Lowering the Barriers to Medication Treatment for People with Opioid Use Disorder: Evidence for a Low-Threshold Approach

Overdose deaths have reached unprecedented levels in the U.S., despite effective medications to treat opioid use disorders (OUDs). Because the regulatory and administrative barriers to treatment are high, only about 11% of people with OUD receive effective medications, which include buprenorphine, methadone, and naltrexone. In response, clinicians and advocates have looked to a “low-threshold” approach that reduces the stigma surrounding effective medications and facilitates their use. This brief summarizes the barriers to treatment, the evidence on the low-threshold approach, and areas for future research. The evidence suggests that low-threshold approaches can increase access to treatment, with outcomes comparable to high-barrier, standard care. Policymakers, providers, and payers should lower the barriers to medication treatment through regulatory flexibility (including telehealth prescribing), and harm reduction strategies that de-emphasize abstinence and place a priority on initiating or re-initiating treatment whenever and wherever individuals are ready to do so

Improving health equity and ending the HIV epidemic in the USA: a distributional cost-effectiveness analysis in six cities

In the USA, Black and Hispanic or Latinx individuals continue to be disproportionately affected by HIV. Applying a distributional cost-effectiveness framework, we estimated the cost-effectiveness and epidemiological impact of two combination implementation approaches to identify the approach that best meets the dual objectives of improving population health and reducing racial or ethnic health disparities. We adapted a dynamic, compartmental HIV transmission model to characterise HIV micro-epidemics in six US cities: Atlanta, Baltimore, Los Angeles, Miami, New York, and Seattle. We considered combinations of 16 evidence-based interventions to diagnose, treat, and prevent HIV transmission according to previously documented levels of scale-up. We then identified optimal combination strategies for each city, with the distribution of each intervention implemented according to existing service levels (proportional services approach) and the racial or ethnic distribution of new diagnoses (between Black, Hispanic or Latinx, and White or other ethnicity individuals; equity approach). We estimated total costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios of strategies implemented from 2020 to 2030 (health-care perspective; 20-year time horizon; 3% annual discount rate). We estimated three measures of health inequality (between-group variance, index of disparity, Theil index), incidence rate ratios, and rate differences for the selected strategies under each approach. In all cities, optimal combination strategies under the equity approach generated more QALYs than those with proportional services, ranging from a 3·1% increase (95% credible interval [CrI] 1·4–5·3) in New York to more than double (101·9% [75·4–134·6]) in Atlanta. Compared with proportional services, the equity approach delivered lower costs over 20 years in all cities except Los Angeles; cost reductions ranged from $22·9 million (95$579·8 million (255·4–940·5 million) in Atlanta. The equity approach also reduced incidence disparities and health inequality measures in all cities except Los Angeles. Equity-focused HIV combination implementation strategies that reduce disparities for Black and Hispanic or Latinx individuals can significantly improve population health, reduce costs, and drive progress towards Ending the HIV Epidemic goals in the USA. National Institute on Drug Abuse