A new study of organizations that claim to provide residential opioid substance use services in North Carolina found that only 12% of the organizations were licensed by the state to provide residential substance use treatment. What’s more, only about a quarter of the organizations even allowed patients to access the only treatment for opioid use disorder proven to reduce overdose deaths.
“We wanted to know how many organizations in North Carolina that purport to provide residential opioid substance use services actually provide patients with evidence-based treatment or allow patients to access evidence-based treatment services,” says Jennifer Carroll, lead author of the study and an associate professor of anthropology at North Carolina State University. “Specifically, we wanted to know how many of these organizations allowed patients to access opioid agonist treatment (OAT).”
OAT refers to treatment services that use FDA-approved opioid medications, such as methadone or buprenorphine, to treat addiction and help patients cease illicit substance use.
“We focused on OAT because OAT programs have better outcomes than other treatments by virtually every measure – and have also been proven to cut the risk of overdose deaths in half,” Carroll says.
For the study, researchers conducted a statewide inventory of residential substance use service providers in North Carolina. The researchers then had “secret shoppers” pose as people seeking help for heroin addiction and call every organization that claimed to provide residential services for opioid use disorder, with the goal of learning more about what services the different programs offered. The researchers identified 82 providers. Sixteen of the providers declined to answer any questions when contacted. The remaining 66 answered some or all of the questions from the researchers.
The study found that only seven of the organizations provided OAT to patients on site, while an additional nine organizations allowed patients to access OAT through an outside or community-based prescriber. In addition, only eight of the providers were licensed to provide residential substance use treatment.
“Thousands of North Carolinians die of opioid overdoses every year,” Carroll says. “And most of the places in North Carolina that people might turn to for help don’t allow patients to access the treatment that is most likely to help them stay alive and treat their opioid use disorder.
“What’s more, we found that 33 – fully half – of the organizations we talked with were dismissive of OAT services.”
The researchers also found that 20 of the service providers fit a very specific profile: they were faith-based organizations that were not licensed to provide any form of substance use-related services, barred access to OAT, and required patients to work without pay – often for businesses that were owned and operated by the organization itself.
“The fact that the most common residential substance use service providers in the state are not licensed in any way, do not allow patients to access OAT, and frequently profit from the unpaid labor of the patients they serve is deeply troubling,” says Carroll.
“These findings suggest that public health would benefit from a rigorous assessment of the substance use treatment services being provided in North Carolina and the regulations that govern those services.”
The study, “Evidence-based treatment for opioid use disorder is widely unavailable and often discouraged by providers of residential substance use services in North Carolina,” is published open access in the Journal of Substance Use & Addiction Treatment.
The paper was co-authored by Sarah Dixon, a former graduate student at NC State; Brandon Morrissey, a Ph.D. student at NC State; Nabarun Dasgupta of the University of North Carolina Chapel Hill; Bayla Ostrach of Boston University and Fruit of Labor Action Research and Technical Assistance, LLC; Taleed El-Sabawi of Florida International University; and Roxanne Saucier of the Open Society Foundations.
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Note to Editors: The study abstract follows.
“Evidence-based treatment for opioid use disorder is widely unavailable and often discouraged by providers of residential substance use services in North Carolina”
Authors: Jennifer J. Carroll, Sarah Dixon and Brandon Morrissey, North Carolina State University; Nabarun Dasgupta, University of North Carolina Chapel Hill; Bayla Ostrach, Boston University and Fruit of Labor Action Research and Technical Assistance, LLC; Taleed El-Sabawi, Florida International University; Roxanne Saucier, Open Society Foundations
Published: Aug. 22, Journal of Substance Use & Addiction Treatment
DOI: 10.1016/j.josat.2024.209474
Abstract:
Introduction
Opioid agonist treatment (OAT) is the only treatment for opioid use disorder (OUD) proven to reduce overdose mortality, yet access to this evidence-based treatment remains poor. The purpose of this cross-sectional audit study was to assess OAT availability at residential substance use services in North Carolina.
Methods
We conducted a state-wide inventory of residential substance use service providers in North Carolina and subsequently called all providers identified, posing as uninsured persons who use heroin, seeking treatment services. Program characteristics, as reported in phone calls, were systematically recorded. We used Fisher’s exact tests to assess what program characteristics were associated with OAT availability and with staff making discouraging comments about OAT. We used unsupervised agglomerative clustering to identify facilities with similar characteristics.
Results
Of the 94 treatment providers identified, we successfully contacted and collected data from 66. Of those, only 7 (10.6%) provide OAT on site; an additional 9 (13.6%) allow OAT through an outside or community-based prescriber. Only 8 (12.1%) providers were licensed to provide residential substance use treatment. Staff from 33 (50.0%) providers made negative, discouraging, or stigmatizing remarks about OAT—for example, that OAT substitutes one addiction for another or does not constitute “true recovery.” OAT availability was positively associated with a provider holding a state license for any substance use-related service (41.9% vs 8.6%, p=0.002) and offering 12-step programming (36.1% vs. 10/0%, p=0.020). OAT availability was negatively associated with faith-based programming (6.1% vs 42.4%, p=0.001), dress codes (5.3% vs 50.0%, p<0.001), and mandates that residents work in a provider-owned and -operated commercial enterprise (5.0% vs 32.6%, p=0.026). Cluster analysis revealed that the most common (n=21) type of service provider in North Carolina is an unlicensed, faith-based organization that prohibits OAT, imposes a dress code, and mandates that residents work, often in provider-owned and -operated commercial enterprises.
Conclusion
Evidence-based treatments for OUD are largely unavailable at providers of residential substance use services in North Carolina. The prohibition of OAT occurs most often among providers who are unlicensed and impose labor and/or 12-step mandates on residents. Changes to state licensure requirements and exemptions may help improve OAT availability.
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