opioids. 2017 data are the most recent available from the CDC. “Drug Overdose Deaths in the United States, 1999-2017,” Centers for Disease Control and Prevention.

2

The 30 percent rise in opioid overdoses was calculated by the CDC using data from 52 areas in 45 states. “Opioid Overdoses Treated in Emergency Departments,” Centers for Disease Control and Prevention.

3

For additional information about the 2015 drug overdose mortality rate in the Fifth District, please see “The Opioid Epidemic in the Fifth District,” 5th District Footprint, Federal Reserve Bank of Richmond, November 2017.

4

For additional information about this body of research, see e.g. Waddell, Sonya Ravindranath, “The Opioid Epidemic, the Fifth District, and the Labor Force,” Econ Focus, Federal Reserve Bank of Richmond, Second Quarter 2018; Florence, C. S., C. Zhou, F. Luo and L. Xu, “The Economic Burden of Prescription Opioid Overdose, Abuse, and Dependence in the United States, 2013,” Med Care 54(10), October 2016; Brill, Alex and Scott Ganz, “The Geographic Variation in the Cost of the Opioid Crisis,” American Enterprise Institute Working Paper 2018-03, March 2018.

5

The average treatment costs cited refer to the average cost of medication-assisted treatment programs. “Dispatches From A 'Dopesick' America,” Fresh Air, National Public Radio, August 21, 2018; “How Much Does Opioid Treatment Cost?” National Institute on Drug Abuse.

6

The prescription drugs approved for MAT by the U.S. Food and Drug Administration include buprenorphine products, methadone products and naltrexone products. “Information about Medication-Assisted Treatment (MAT),” U.S. Food and Drug Administration.

7

The SAMHSA OTP directory can be found at dpt2.samhsa.gov/treatment/directory.aspx.

8

Drug Overdose Deaths in the United States, 1999-2017,” Centers for Disease Control and Prevention.

9

Ibid.

10

Ibid.

11

Ibid. In 2017 the overdose mortality rates for West Virginia, Ohio, Pennsylvania and the District of Columbia were 57.8 individuals per 100,000, 46.3 individuals per 100,000, 44.3 individuals per 100,000 and 44.0 individuals per 100,000, respectively.

12

Drug Overdose Death Data: 2016,” Centers for Disease Control and Prevention; "Drug Overdose Deaths in the United States, 1999-2017,” Centers for Disease Control and Prevention.

13

The total number of individuals with opioid use disorder in 2016 is 2,144,000. “Treatment Episode Data Set (TEDS) 2016,” Department of Health and Human Services Substance Abuse and Mental Health Services Administration, August 2018; “Results from the 2016 National Survey on Drug Use and Health: Detailed Tables,” Department of Health and Human Services Substance Abuse and Mental Health Services Administration Center for Behavioral Health Statistics and Quality, 2017.

14

Of the 225 OTPs in the Fifth District, five could not be geocoded and so are not represented on the map. Of the five OTPs not represented on the map, one is in Maryland, three are in South Carolina and one is in Virginia.

15

Substance Use Disorder (SUD) Program Locator,” U.S. Department of Veterans Affairs.

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