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Choe S, Agley J, Elam K, Bidulescu A, Seo DC. Identifying predictors of multi-year cannabis vaping in U.S. Young adults using machine learning. Addict Behav 2024; 160:108167. [PMID: 39341185 DOI: 10.1016/j.addbeh.2024.108167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 09/14/2024] [Accepted: 09/14/2024] [Indexed: 09/30/2024]
Abstract
INTRODUCTION Increasing number of current cannabis users report using a vaporized form of cannabis and young adults are most likely to vape cannabis. However, the number of studies on cannabis vaping is limited, and predictors of cannabis vaping among U.S. young adults remain unclear. Previous studies on cannabis vaping have known limitations, as they (1) relied heavily on regression-based approaches that often fail to examine complex and non-linear interactive effects, (2) focused on examining cannabis vaping initiation but not on its use over multiple years, and (3) failed to account for recreational cannabis legalization (RCL) status. METHODS This study was a secondary analysis of the restricted use files of the Population Assessment of Tobacco and Health Study, Waves 4-6 (December 2016-November 2021). A two-stage machine learning approach, which included Least Absolute Shrinkage and Selection Operator (LASSO) and Classification and Regression Tree (CART), was used to identify predictors of multi-year cannabis vaping while accounting for state-level RCL status among a representative sample of U.S. young adults. RESULTS Stratified CART created a five-terminal-node prediction model for states with RCL (split by cannabis use, cigarette use, bullying behavior, and ethnicity) and a different five-terminal-node prediction model for states without RCL (split by cannabis use, heroin use, nicotine vaping, and hookah use). CONCLUSIONS Characteristics predicting multi-year cannabis vaping appear to differ from those of cannabis vaping initiation. Results also highlight the importance of accounting for RCL status because predictors of cannabis vaping may differ for individuals living in states with and without RCL.
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Affiliation(s)
- Siyoung Choe
- Department of Applied Health Science, Indiana University School of Public Health, 1025 E. 7th St., Bloomington, IN 47405-7109, USA.
| | - Jon Agley
- Department of Applied Health Science, Indiana University School of Public Health, 1025 E. 7th St., Bloomington, IN 47405-7109, USA.
| | - Kit Elam
- Department of Applied Health Science, Indiana University School of Public Health, 1025 E. 7th St., Bloomington, IN 47405-7109, USA.
| | - Aurelian Bidulescu
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health, 1025 E. 7th St., Bloomington, IN 47405-7109, USA.
| | - Dong-Chul Seo
- Department of Applied Health Science, Indiana University School of Public Health, 1025 E. 7th St., Bloomington, IN 47405-7109, USA.
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Ibragimov U, Giordano NA, Amaresh S, Getz T, Matuszewski T, Steck AR, Schmidt M, Iglesias J, Li Y, Blum EH, Glasheen DA, Tuttle J, Pipalia H, Cooper HLF, Carpenter JE. Early-stage implementation of peer-led interventions for emergency department patients with substance use disorder: Findings from a formative qualitative evaluation. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 167:209518. [PMID: 39265917 DOI: 10.1016/j.josat.2024.209518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 08/20/2024] [Accepted: 09/08/2024] [Indexed: 09/14/2024]
Abstract
INTRODUCTION Emergency department (ED)-based peer recovery coach (PRC) programs can improve access to substance use disorder treatment (SUD) for ED patients. As literature on early stages of PRC implementation is limited, we conducted a qualitative assessment of ED PRC program implementation from several US-based PRC programs focusing on barriers and facilitators for implementation and providing recommendations based on the findings. METHODS We collected qualitative data from 39 key informants (peer recovery coaches, PRC program managers, ED physicians and staff, representatives of community-based organizations) via 6 focus groups and 21 interviews in February-December 2023. We transcribed audio-recordings and analyzed data using codebook thematic analysis. RESULTS We identified the following major themes related to specific barriers and recommendations to address them. To facilitate timely linkage to PRCs, programs would regularly inform ED staff about the program and its linkage procedures, establish trust between PRC and ED staff, streamline the linkage procedures, and choose an "opt-out" linkage approach. To address barriers related to external referrals, programs use "warm handoff" and "warm line" strategies, maintain and update a comprehensive catalog of resources, and familiarize peer coaches with local service providers. Telehealth services implementation requires addressing logistical barriers, ensuring patients' privacy, and training peer coaches on building trust and rapport online. Peer coaches' wellness and quality of services can be improved by limiting PRC's workload, prioritizing quality over quantity, facilitating self-, peer- and professional care to mitigate stress and burnout; and, importantly, by providing supportive supervision and training to peer coaches and advocating for PRC team as an equal partner in the ED settings. To facilitate PRC program adoption and sustainment program managers engage local communities and program champions, seek diverse sources of funding, and advocate for structural changes to accommodate recruitment and retention of peer recovery coaches. CONCLUSIONS We compiled a wealth of best practices used by PRC programs to address numerous implementation barriers and challenges. These recommendations are intended for PRC program planners, managers and champions, hospital leadership, and state and local public health agencies leading SUD epidemic response.
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Affiliation(s)
- Umedjon Ibragimov
- Center for Population Sciences and Health Equity, College of Nursing, Florida State University, Tallahassee, FL, United States of America.
| | - Nicholas A Giordano
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, United States of America
| | - Sneha Amaresh
- Department of Behavioral, Social and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Tatiana Getz
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, GA, United States of America
| | - Tatiana Matuszewski
- Department of Behavioral, Social and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Alaina R Steck
- Department of Emergency Medicine, School of Medicine, Emory University, Atlanta, GA, United States of America
| | - MaryJo Schmidt
- Department of Behavioral, Social and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Jose Iglesias
- Department of Behavioral, Social and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Yan Li
- Department of Emergency Medicine, School of Medicine, Emory University, Atlanta, GA, United States of America
| | - Eliot H Blum
- Department of Emergency Medicine, School of Medicine, Emory University, Atlanta, GA, United States of America
| | - D Ann Glasheen
- Department of Emergency Medicine, School of Medicine, Emory University, Atlanta, GA, United States of America
| | - Jessica Tuttle
- Georgia Department of Public Health, Atlanta, GA, United States of America
| | - Hardik Pipalia
- Aniz, Inc. Holistic Harm Reduction Integrated Care Clinic, Atlanta, GA, United States of America
| | - Hannah L F Cooper
- Department of Behavioral, Social and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Joseph E Carpenter
- Department of Emergency Medicine, School of Medicine, Emory University, Atlanta, GA, United States of America; Georgia Poison Center, Atlanta, GA, United States of America
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Bandara S, Byrne L, Berman V, Hurst A, King D, Gibbons JB, Sugarman OK, Livingston A, Kerins L, Hulsey EG, Alves A, Saloner B. Harm Reduction and Treatment Among People at High Risk of Overdose. JAMA Netw Open 2024; 7:e2427241. [PMID: 39133486 PMCID: PMC11320172 DOI: 10.1001/jamanetworkopen.2024.27241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 06/13/2024] [Indexed: 08/13/2024] Open
Abstract
Importance Rates of overdose deaths involving synthetic opioids remain high, increasingly involve stimulants combined with opioids, and are increasing rapidly in racially and ethnically minoritized communities, yet little is known about access to harm reduction and treatment services in these groups. Objective To characterize access and barriers to harm reduction and treatment in a racially and ethnically diverse population of people who use drugs. Design, Setting, and Participants A cross-sectional telephone survey of people recruited from 39 treatment, harm reduction, and social service organizations in Milwaukee County, Wisconsin; Flint and Detroit, Michigan; and statewide in New Jersey was conducted from January 30 to July 28, 2023. Adults who used cocaine, methamphetamine, or opioids in the past 30 days called a study hotline and completed an interview in English or Spanish. Exposures Overdose experience, drug types used (opioids only, stimulants only, and polysubstance), and social risk factors (eg, financial instability and criminal legal involvement). Main Outcomes and Measures Recent use of any harm reduction services, fentanyl test strips, naloxone possession, treatment, and self-reported barriers to services. Results Of the total sample of 1240 adults, 486 (39.2%) were Black non-Hispanic, 183 (14.8%) were Hispanic, and 464 (37.4%) were White non-Hispanic. In the past 30 days, 826 individuals (66.6%) were polysubstance users, 135 (10.9%) used only opioids, and 279 (22.5%) used only stimulants. A total of 349 respondents (28.1%) experienced a prior-year overdose. Compared with those without a prior-year overdose, people with overdose were more likely to possess naloxone (80.7% vs 68.2%; P < .001), possess fentanyl test strips (36.8% vs 23.5%; P < .001), and use harm reduction services (63.4% vs 53.0%; P = .003), while differences in treatment use were nonsignificant (52.0% vs 46.6%; P = .24). Among stimulant-only users, 51.4% possessed naloxone compared with 77.3% of opioid-only users (P < .001) and 77.6% of polysubstance users (P < .001), with similar disparities in fentanyl test strip possession. Conclusions and Relevance In this cross-sectional study of people who used drugs in the past 30 days, findings highlighted low use of harm reduction and treatment services among people who use stimulants. Additional communication regarding their importance may help increase the use of the services amidst a rapidly changing drug supply.
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Affiliation(s)
- Sachini Bandara
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Lauren Byrne
- Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Vanessa Berman
- Pacific Institute for Research and Evaluation, Chapel Hill, North Carolina
| | | | | | | | - Olivia K. Sugarman
- Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Amy Livingston
- Pacific Institute for Research and Evaluation, Chapel Hill, North Carolina
| | | | | | | | - Brendan Saloner
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Lazic A, Tilford JM, Davis VP, Brown CC. Association of copayments with healthcare utilization and expenditures among Medicaid enrollees with a substance use disorder. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 161:209314. [PMID: 38369244 PMCID: PMC11090739 DOI: 10.1016/j.josat.2024.209314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 01/04/2024] [Accepted: 02/11/2024] [Indexed: 02/20/2024]
Abstract
BACKGROUND The purpose of this study was to examine the association between copayments and healthcare utilization and expenditures among Medicaid enrollees with substance use disorders. METHODS This study used claims data (2020-2021) from a private insurer participating in Arkansas's Medicaid expansion. We compared service utilization and expenditures for enrollees in different Medicaid program structures with varying copayments. Enrollees with incomes above 100 % FPL (N = 10,240) had copayments for substance use treatment services while enrollees below 100 % FPL (N = 2478) did not. Demographic, diagnostic, utilization, and cost information came from claims and enrollment information. The study identified substance use and clinical comorbidities using claims from July through December 2020 and evaluated utilization and costs in 2021. Generalized linear models (GLM) estimated outcomes using single equation and two-part modeling. A gamma distribution and log link were used to model expenditures, and negative binomial models were used to model utilization. A falsification test comparing behavioral health telemedicine utilization, which had no cost sharing in either group, assessed whether differences in the groups may be responsible for observed findings. RESULTS Substance use enrollees with copayments were less likely to have a substance use or behavioral health outpatient (-0.04 PP adjusted; p = 0.001) or inpatient visit (-0.04 PP; p = 0.001) relative to their counterparts without copayments, equal to a 17 % reduction in substance use or behavioral health outpatient services and a nearly 50 % reduction in inpatient visits. The reduced utilization among enrollees with a copayment was associated with a significant reduction in total expenses ($954; p = 0.001) and expenses related to substance use or behavioral health services ($532; p = 0.001). For enrollees with at least one behavioral health visit, there were no differences in outpatient or inpatient utilization or expenditures between enrollees with and without copayments. Copayments had no association with non-behavioral health or telemedicine services where neither group had cost sharing. CONCLUSION Copayments serve as an initial barrier to substance use treatment, but are not associated with the amount of healthcare utilization conditional on using services. Policy makers and insurers should consider the role of copayments for treatment services among enrollees with substance use disorders in Medicaid programs.
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Affiliation(s)
- Antonije Lazic
- Fay W. Boozman College of Public Health, Department of Health Policy and Management, University of Arkansas for Medical Science, Little Rock, AR 72205, USA
| | - J Mick Tilford
- Fay W. Boozman College of Public Health, Department of Health Policy and Management, University of Arkansas for Medical Science, Little Rock, AR 72205, USA
| | - Victor P Davis
- Actuarial Services & Enterprise Underwriting, Arkansas Blue Cross Blue Shield, Little Rock, AR 72201, USA
| | - Clare C Brown
- Fay W. Boozman College of Public Health, Department of Health Policy and Management, University of Arkansas for Medical Science, Little Rock, AR 72205, USA.
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Michener PS, Knee A, Wilson D, Boama-Nyarko E, Friedmann PD. Association of random and observed urine drug screening with long-term retention in opioid treatment programs. Drug Alcohol Depend 2024; 255:111067. [PMID: 38183832 PMCID: PMC10956422 DOI: 10.1016/j.drugalcdep.2023.111067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND In the US, opioid treatment providers (OTPs) have wide latitude to perform urine drug screening (UDS) and discharge clients for positive results. OTP clients have identified randomized and directly observed UDS as potentially stigmatizing, but little research has examined the association between UDS modality and retention in OTPs. METHODS This cross-sectional study uses the 2016-2017 NDATSS wave among OTPs that administered methadone. The exposure was a 4-level variable based on whether OTPs had a high percentage (≥ 90% of clients) who experienced randomized, observed, both, or neither modality of UDS. The outcome was the proportion of clients retained in treatment 1 year or longer (long-term retention). Analyses were conducted using fractional logit regression with survey weighting and presented as percentages and 95% confidence intervals. We also present how policies for involuntary clinic discharge modify these effects. RESULTS 150 OTPs were eligible with a median of 310 clients. 40 (27%) OTPs did not highly utilize either randomized or observed UDS, 22 (15%) only highly utilized observed UDS, 42 (28%) only highly utilized randomized UDS and 46 (31%) utilized both practices on ≥ 90% of clients. Adjusted estimates for long-term retention ranged from 57.7% in OTPs that conducted both randomized and observed UDS on ≥ 90% of clients and 70.4% in OTPs that did not highly utilize these practices. Involuntary discharge may moderate this relationship. CONCLUSION Findings showed an association between high utilization of randomized and observed UDS and decreased long-term retention, suggesting that UDS modality may impact long-term OTP retention.
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Affiliation(s)
- Pryce S Michener
- Clinical and Population Health Research Program, Graduate School of Biomedical Sciences University of Massachusetts Chan Medical School, 55 N Lake Ave, Worcester, MA 01655, USA.
| | - Alexander Knee
- Dept. of Medicine, UMass Chan Medical School - Baystate, 759 Chestnut St, Springfield, MA 01199, USA; Epidemiology/Biostatistics Research Core - Baystate Medical Center, Office of Research, 3601 Main Street, Third Floor, Springfield, MA 01199, USA
| | - Donna Wilson
- Dept. of Medicine, UMass Chan Medical School - Baystate, 759 Chestnut St, Springfield, MA 01199, USA; Epidemiology/Biostatistics Research Core - Baystate Medical Center, Office of Research, 3601 Main Street, Third Floor, Springfield, MA 01199, USA
| | - Esther Boama-Nyarko
- Clinical and Population Health Research Program, Graduate School of Biomedical Sciences University of Massachusetts Chan Medical School, 55 N Lake Ave, Worcester, MA 01655, USA
| | - Peter D Friedmann
- Dept. of Medicine, UMass Chan Medical School - Baystate, 759 Chestnut St, Springfield, MA 01199, USA
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DeBruin H, St Marie BJ. Health disparities in ethnic and racial minority populations with pain and opioid use disorder. J Opioid Manag 2023; 19:23-36. [PMID: 37879657 DOI: 10.5055/jom.2023.0796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
Healthcare providers are not prepared to address health disparities among ethnic and racial minority populations with either persistent and chronic pain or substance use disorder (SUD). Recognizing biases from policies to provide pain management and treatment for SUD in our healthcare systems, from our individual state laws and federal guidelines, is necessary. Biases are embedded in the screening and treatment of patients with chronic pain through the use of screening tools, opioid treatment agreements, and prescription drug monitoring programs. Additionally, the punitive treatment of people of ethnic and racial minority populations who experience persistent and chronic pain, opioid use disorders, or other SUDs needs to be redirected to facilitate solutions rooted in equity.
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Affiliation(s)
| | - Barbara J St Marie
- University of Iowa, College of Nursing, Iowa City, Iowa. ORCID: https://orcid.org/0000-0003-0231-9464
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Thompson RA, Johnson D, Whitter M, Ashworth M, Fletcher E. State-Level Support for Recovery Housing: Results from a National Collaborative Study of U.S. Single State Agencies. J Psychoactive Drugs 2023:1-9. [PMID: 37720982 DOI: 10.1080/02791072.2023.2253811] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 08/09/2023] [Indexed: 09/19/2023]
Abstract
Single State Agencies (SSAs) are responsible for managing the publicly funded alcohol and other drug prevention, treatment, and recovery service system. Recovery housing (RH) is an important recovery support service (RSS) for individuals experiencing substance use disorder (SUD). Despite its effectiveness, information on state utilization and support is limited. To assess state-level support for RH and its incorporation within the SSA-managed SUD service systems, we administered a survey with SSAs in the 50 United States and the District of Columbia. In total, 48 out of the 51 SSAs responded, yielding a 94% response rate. Findings indicate strong state-level support for RH in terms of it being an integral RSS (98%), part of state-level strategic plans (73%) and prioritized for funding (87.5%). States are making progress to formalize RH with 68% reporting RH had been defined formally or within their agency. However, activities around understanding the capacity and need for RH are limited, with 44% indicating a needs assessment had not been conducted. At the same time, states perceive RH as a priority RSS, with growing recognition of its positive impact on long-term SUD recovery. This research identifies the opportunities for stakeholders to further evolve and expand RH at the federal, state, and local levels.
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Affiliation(s)
| | | | - Melanie Whitter
- National Association of State Alcohol and Drug Abuse Directors, Washington, DC, USA
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Andrews CM, Hinds OM, Lozano-Rojas F, Besmann WL, Abraham AJ, Grogan CM, Silverman AF. State Funding For Substance Use Disorder Treatment Declined In The Wake Of Medicaid Expansion. Health Aff (Millwood) 2023; 42:981-990. [PMID: 37406236 DOI: 10.1377/hlthaff.2022.01568] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
The US continues to grapple with an escalating epidemic of opioid-related overdose and mortality. State funds, which are the second-largest source of public funding for substance use disorder (SUD) treatment and prevention, play a critically important role in responding to this crisis. Despite their importance, little is known about how these funds are allocated and how they have changed over time, particularly within the context of Medicaid expansion. In this study we assessed trends in state funds during the period 2010-19, using difference-in-differences regression and event history models. Our findings reveal dramatic variation in state funding across states, from a low of $0.61 per capita in Arizona to a high of $51.11 per capita in Wyoming in 2019. Moreover, state funding declined during the period after Medicaid expansion by an average of $9.95 million in expansion states (relative to nonexpansion states), especially in states that expanded eligibility under Republican-controlled legislatures, where it declined by an average of $15.94 million. Medicaid substitution strategies, which, in effect, shift some of the financial burden for financing SUD treatment from the state to the federal level, may erode resources for broader system-level efforts that are urgently needed in the midst of the opioid epidemic.
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Affiliation(s)
- Christina M Andrews
- Christina M. Andrews , University of South Carolina, Columbia, South Carolina
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Stein BD, Saloner BK, Golan OK, Andraka-Christou B, Andrews CM, Dick AW, Davis CS, Sheng F, Gordon AJ. Association of Selected State Policies and Requirements for Buprenorphine Treatment With Per Capita Months of Treatment. JAMA HEALTH FORUM 2023; 4:e231102. [PMID: 37234015 PMCID: PMC10220518 DOI: 10.1001/jamahealthforum.2023.1102] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 03/24/2023] [Indexed: 05/27/2023] Open
Abstract
Importance Expanding the use of buprenorphine for treating opioid use disorder is a critical component of the US response to the opioid crisis, but few studies have examined how state policies are associated with buprenorphine dispensing. Objective To examine the association of 6 selected state policies with the rate of individuals receiving buprenorphine per 1000 county residents. Design, Setting, and Participants This cross-sectional study used 2006 to 2018 US retail pharmacy claims data for individuals dispensed buprenorphine formulations indicated for treating opioid use disorder. Exposures State implementation of policies requiring additional education for buprenorphine prescribers beyond waiver training, continuing medical education related to substance misuse and addiction, Medicaid coverage of buprenorphine, Medicaid expansion, mandatory prescriber use of prescription drug monitoring programs, and pain management clinic laws were examined. Main Outcomes and Measures The main outcome was buprenorphine treatment months per 1000 county residents as measured using multivariable longitudinal models. Statistical analyses were conducted from September 1, 2021, through April 30, 2022, with revised analyses conducted through February 28, 2023. Results The mean (SD) number of months of buprenorphine treatment per 1000 persons nationally increased steadily from 1.47 (0.04) in 2006 to 22.80 (0.55) in 2018. Requiring that buprenorphine prescribers receive additional education beyond that required to obtain the federal X-waiver was associated with significant increases in the number of months of buprenorphine treatment per 1000 population in the 5 years following implementation of the requirement (from 8.51 [95% CI, 2.36-14.64] months in year 1 to 14.43 [95% CI, 2.61-26.26] months in year 5). Requiring continuing medical education for physician licensure related to substance misuse or addiction was associated with significant increases in buprenorphine treatment per 1000 population in each of the 5 years following policy implementation (from 7.01 [95% CI, 3.17-10.86] months in the first year to 11.43 [95% CI, 0.61-22.25] months in the fifth year). None of the other policies examined was associated with a significant change in buprenorphine months of treatment per 1000 county residents. Conclusions and Relevance In this cross-sectional study of US pharmacy claims, state-mandated educational requirements beyond the initial training required to prescribe buprenorphine were associated with increased buprenorphine use over time. The findings suggest requiring education for buprenorphine prescribers and training in substance use disorder treatment for all controlled substance prescribers as an actionable proposal for increasing buprenorphine use, ultimately serving more patients. No single policy lever can ensure adequate buprenorphine supply; however, policy maker attention to the benefits of enhancing clinician education and knowledge may help to expand buprenorphine access.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Adam J. Gordon
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy, Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
- Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, Utah
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10
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Ortega A. Medicaid Expansion and mental health treatment: Evidence from the Affordable Care Act. HEALTH ECONOMICS 2023; 32:755-806. [PMID: 36480355 DOI: 10.1002/hec.4633] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 10/21/2022] [Accepted: 11/01/2022] [Indexed: 06/17/2023]
Abstract
This study uses a difference-in-differences design within an event-study framework to examine how state decisions to expand Medicaid following the passage of the Affordable Care Act (ACA) affected mental health treatment. The findings suggest that expansion states experienced increased admissions to mental health treatment facilities and Medicaid-reimbursed prescriptions for medications used to treat common forms of mental illness. The results also indicate an increase in admissions with trauma, anxiety, conduct, and depression disorders. There is also suggestive evidence of an increase in the number of mental health treatment facilities accepting Medicaid as a form of payment. Lastly, as with previous studies, I find weak evidence of a decrease in suicides in Medicaid expansion states. These findings highlight the vital role of the ACA in providing access to mental health treatment for low-income Americans.
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Affiliation(s)
- Alberto Ortega
- O'Neill School of Public and Environmental Affairs, Indiana University, Bloomington, Indiana, USA
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11
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Tomko C, Olfson M, Mojtabai R. Gaps and barriers in drug and alcohol treatment following implementation of the affordable care act. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 5:100115. [PMID: 36644223 PMCID: PMC9835109 DOI: 10.1016/j.dadr.2022.100115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Background This study examines changes in the substance use disorder (SUD) treatment gap and barriers to treatment for low-income adults following Affordable Care Act (ACA) implementation. Methods National Survey on Drug Use and Health (NSDUH) data were pooled to assess pre-ACA (2009-2013) and post-ACA (2015-2019) implementation. The sample (n = 44,622) included respondents 18-64 years old, income <200% federal poverty level, and meeting SUD criteria for abuse or dependence of heroin, powdered cocaine, crack cocaine, marijuana, or alcohol. The primary outcome was NSDUH-defined past-year illicit drug or alcohol treatment gap (needing but not receiving SUD specialty treatment). A secondary analysis assessed barriers to SUD treatment including insurance-related barriers, stigma, barriers to access, priority of treatment, and no interest in stopping substance use. Results Ninety-three percent of respondents reported a drug or alcohol treatment gap before and after ACA implementation. No interest in stopping use was the greatest barrier (40%), followed by insurance-related barriers (39%) and stigma (20%). After adjusting for covariates, results did not show a significant change in SUD treatment gap post-ACA compared to pre-ACA (adjusted odds ratio [aOR]=1.11, 95% confidence interval [CI]=0.97, 1.28, p = 0.13). Compared to pre-ACA, odds of reporting stigma-related barriers (aOR=1.66, 95% CI=1.17, 2.37, p = 0.01) and access-related barriers (aOR=1.79, 95% CI=1.34, 2.38, p < 0.001) increased post-ACA. Conclusions There was no significant change in the prevalence of SUD treatment gap after ACA implementation. Increasing access to SUD treatment for low-income individuals will require intervening at multiple socioecological levels beyond reforming treatment financing.
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Affiliation(s)
- Catherine Tomko
- Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, 624 N. Broadway, Hampton House 161, Baltimore, MD 21205, USA,Corresponding author. (C. Tomko)
| | - Mark Olfson
- Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, 630 West 168th Street, New York NY 10032, USA,Mailman School of Public Health, Columbia University, 722 W 168th St., New York, NY 10032, USA
| | - Ramin Mojtabai
- Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, 624 N. Broadway, Hampton House 161, Baltimore, MD 21205, USA,Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, 600 N. Wolfe St., Baltimore, MD 21205, USA
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12
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Guerrero EG, Kong Y, Frimpong JA, Khachikian T, Wang S, D’Aunno T, Howard DL. Workforce Diversity and disparities in wait time and retention among opioid treatment programs. Subst Abuse Treat Prev Policy 2022; 17:74. [PMID: 36384761 PMCID: PMC9670430 DOI: 10.1186/s13011-022-00500-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Workforce diversity is a key strategy to improve treatment engagement among members of racial and ethnic minority groups. In this study, we seek to determine whether workforce diversity plays a role in reducing racial and ethnic differences in wait time to treatment entry and retention in different types of opioid use disorder treatment programs. METHODS We conducted comparative and predictive analysis in a subsample of outpatient opioid treatment programs (OTPs), who completed access and retention survey questions in four waves of the National Drug Abuse Treatment System Survey (162 OTPs in 2000, 173 OTPs in 2005, 282 OTPs in 2014, and 300 OTPs in 2017). We sought to assess the associations between workforce diversity on wait time and retention, accounting for the role of Medicaid expansion and the moderating role of program ownership type (i.e., public, non-profit, for-profit) among OTPs located across the United States. RESULTS We found significant differences in wait time to treatment entry and retention in treatment across waves. Average number of waiting days decreased in 2014 and 2017; post Medicaid expansion per the Affordable Care Act, while retention rates varied across years. Key findings show that programs with high diversity, measured by higher percent of African American staff and a higher percent of African American clients, were associated with longer wait times to enter treatment, compared to low diversity programs. Programs with higher percent of Latino staff and a higher percent of Latino clients were associated with lower retention in treatment compared with low diversity programs. However, program ownership type (public, non-profit and for-profit) played a moderating role. Public programs with higher percent of African American staff were associated with lower wait time, while non-profit programs with higher percent of Latino staff were related to higher retention. CONCLUSIONS Findings show decreases in wait time over the years with significant variation in retention during the same period. Concordance in high workforce and client diversity was associated with higher wait time and lower retention. But these relations inverted (low wait time and high retention) in public and non-profit programs with high staff diversity. Findings have implications for building resources and service capacity among OTPs that serve a higher proportion of minority clients.
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Affiliation(s)
- Erick G. Guerrero
- Research to End Healthcare Disparities Corp, I-Lead Institute, Los Angeles, CA USA
| | - Yinfei Kong
- Mihaylo College of Business and Economics, California State University, Fullerton, CA USA
| | - Jemima A. Frimpong
- Business, Organizations and Society, New York University, Abu Dhabi, United Arab Emirates
| | | | - Suojin Wang
- Department of Psychological and Brain Sciences, Texas A&M University, College Station, TX USA
| | - Thomas D’Aunno
- Wagner Graduate School of Public Service, New York University, New York City, New York USA
| | - Daniel L. Howard
- Department of Psychological and Brain Sciences, Texas A&M University, College Station, TX USA
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13
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Olfson M, Mauro C, Wall MM, Barry CL, Choi CJ, Mojtabai R. Medicaid Expansion and Racial-Ethnic Health Care Coverage Disparities Among Low-Income Adults With Substance Use Disorders. Psychiatr Serv 2022:appips20220155. [PMID: 36321322 DOI: 10.1176/appi.ps.20220155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
OBJECTIVE In light of historical racial-ethnic disparities in health care coverage, the authors assessed changes in coverage in nationally representative samples of Black, White, and Hispanic low-income adults with substance use disorders after the 2014 Affordable Care Act Medicaid expansion. METHODS Data from 12 years of the annual National Survey on Drug Use and Health (2008-2019) identified low-income adults ages 18-64 years with alcohol, cannabis, cocaine, or heroin use disorder (N=749,033). Trends in coverage focused on non-Hispanic Black, non-Hispanic White, and Hispanic individuals. Age- and sex-adjusted difference-in-differences analysis assessed effects of expansion state residence on insurance coverage for the three groups. RESULTS Before Medicaid expansion (2008-2013), 38.5% of Black, 37.6% of White, and 51.2% of Hispanic low-income adults with substance use disorders were uninsured. After expansion (2014-2019), these proportions significantly declined for Black (24.2%), White (22.0%), and Hispanic (34.5%) groups. Decreases in rates of individuals without insurance and increases in Medicaid coverage tended to be more pronounced for those in expansion states than for those in nonexpansion states. In nonexpansion states, the proportions of those without insurance significantly decreased among Black and White individuals but not among Hispanic individuals. Proportions receiving past-year substance use treatment did not significantly change and remained low postexpansion: Black, 10.7%; White, 14.6%; and Hispanic, 9.0%. CONCLUSIONS After Medicaid expansion, coverage increased for low-income Black, White, and Hispanic adults with substance use disorders. For all three groups, Medicaid coverage disproportionately increased among those living in expansion states. However, coverage remained far from universal, especially for Hispanic adults with substance use disorders.
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Affiliation(s)
- Mark Olfson
- Department of Psychiatry, Vagelos College of Physicians and Surgeons (Olfson, Wall), and Mailman School of Public Health (Olfson, Mauro, Wall), Columbia University, New York City; Jeb E. Brooks School of Public Policy, Cornell University, Ithaca, New York (Barry); Division of Mental Health Data Science, New York State Psychiatric Institute, New York City (Choi); Department of Mental Health, Bloomberg School of Public Health, and Department of Psychiatry, Johns Hopkins University, Baltimore (Mojtabai)
| | - Christine Mauro
- Department of Psychiatry, Vagelos College of Physicians and Surgeons (Olfson, Wall), and Mailman School of Public Health (Olfson, Mauro, Wall), Columbia University, New York City; Jeb E. Brooks School of Public Policy, Cornell University, Ithaca, New York (Barry); Division of Mental Health Data Science, New York State Psychiatric Institute, New York City (Choi); Department of Mental Health, Bloomberg School of Public Health, and Department of Psychiatry, Johns Hopkins University, Baltimore (Mojtabai)
| | - Melanie M Wall
- Department of Psychiatry, Vagelos College of Physicians and Surgeons (Olfson, Wall), and Mailman School of Public Health (Olfson, Mauro, Wall), Columbia University, New York City; Jeb E. Brooks School of Public Policy, Cornell University, Ithaca, New York (Barry); Division of Mental Health Data Science, New York State Psychiatric Institute, New York City (Choi); Department of Mental Health, Bloomberg School of Public Health, and Department of Psychiatry, Johns Hopkins University, Baltimore (Mojtabai)
| | - Colleen L Barry
- Department of Psychiatry, Vagelos College of Physicians and Surgeons (Olfson, Wall), and Mailman School of Public Health (Olfson, Mauro, Wall), Columbia University, New York City; Jeb E. Brooks School of Public Policy, Cornell University, Ithaca, New York (Barry); Division of Mental Health Data Science, New York State Psychiatric Institute, New York City (Choi); Department of Mental Health, Bloomberg School of Public Health, and Department of Psychiatry, Johns Hopkins University, Baltimore (Mojtabai)
| | - C Jean Choi
- Department of Psychiatry, Vagelos College of Physicians and Surgeons (Olfson, Wall), and Mailman School of Public Health (Olfson, Mauro, Wall), Columbia University, New York City; Jeb E. Brooks School of Public Policy, Cornell University, Ithaca, New York (Barry); Division of Mental Health Data Science, New York State Psychiatric Institute, New York City (Choi); Department of Mental Health, Bloomberg School of Public Health, and Department of Psychiatry, Johns Hopkins University, Baltimore (Mojtabai)
| | - Ramin Mojtabai
- Department of Psychiatry, Vagelos College of Physicians and Surgeons (Olfson, Wall), and Mailman School of Public Health (Olfson, Mauro, Wall), Columbia University, New York City; Jeb E. Brooks School of Public Policy, Cornell University, Ithaca, New York (Barry); Division of Mental Health Data Science, New York State Psychiatric Institute, New York City (Choi); Department of Mental Health, Bloomberg School of Public Health, and Department of Psychiatry, Johns Hopkins University, Baltimore (Mojtabai)
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14
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Mumba MN, Jaiswal J, Bui C, Evans T, Mainzinger L, Davis L, Mugoya GT. Substance use treatment services for older adults in five states in the Southern United States: a state-by-state comparison of available treatment services. Aging Ment Health 2022; 27:1028-1036. [PMID: 35848207 DOI: 10.1080/13607863.2022.2098911] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Objectives: Substance use disorders (SUD) among older adults have become a serious public health concern. The purpose of this study was to assess which states in the Southern U.S. are more responsive to SUD treatment needs of older adults.Methods: This study is a secondary data analysis of the N-SSATS-2019 dataset.Results: There were 1,215 substance treatment facilities in the five states. Kentucky had the highest number of substance use treatment facilities (n = 449, 37%), followed by Georgia (357, 29%), Alabama (153, 13%), Louisiana (146, 12%) and then Mississippi (110, 9%). Out of the 1,215 facilities, only 20% (n = 244) indicated that they had programs specifically tailored for older adults. Kentucky had the largest number of facilities per 1 million older adults while Mississippi had the highest number of facilities per 1 million older adults offering detoxification services. Alabama had the lowest number of services per 1 million adults in all categories examined.Conclusion: Across the U.S., most adults with SUD do not have access to substance use treatment; in the southeastern region of the country, higher rates of poverty, rural geography and stigma, and lack of treatment availability may further complicate individuals' ability to access substance use-related medical care.
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Affiliation(s)
- Mercy Ngosa Mumba
- Center for Substance Use Research and Related Conditions, Capstone College of Nursing, The University of Alabama, Tuscaloosa, AL, USA.,Tuscaloosa VA Medical Center, Tuscaloosa, AL, USA
| | - Jessica Jaiswal
- College of Human and Environmental Sciences, The University of Alabama, Tuscaloosa, AL, USA
| | - Chuong Bui
- Alabama Life Research Institute, The University of Alabama, Tuscaloosa, AL, USA
| | | | | | - Lori Davis
- Tuscaloosa VA Medical Center, Tuscaloosa, AL, USA
| | - George T Mugoya
- Department of Educational Studies in Psychology, Research Methodology and Counseling, The University of Alabama, Tuscaloosa, AL, USA
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15
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Alegría M, Falgas-Bague I, Fukuda M, Zhen-Duan J, Weaver C, O’Malley I, Layton T, Wallace J, Zhang L, Markle S, Neighbors C, Lincourt P, Hussain S, Manseau M, Stein BD, Rigotti N, Wakeman S, Kane M, Evins AE, McGuire T. Performance Metrics of Substance Use Disorder Care Among Medicaid Enrollees in New York, New York. JAMA HEALTH FORUM 2022; 3:e221771. [PMID: 35977217 PMCID: PMC9250047 DOI: 10.1001/jamahealthforum.2022.1771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 04/28/2022] [Indexed: 11/14/2022] Open
Abstract
Importance There is limited evaluation of the performance of Medicaid managed care (MMC) private plans in covering substance use disorder (SUD) treatment. Objective To compare the performance of MMC plans across 19 indicators of access, quality, and outcomes of SUD treatment. Design Setting and Participants This cross-sectional study used administrative claims and mandatory assignment to plans of up to 159 016 adult Medicaid recipients residing in 1 of the 5 counties (boroughs) of New York, New York, from January 2009 to December 2017 to identify differences in SUD treatment access, patterns, and outcomes among different types of MMC plans. Data from the latest years were received from the New York State Department of Health in October 2019, and analysis began soon thereafter. Approximately 17% did not make an active choice of plan, and a subset of these (approximately 4%) can be regarded as randomly assigned. Exposures Plan assignment. Main Outcomes and Measures Percentage of the enrollees achieving performance measures across 19 indicators of access, process, and outcomes of SUD treatment. Results Medicaid claims data from 159 016 adults (mean [SD] age, 35.9 [12.7] years; 74 261 women [46.7%]; 8746 [5.5%] Asian, 73 783 [46.4%] Black, and 40 549 [25.5%] White individuals) who were auto assigned to an MMC plan were analyzed. Consistent with national patterns, all plans achieved less than 50% (range, 0%-62.1%) on most performance measures. Across all plans, there were low levels of treatment engagement for alcohol (range, 0%-0.4%) and tobacco treatment (range, 0.8%-7.2%), except for engagement for opioid disorder treatment (range, 41.5%-61.4%). For access measures, 4 of the 9 plans performed significantly higher than the mean on recognition of an SUD diagnosis, any service use for the first time, and tobacco use screening. Of the process measures, total monthly expenditures on SUD treatment was the only measure for which plans differed significantly from the mean. Outcome measures differed little across plans. Conclusions and Relevance The results of this cross-sectional study suggest the need for progress in engaging patients in SUD treatment and improvement in the low performance of SUD care and limited variation in MMC plans in New York, New York. Improvement in the overall performance of SUD treatment in Medicaid potentially depends on general program improvements, not moving recipients among plans.
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Affiliation(s)
- Margarita Alegría
- Disparities Research Unit, Massachusetts General Hospital, Boston
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
| | - Irene Falgas-Bague
- Disparities Research Unit, Massachusetts General Hospital, Boston
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Marie Fukuda
- Disparities Research Unit, Massachusetts General Hospital, Boston
| | - Jenny Zhen-Duan
- Disparities Research Unit, Massachusetts General Hospital, Boston
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
| | - Cole Weaver
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Isabel O’Malley
- Disparities Research Unit, Massachusetts General Hospital, Boston
| | - Timothy Layton
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Jacob Wallace
- Yale School of Public Health, New Haven, Connecticut
| | - Lulu Zhang
- Disparities Research Unit, Massachusetts General Hospital, Boston
| | - Sheri Markle
- Disparities Research Unit, Massachusetts General Hospital, Boston
| | - Charles Neighbors
- Grossman School of Medicine, New York University, New York
- Wagner School of Public Service, New York University, New York
| | - Pat Lincourt
- New York State Office of Alcoholism and Substance Abuse Services, Albany, New York
| | - Shazia Hussain
- New York State Office of Alcoholism and Substance Abuse Services, Albany, New York
| | - Marc Manseau
- Grossman School of Medicine, New York University, New York
- New York State Office of Mental Health, New York
| | | | - Nancy Rigotti
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine, Massachusetts General Hospital, Boston
- Tobacco Research and Treatment Center, Massachusetts General Hospital, Boston
| | - Sarah Wakeman
- Department of Medicine, Harvard Medical School, Boston, Massachusetts
- Substance Use Disorder Initiative, Massachusetts General Hospital, Boston
| | - Martha Kane
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
- Addictions Services Unit, Massachusetts General Hospital, Boston
| | - A. Eden Evins
- Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
- Center for Addiction Medicine, Massachusetts General Hospital, Boston
| | - Thomas McGuire
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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16
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Donohue JM. Meeting the Needs of Medicaid Beneficiaries With Substance Use Disorders in Managed Care. JAMA HEALTH FORUM 2022; 3:e221722. [DOI: 10.1001/jamahealthforum.2022.1722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Julie M. Donohue
- Health Policy and Management, University of Pittsburgh, Pittsburgh, Pennsylvania
- Associate Editor, JAMA Health Forum
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17
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Dickson-Gomez J, Weeks M, Green D, Boutouis S, Galletly C, Christenson E. Insurance barriers to substance use disorder treatment after passage of mental health and addiction parity laws and the affordable care act: A qualitative analysis. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 3:100051. [PMID: 36845978 PMCID: PMC9948907 DOI: 10.1016/j.dadr.2022.100051] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 03/24/2022] [Accepted: 03/28/2022] [Indexed: 11/18/2022]
Abstract
Introduction People who use drugs (PWUDs) in the United States historically have had a higher probability of being uninsured. Passage of the Affordable Care Act, the Paul Wellstone and Pete Domenici Health Parity and Addiction Equity was expected to increase access to treatment for substance use disorder. Few studies to date have conducted qualitative research with substance use disorder (SUD) treatment providers regarding Medicaid and other insurance coverage of SUD treatment following passage of the ACA and parity laws. The present paper fills this gap by reporting data from in-depth interviews with treatment providers from three states, Connecticut, Kentucky, and Wisconsin, that differ in implementation of the ACA. Methods Study teams in each state conducted in-depth, semi-structured interviews with key informants who provided SUD treatment, including providers of behavioral health residential or outpatient programs, office-based buprenorphine providers and opioid treatment programs [OTP, i.e. methadone clinics] (n = 24 in Connecticut, n = 63 in Kentucky and n = 63 in Wisconsin). Key informants were asked for their perceptions on how Medicaid and private insurance facilitates or limits access to drug treatment. All interviews were transcribed verbatim and analyzed for key themes using MAXQDA software using a collaborative approach. Results Results from this study suggest that the promise of the ACA and parity laws to increase access to SUD treatment has only partially been realized. There is wide variation among the three states' Medicaid programs and among private insurance in the types of SUD treatment that is covered. Neither Kentucky's nor Connecticut's Medicaid covered methadone. Wisconsin Medicaid did not cover residential or intensive outpatient treatment. Thus, none of the states studied here provided all levels of care that the ASAM recommends for treating SUD. Further, there were several quantitative limits placed on SUD treatment such as number of urine drug screens or visits allowed. Providers complained that many treatments required prior authorizations, including MOUD like buprenorphine. Conclusions More reform is needed to make SUD treatment accessible to all who need it. Such reforms should consider defining standards for opioid use disorder treatment with reference to evidence-based practices, not be attempting parity with an arbitrarily defined medical standard.
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Affiliation(s)
- Julia Dickson-Gomez
- Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Margaret Weeks
- Institute for Community Research, Hartford, CT, United States
| | - Danielle Green
- Institute for Community Research, Hartford, CT, United States
| | - Sophie Boutouis
- Department of Psychology, University of Texas, Dallas, United States
| | - Carol Galletly
- Center for AIDS Intervention Research, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Erika Christenson
- Center of Excellence in Women's Health, Boston Medical Center, BUSM, New England
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18
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Abraham AJ, Lawler EC, Harris SJ, Bagwell Adams G, Bradford WD. Spillover of Medicaid Expansion to Prescribing of Opioid Use Disorder Medications in Medicare Part D. Psychiatr Serv 2022; 73:418-424. [PMID: 34407628 DOI: 10.1176/appi.ps.202000824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The authors examined whether there were positive spillovers in opioid use disorder medication prescribing to Medicare Part D beneficiaries in Medicaid expansion states. Although prior studies have shown several positive benefits of Medicaid expansion for Americans with opioid use disorder, research has not examined potential spillovers to Medicare beneficiaries who have been hit hard by the opioid crisis. METHODS Prescribing data were taken from the Medicare Part D Prescription Public Use File (2010-2017). A difference-in-differences linear regression framework was used to identify spillovers in prescribing of buprenorphine and injectable naltrexone to Medicare Part D beneficiaries in Medicaid expansion states. Three sets of dependent variables measured medication prescribing at the county-year level (N=24,850). All models included county and year fixed effects, with standard errors clustered at the state level to address within-state serial correlation. RESULTS Medicaid expansion was associated with an increase in the probability of a county having an injectable naltrexone provider (p<0.01). After expansion, the number of buprenorphine providers in expansion states increased by 5.6% (p<0.05), and the number of injectable naltrexone providers increased by 3.3% (p<0.01), relative to nonexpansion states. Expansion was associated with a 23.1% (p<0.01) increase in the number of daily doses of injectable naltrexone, relative to nonexpansion states. CONCLUSIONS Medicaid expansion states may be better equipped to address the opioid crisis because of direct benefits to Medicaid beneficiaries and availability of opioid use disorder medications for Medicare Part D beneficiaries. However, additional efforts are likely needed to close the opioid use disorder treatment gap for Medicare beneficiaries.
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Affiliation(s)
- Amanda J Abraham
- School of Public and International Affairs (Abraham, Lawler, Bradford) and College of Public Health (Bagwell Adams), University of Georgia, Athens; Bloomberg School of Public Health, Johns Hopkins University, Baltimore (Harris)
| | - Emily C Lawler
- School of Public and International Affairs (Abraham, Lawler, Bradford) and College of Public Health (Bagwell Adams), University of Georgia, Athens; Bloomberg School of Public Health, Johns Hopkins University, Baltimore (Harris)
| | - Samantha J Harris
- School of Public and International Affairs (Abraham, Lawler, Bradford) and College of Public Health (Bagwell Adams), University of Georgia, Athens; Bloomberg School of Public Health, Johns Hopkins University, Baltimore (Harris)
| | - Grace Bagwell Adams
- School of Public and International Affairs (Abraham, Lawler, Bradford) and College of Public Health (Bagwell Adams), University of Georgia, Athens; Bloomberg School of Public Health, Johns Hopkins University, Baltimore (Harris)
| | - W David Bradford
- School of Public and International Affairs (Abraham, Lawler, Bradford) and College of Public Health (Bagwell Adams), University of Georgia, Athens; Bloomberg School of Public Health, Johns Hopkins University, Baltimore (Harris)
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19
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Shakya S, Harris SJ. Medicaid expansion and opioid supply policies to address the opioid overdose crisis. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 3:100042. [PMID: 36845983 PMCID: PMC9948913 DOI: 10.1016/j.dadr.2022.100042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Revised: 03/08/2022] [Accepted: 03/10/2022] [Indexed: 11/28/2022]
Abstract
Background: The opioid overdose crisis remains of critical concern after historic increases in overdose mortality in the United States between 2020 and 2021. Improving access to buprenorphine -a partial opioid agonist and one of three FDA-approved medications for opioid use disorder (OUD) treatment- and reducing inappropriate opioid prescriptions may help curb mortality. Here, we examined the impact of Medicaid expansion and pain management clinic laws on opioid prescription rates and buprenorphine availability. Methods: We examined both retail opioid prescriptions per 100 persons in the state population using data from the Centers for Disease Control and Prevention and data on buprenorphine distributions in kilograms per 100,000 persons in the state population from the Automated Reports and Consolidated Ordering System database. We employed difference-in-difference frameworks to estimate the impact of Medicaid expansion on buprenorphine access and retail opioid prescription rates. Models considered three separate treatment variables: Medicaid expansion, pain management clinic ("pill mill") laws, and the interaction of Medicaid expansion and pain management clinic laws. Results: Findings showed that Medicaid expansion was associated with increased access to buprenorphine in expansion states that also employed more stringent supply-side policies, including pain management clinic laws, relative to states that did not implement policies targeting the over-supply of prescription opioids over the same time period. Conclusions. Together, Medicaid expansion and policies limiting inappropriate opioid prescriptions show promise for improving the accessibility of buprenorphine treatment for OUD.
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Affiliation(s)
- Shishir Shakya
- Department of Economics, Shippensburg University of Pennsylvania, USA
| | - Samantha J. Harris
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, USA,Corresponding author.
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20
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Khachikian T, Amaro H, Guerrero E, Kong Y, Marsh JC. Disparities in opioid treatment access and retention among women based on pregnancy status from 2006 to 2017. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 2. [PMID: 35369381 PMCID: PMC8975179 DOI: 10.1016/j.dadr.2022.100030] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background: The purpose of this study is to assess differences in wait time and retention in opioid use disorder (OUD) treatment among a sample of pregnant and non-pregnant women from low-income urban communities in Los Angeles, California. Methods: Data were collected in 9 waves consisting of consecutive years from 2006 to 2011, and then including 2013, 2015, and 2017. The sample consisted of 12,558 women, with 285 being pregnant and 12,273 being non-pregnant. We compared pregnant women with non-pregnant women at admission on key characteristics and relied on two multilevel negative binomial regressions analyses to examine factors related to access (days on the waiting list) and retention (days in treatment). Results: We detected disparities existed in access and retention. Pregnant women spent less time waiting to initate treatment than non-pregnant women and, once in treatment, had longer treatment episodes. Among pregnant women, clients identifying as Latina or Other waited longer to enter treatment compared to clients identifying as non-Latina White or Black. Women entering residential waited longer than those entering methadone or counseling services. Pregnant women were more likely to be in treatment longer if they had mental health issues, greater parenting responsibilities (number of children less than 18), and greater SUD severity (number of prior treatment episodes). Conclusions: Findings suggest pregnant women’s access and retention can be improved through Medicaid coverage and through the implementation of a standard of care that includes MOUD (methadone) along with ancillary health and social services.
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Affiliation(s)
- Tenie Khachikian
- University of Chicago, School of Social Service Administration, 969 E. 60th Street, Chicago, IL 60637, USA
- Corresponding author.
| | - Hortensia Amaro
- Florida International University, Herbert Wertheim College of Medicine and Robert Stempel College of Public Health and Social Work, 11200 SW 8th St, AHC4, Miami, Florida 33199, USA
| | - Erick Guerrero
- I-LEAD Institute, Research to End Healthcare Disparities Corp, 12300 Wilshire Blvd, Suite 210, Los Angeles, CA 90025 USA
| | - Yinfei Kong
- California State University, Fullerton, College of Business and Economics, 800N State College Blvd, Fullerton CA 92831 USA
| | - Jeanne C. Marsh
- University of Chicago, School of Social Service Administration, 969 E. 60th Street, Chicago, IL 60637, USA
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Knudsen HK, Hartman J, Walsh SL. The effect of Medicaid expansion on state-level utilization of buprenorphine for opioid use disorder in the United States. Drug Alcohol Depend 2022; 232:109336. [PMID: 35123365 PMCID: PMC8885876 DOI: 10.1016/j.drugalcdep.2022.109336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 01/20/2022] [Accepted: 01/22/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Research on the impact of Medicaid expansion on buprenorphine utilization has largely focused on the Medicaid program. Less is known about its associations with total buprenorphine utilization and non-Medicaid payers. METHODS Monthly prescription data (June 2013-May 2018) for proprietary and generic sublingual as well as buccal buprenorphine products were purchased from IQVIA®. Population-adjusted state-level utilization measures were constructed for Medicaid, commercial insurance, Medicare, cash, and total utilization. A difference-in-differences (DID) approach with population weights estimated the association between Medicaid expansion and buprenorphine utilization, while controlling for treatment capacity. RESULTS Monthly total buprenorphine prescriptions increased by 68% overall and increased 283% for Medicaid, 30% for commercial insurance, and 143% for Medicare. Cash prescriptions decreased by 10%. The DID estimate for Medicaid expansion was not statistically significant for total utilization (-19.780, 95% CI = -45.118, 5.558, p = .123). For Medicaid buprenorphine utilization, there was a significant increase of 27.120 prescriptions per 100,000 total state residents (95% CI = 9.458, 44.782, p = .003) in expansion states versus non-expansion states post-Medicaid expansion. Medicaid expansion had a negative effect on commercial insurance (DID estimate = -37.745, 95% CI = -62.946, -12.544, p = .004), cash utilization (DID estimate = -6.675, 95% CI = -12.627, -0.723, p = .029), and Medicare utilization (DID estimate = -1.855, 95% CI = -3.697, -0.013, p = .048). DISCUSSION The associations between Medicaid expansion and buprenorphine utilization varied across different types of payers, such that the overall impact of Medicaid expansion on buprenorphine utilization was not significant.
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Affiliation(s)
- Hannah K Knudsen
- Department of Behavioral Science and Center on Drug and Alcohol Research, University of Kentucky, 845 Angliana Avenue, Room 204, Lexington, KY 40508, USA.
| | - Jeanie Hartman
- Substance Use Research Priority Area, University of Kentucky, 845 Angliana Avenue, Room 121, Lexington, KY 40508, USA.
| | - Sharon L Walsh
- Department of Behavioral Science and Center on Drug and Alcohol Research, University of Kentucky, 845 Angliana Avenue, Room 202, Lexington, KY 40508, USA.
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Mulia N, Lui CK, Bensley KM, Subbaraman MS. Effects of Medicaid expansion on alcohol and opioid treatment admissions in U.S. racial/ethnic groups. Drug Alcohol Depend 2022; 231:109242. [PMID: 35007958 PMCID: PMC9009866 DOI: 10.1016/j.drugalcdep.2021.109242] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 10/29/2021] [Accepted: 11/23/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Excessive drinking and opioid misuse exact a high toll on U.S. lives and differentially affect U.S. racial/ethnic groups in exposure and resultant harms. Increasing access to specialty treatment is an important policy strategy to mitigate this, particularly for lower-income and racial/ethnic minority persons who face distinctive barriers to care. We examined whether the U.S. Affordable Care Act's Medicaid expansion improved treatment utilization in the overall population and for Black, Latino, and White Americans separately. METHODS We analyzed total and Medicaid-insured alcohol and opioid treatment admissions per 10,000 adult, state residents using 2010-2016 data from SAMHSA's Treatment Episode Data Set (N = 20 states), with difference-in-difference models accounting for state fixed effects and time-varying state demographic characteristics, treatment need, and treatment supply. RESULTS Total treatment admission rates in the overall population declined for alcohol and remained roughly flat for opioids in both expansion and non-expansion states from 2010 through 2016. By contrast, estimated Medicaid-insured alcohol and opioid treatment rates rose in expansion states and decreased in non-expansion states following Medicaid expansion in 2014. The latter results were found for alcohol treatment in the total population and in each racial/ethnic group, as well as for Black and White Americans for opioid treatment. CONCLUSIONS Medicaid expansion was associated with greater specialty treatment entry at a time when alcohol and opioid treatment rates were declining or flat. Findings underscore benefits of expanding Medicaid eligibility to increase treatment utilization for diverse racial/ethnic groups, but also suggest an emerging treatment disparity between lower-income Americans in expansion and non-expansion states.
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Affiliation(s)
- Nina Mulia
- Alcohol Research Group, 6001 Shellmound St., Suite 405, Emeryville, CA 94608, USA.
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Black clients in expansion states who used opioids were more likely to access medication for opioid use disorder after ACA implementation. J Subst Abuse Treat 2022; 133:108533. [PMID: 34218991 PMCID: PMC8664894 DOI: 10.1016/j.jsat.2021.108533] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 04/20/2021] [Accepted: 06/08/2021] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Black people in the United States who use opioids receive less treatment and die from overdoses at higher rates than White people. Medication for opioid use disorder (MOUD) decreases overdose risk. Implementation of the Affordable Care Act (ACA) in the United States was associated with an increase in MOUD. To what extent racial disparity exists in MOUD following ACA implementation remains unclear. Using a national sample of people seeking treatment for opioids (clients), we compared changes in MOUD after the ACA to determine whether implementation was associated with increased MOUD for Black clients relative to White clients. METHODS We identified 878,110 first episodes for clients with opioids as primary concern from SAMHDA's Treatment Episodes Dataset-Admissions (TEDS-A; 2007-2018). We performed descriptive and logistic regression analyses to estimate odds of MOUD for Black and White clients by Medicaid expansion status. We interacted ACA implementation with racial group and performed subpopulation analyses for Medicaid enrollees and criminal justice-referred clients. RESULTS In expansion states post-ACA, MOUD increased from 33.6% to 51.3% for White clients and from 36.2% to 61.7% for Black clients. Pre-ACA, Black clients were less likely than White clients to use MOUD (adjusted odds ratio (aOR) = 0.88, 99th Confidence Interval (CI) = [0.85, 0.91]), and post-ACA, the change in odds of MOUD did not differ. Criminal justice-referred clients experienced less of a change in odds of MOUD among Black clients than among White clients (aOR = 0.74, CI = [0.62, 0.89]). Among Medicaid-insured clients, the change in odds of MOUD among Black clients was larger (aOR = 1.16, CI = [1.03, 1.30]). In the non-expansion states before 2014, Black clients were less likely to receive MOUD (aOR = 0.86, CI = [0.77, 0.95]) than White clients. After 2014, the change in odds of MOUD increased more for Black clients relative to White clients (aOR = 1.24, CI = [1.07, 1.44]). We did not find significant changes in MOUD for clients referred through the criminal justice system or with Medicaid. CONCLUSION The ACA was associated with increased use of MOUD among Black clients and reduction in treatment disparity between Black and White clients. For criminal justice-referred Black clients, disparities in MOUD persist. Black clients with Medicaid in expansion states had the greatest reduction in disparities.
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Burns ME, Cook S, Brown LM, Dague L, Tyska S, Hernandez Romero K, McNamara C, Westergaard RP. Association Between Assistance With Medicaid Enrollment and Use of Health Care After Incarceration Among Adults With a History of Substance Use. JAMA Netw Open 2022; 5:e2142688. [PMID: 34994791 PMCID: PMC8742194 DOI: 10.1001/jamanetworkopen.2021.42688] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The transition from prison to community is characterized by elevated morbidity and mortality, particularly owing to drug overdose. However, most formerly incarcerated adults with substance use disorders do not use any health care, including treatment for substance use disorders, during the initial months after incarceration. OBJECTIVE To evaluate whether a prerelease Medicaid enrollment assistance program is associated with increased health care use within 30 days after release from prison. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included 16 307 adults aged 19 to 64 years with a history of substance use who were released from state prison between April 1, 2014, and December 31, 2016. The Wisconsin Department of Corrections implemented prerelease Medicaid enrollment assistance in January 2015. Statistical analysis was performed from January 1 to August 31, 2021. EXPOSURE A statewide Medicaid prerelease enrollment assistance program. MAIN OUTCOMES AND MEASURES The main outcome was Medicaid-reimbursed health care, associated with substance use disorders and for any cause, within 30 days of prison release, including outpatient, emergency department, and inpatient care. Mean outcomes were compared for those released before and after implementation of prerelease Medicaid enrollment assistance using an intention-to-treat analysis and person-level data from the Wisconsin Department of Corrections and Medicaid. RESULTS The sample included 16 307 individuals with 18 265 eligible releases (men accounted for 16 320 of 18 265 total releases, and 6213 of 18 265 releases were among Black individuals; mean [SD] age at release, 35.5 [10.7] years). The likelihood of outpatient care use within 30 days of release increased after implementation of enrollment assistance relative to baseline by 7.7 percentage points for any visit (95% CI, 6.4-8.9 percentage points; P < .001), by 0.7 percentage points for an opioid use disorder visit (95% CI, 0.4-1.0 percentage points; P < .001), by 1.0 percentage point for any substance use disorder visit (95% CI, 0.5-1.6 percentage points; P < .001), and by 0.4 percentage points for receipt of medication for opioid use disorder (95% CI, 0.2-0.6 percentage points; P < .001). There was no significant change in use of the emergency department (0.7 percentage points [95% CI, -0.15 to 1.4 percentage points]). The probability of an inpatient stay increased by 0.4 percentage points (95% CI, 0.03-0.7 percentage points; P = .03). CONCLUSIONS AND RELEVANCE The results of this cohort study suggest that prerelease Medicaid enrollment assistance was associated with increased use of outpatient health care after incarceration and highlights the value of making this assistance universally available within correctional settings. More tailored interventions may be needed to increase the receipt of treatment for substance use disorders.
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Affiliation(s)
- Marguerite E. Burns
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison
| | - Steven Cook
- Institute for Research on Poverty, University of Wisconsin–Madison, Madison
| | | | - Laura Dague
- The Bush School of Government and Public Service, Texas A&M University, College Station
| | - Steve Tyska
- Division of Medicaid Services, Wisconsin Department of Health Services, Madison
| | | | - Cici McNamara
- Department of Economics, University of Wisconsin–Madison, Madison
| | - Ryan P. Westergaard
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison
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Hudgins A, Uzwiak B, Pizzicato L, Viner K. Barriers to effective care: Specialty drug treatment in Philadelphia. J Subst Abuse Treat 2021; 131:108639. [PMID: 34728133 DOI: 10.1016/j.jsat.2021.108639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 09/23/2021] [Accepted: 10/19/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION In Philadelphia, the poorest big city in the United States, an estimated 60,000 people misuse opioids and more than 3500 have died of overdose in the past three years. In 2019, fentanyl was detected in 76% of drug-related deaths and 94% of opioid-involved deaths. While much attention has been directed at the public face of the city's drug problem, more than 75% of drug deaths in 2017 took place in a private residence. METHOD Based on qualitative research to understand the vulnerabilities of this hidden population of drug users, we interviewed kin of 35 people who had died of opioid overdose in 2017 to learn whether their loved one had interacted with any social services or harm-reduction interventions. RESULTS In our demographically and geographically representative sample of decedents, we found that while most had received treatment at least once, many faced barriers to getting treatment when they needed it, including barriers related to stigma, structural racism, gender inequities, bureaucracy, insurance requirements, and cost. CONCLUSION We argue that these barriers place an undue burden on people with substance use disorder and their kin during particularly fraught moments of heightened vulnerability. The failure of state and federal policies, practices, and infrastructure to address these barriers, and the failure to require that evidence-based care be provided during treatment have deleterious effects on people affected by the opioid epidemic in the United States.
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Affiliation(s)
| | - Beth Uzwiak
- Ethnologica, 4732 Stenton Ave., Philadelphia, PA 19144, USA
| | - Lia Pizzicato
- Division of Substance Use Prevention and Harm Reduction, Philadelphia Department of Public Health, 123 S. Broad Street, Suite 1120, Philadelphia, PA 19109, USA
| | - Kendra Viner
- Division of Substance Use Prevention and Harm Reduction, Philadelphia Department of Public Health, 123 S. Broad Street, Suite 1120, Philadelphia, PA 19109, USA
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Saloner B, Maclean JC. Specialty Substance Use Disorder Treatment Admissions Steadily Increased In The Four Years After Medicaid Expansion. Health Aff (Millwood) 2021; 39:453-461. [PMID: 32119615 DOI: 10.1377/hlthaff.2019.01428] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The Affordable Care Act's Medicaid expansion provided insurance coverage to many low-income adults with substance use disorders, but it is unclear whether this led to more people receiving treatment. We used the Treatment Episode Data Set and a difference-in-differences approach to compare annual rates of specialty treatment admissions in expansion versus nonexpansion states in the period 2010-17. We found that admissions to treatment steadily increased in the four years after Medicaid expansion, with 36 percent more people entering treatment by the fourth expansion year in expansion states compared to nonexpansion states. Changes were largest for people entering intensive outpatient programs and those seeking medication treatment for opioid use disorder. The share of admissions paid for by Medicaid increased 23 percentage points in expansion states compared to nonexpansion states, largely displacing treatment paid for by state and local governments. The gradual increase in specialty substance use disorder treatment admissions after Medicaid expansion may reflect improving capacity and access to care.
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Affiliation(s)
- Brendan Saloner
- Brendan Saloner ( bsaloner@jhu. edu ) is an associate professor in the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, in Baltimore, Maryland
| | - Johanna Catherine Maclean
- Johanna Catherine Maclean is an associate professor of economics at Temple University, in Philadelphia, Pennsylvania, and a research associate at the National Bureau of Economic Research in Cambridge, Massachusetts
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27
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Dennis ML, Davis JP. Screening for more with less: Validation of the Global Appraisal of Individual Needs Quick v3 (GAIN-Q3) screeners. J Subst Abuse Treat 2021; 126:108414. [PMID: 34116811 DOI: 10.1016/j.jsat.2021.108414] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 04/12/2021] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Abstract
Multi-morbidity is the norm among adolescents and adults with substance use and other mental disorders and warrants a multi-pronged screening approach. However, the time constraints on assessment inherent in clinical practice often temper the desire for a full understanding of multi-morbidity problems. The 15- to 25-minute Global Appraisal of Individual Needs Quick version 3 (GAIN-Q3) includes screeners for 9 common clinical problems that are short (4 to 10 items) and provide dimensional measures of problem severity in each area that are also categorized to guide clinical decision making. The screeners are summed into a total score that represents a 10th screener for multi-morbidity. This paper provides background on the development of the GAIN-Q3 screeners, their psychometric behaviors, efficiency, and predictive power relative to the 1-2 h full GAIN-I. Based on literature showing differential item and scale functioning by age, analyses were conducted separately using data from 10,625 adolescent and 10,167 adult treatment clients. Despite the condensed lengths of the screening measures compared with their longer versions, the reliability estimates are within the good to excellent range (0.7 to 0.9) in terms of internal consistency for 6 of the 10 screeners for adolescents and 7 of the 10 screeners for adults. In addition, the part to whole correlation for all 10 comparisons for both adolescents and adults are excellent (0.82 to 0.96). Moreover, there is strong evidence for the measures' convergent and discriminant validity and efficiency (i.e., maximum information gathered in as few items possible) relative to the full-length scales as well as relative to other scales in the full GAIN-I. Analyses of the interpretive cut-scores provide accurate identification of cases with high sensitivity and specificity, thus supporting the screeners' capacity to triage. PUBLIC SIGNIFICANCE STATEMENT: This study reports on the ability (GAIN-Q3) to efficiently screen for multiple co-occurring substance use, mental health, and associated problems. Multi-problem presentation in the social service sector is the normal expectation, yet time constraints prevent broad assessment of potentially many problematic areas. The GAIN-Q3 showed convergent and discriminant validity relative to the full-length scales as well as other scales assessed in the GAIN-I. The GAIN-Q3 achieves the desired balance between broad coverage and measurement efficiency to provide ample information to identify the best course of action for an individual.
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Affiliation(s)
- Michael L Dennis
- Chestnut Health Systems, GAIN Coordinating Center, Normal, IL, United States of America.
| | - Jordan P Davis
- Suzanne Dworak-Peck School of Social Work, USC Center for Artificial Intelligence in Society, USC Center for Mindfulness Science, USC Institute for Addiction Science, University of Southern California, United States of America
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28
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von Gunten CD, Wu LT. Comorbid Substance Use Disorder Profiles and Receipt of Substance Use Disorder Treatment Services: A National Study. J Stud Alcohol Drugs 2021; 82:246-256. [PMID: 33823972 PMCID: PMC8864624 DOI: 10.15288/jsad.2021.82.246] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 10/06/2020] [Indexed: 08/25/2023] Open
Abstract
OBJECTIVE Those with comorbid substance use disorders (SUDs) are a particularly vulnerable group. Information regarding the nature of these comorbidities and how they relate to receipt of substance use treatment could reduce the treatment gap that exists among those with comorbid SUDs. METHOD Public-use data from the 2015-2017 National Surveys on Drug Use and Health was used to analyze past-year SUD comorbidity combinations among 12 substances and the relationship between these combinations with past-year treatment in adults (N = 128,740). RESULTS In all, 7.9% of adults had at least one SUD in the past year (6.7% had one SUD, 0.9% had two SUDs, and 0.3% had three or more). Conditioning on specific SUDs, the prevalence of having additional SUDs ranged from 14.9% (alcohol) to 85.1% (hallucinogens). The four most common SUD combinations all included alcohol use disorder. Alcohol and marijuana use disorder was the most common comorbidity combination and had the lowest receipt of treatment. Compared to those with one SUD, adjusted odds of receiving treatment were almost two times greater for those with two SUDs, and more than four times greater for those with three or more SUDs. Treatment prevalence was lower for those who had higher family income and education, were not employed full time, were married, were younger than age 26 years or older than age 50 years, and were Asian. CONCLUSIONS Even though the treatment gap is reduced among those with multiple SUDs, it remains large. The most common and undertreated comorbid SUD combinations, in conjunction with the most underserved groups, could be targeted to facilitate treatment uptake.
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Affiliation(s)
- Curtis D. von Gunten
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University, Durham, North Carolina
| | - Li-Tzy Wu
- Department of Psychiatry and Behavioral Sciences, School of Medicine, Duke University, Durham, North Carolina
- Department of Medicine, Division of General Internal Medicine, School of Medicine, Duke University, Durham, North Carolina
- Center for Child and Family Policy, Sanford School of Public Policy, Duke University, Durham, North Carolina
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Abraham AJ, Yarbrough CR, Harris SJ, Adams GB, Andrews CM. Medicaid Expansion and Availability of Opioid Medications in the Specialty Substance Use Disorder Treatment System. Psychiatr Serv 2021; 72:148-155. [PMID: 33267651 PMCID: PMC8262068 DOI: 10.1176/appi.ps.202000049] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Research has examined the effect of Medicaid expansion on access to physicians with buprenorphine waivers, but less attention has been paid to Medicaid's impact on opioid use disorder medication availability within the specialty substance use disorder treatment system. To address this gap in the literature, this study examined the impact of Medicaid expansion on availability of opioid medications in specialty programs. METHODS This study used data from the National Survey of the Substance Abuse Treatment Services (2002-2017), containing all known substance use disorder treatment programs in the United States, to examine the effect of Medicaid expansion on the availability of opioid use disorder medications by treatment program ownership type (publicly owned, private for profit, and private nonprofit) among opioid treatment programs (OTPs) and non-OTPs. RESULTS The effects of Medicaid expansion were limited to nonprofit and for-profit OTPs. Medicaid expansion was associated with 135.1% and 57.5% increases in the number of nonprofit and for-profit OTPs offering injectable naltrexone, respectively, and with a 64.4% increase in the number of nonprofit OTPs offering buprenorphine. Nonprofit and for-profit OTPs compose <10% of the treatment system, indicating that improvements in opioid use disorder treatment associated with Medicaid expansion were limited to a small share of the specialty system. CONCLUSIONS The limited impact of Medicaid expansion on the specialty treatment system may perpetuate disparities in the accessibility and quality of opioid use disorder treatment for Medicaid enrollees and fail to alleviate high rates of opioid use disorder and opioid overdose deaths in this vulnerable population.
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Affiliation(s)
- Amanda J Abraham
- Department of Public Administration and Policy, School of Public and International Affairs, University of Georgia, Athens (Abraham, Harris); Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta (Yarbrough); Department of Health Policy and Management, College of Public Health, University of Georgia, Athens (Adams); Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia (Andrews)
| | - Courtney R Yarbrough
- Department of Public Administration and Policy, School of Public and International Affairs, University of Georgia, Athens (Abraham, Harris); Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta (Yarbrough); Department of Health Policy and Management, College of Public Health, University of Georgia, Athens (Adams); Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia (Andrews)
| | - Samantha J Harris
- Department of Public Administration and Policy, School of Public and International Affairs, University of Georgia, Athens (Abraham, Harris); Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta (Yarbrough); Department of Health Policy and Management, College of Public Health, University of Georgia, Athens (Adams); Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia (Andrews)
| | - Grace Bagwell Adams
- Department of Public Administration and Policy, School of Public and International Affairs, University of Georgia, Athens (Abraham, Harris); Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta (Yarbrough); Department of Health Policy and Management, College of Public Health, University of Georgia, Athens (Adams); Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia (Andrews)
| | - Christina M Andrews
- Department of Public Administration and Policy, School of Public and International Affairs, University of Georgia, Athens (Abraham, Harris); Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta (Yarbrough); Department of Health Policy and Management, College of Public Health, University of Georgia, Athens (Adams); Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia (Andrews)
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30
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Mojtabai R, Mauro C, Wall MM, Barry CL, Olfson M. Private health insurance coverage of drug use disorder treatment: 2005-2018. PLoS One 2020; 15:e0240298. [PMID: 33035265 PMCID: PMC7546457 DOI: 10.1371/journal.pone.0240298] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 09/23/2020] [Indexed: 11/19/2022] Open
Abstract
Many privately insured adults with drug use disorders in the United States do not have health care coverage for drug use treatment. The Affordable Care Act sought to redress this gap by including substance use treatments as essential health benefits under new plans offered. This study used data from 11,732 privately insured adult participants of the 2005-2018 National Survey on Drug Use and Health with drug use disorders to examine trends in drug use treatment coverage and the association of coverage with receiving treatment. 37.6% of the participants with drug use disorders did not know whether their plan covered drug use treatment, with little change over time. Among those who knew, coverage increased modestly between the 2005-2013 and 2014-2018 periods (73.5% vs. 77.5%, respectively, p = .015). Coverage was associated with receiving drug use treatment (adjusted odds ratio = 2.09, 95% confidence interval = 1.61-2.72, p < .001). However, even among participants with coverage, only 13.4% received treatment. Broader coverage of drug use treatment could potentially improve treatment rates.
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Affiliation(s)
- Ramin Mojtabai
- Department of Mental Health, Bloomberg School of Public Health and Department of Psychiatry, Johns Hopkins University, Baltimore, MD, United States of America
| | - Christine Mauro
- Mailman School of Public Health, Columbia University, New York, NY, United States of America
| | - Melanie M. Wall
- Mailman School of Public Health, Columbia University, New York, NY, United States of America
- Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, United States of America
| | - Colleen L. Barry
- Department of Health Policy and Management and Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States of America
| | - Mark Olfson
- Mailman School of Public Health, Columbia University, New York, NY, United States of America
- Department of Psychiatry, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, United States of America
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Abstract
Despite available treatment options for addiction, there remains an abysmal uptake of treatment initiation and engagement among varying communities. The existing treatment gap is based on historical occurrences, including discriminatory drug policies that have targeted communities of color with addiction. The current opioid epidemic and differential treatment therein exemplifies the severity of the existing disparity in addiction treatment, highlighting barriers such as institutionalized racism and vulnerabilities in the social determinants of health. To mitigate the disparity, an array of solutions to address these inequities are discussed, thereby providing a pathway forward to eliminating this treatment gap.
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Affiliation(s)
- Ayana Jordan
- Department of Psychiatry, Yale University School of Medicine, 300 George Street, Suite 901, New Haven, CT 06511, USA.
| | - Myra L Mathis
- Department of Psychiatry, University of Rochester, 601 Elmwood Avenue, Rochester, NY 14642, USA
| | - Jessica Isom
- Codman Square Health Center, Boston Medical Center, Randolph, Massachusetts, USA
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32
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Harati PM, Cummings JR, Serban N. Provider-Level Caseload of Psychosocial Services for Medicaid-Insured Children. Public Health Rep 2020; 135:599-610. [PMID: 32645279 DOI: 10.1177/0033354920932658] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE We estimated the caseload of providers, practices, and clinics for psychosocial services (including psychotherapy) to Medicaid-insured children to improve the understanding of the current supply of such services and to inform opportunities to increase their accessibility. METHODS We used 2012-2013 Medicaid claims data and data from the 2013 National Plan and Provider Enumeration System to identify and locate therapists, psychiatrists, and mental health centers along with primary, rehabilitative, and developmental care providers in the United States who provided psychosocial services to Medicaid-insured children. We estimated the per-provider, per-location, and state-level caseloads of providers offering these services to Medicaid-insured children in 34 states with sufficiently complete data to perform this analysis, by using the most recent year of Medicaid claims data available for each state. We measured caseload by calculating the number of psychosocial visits delivered by each provider in the selected year. We compared caseloads across states, urbanicity, provider specialty (eg, psychiatry, psychology, primary care), and practice setting (eg, mental health center, single practitioner). RESULTS We identified 63 314 providers, practices, or centers in the Medicaid claims data that provided psychosocial services to Medicaid-insured children in either 2012 or 2013. The median provider-level per-year caseload was <25 children and <250 visits across all provider types. Providers with a mental health center-related taxonomy accounted for >40% of visits for >30% of patients. Fewer than 10% of providers and locations accounted for >50% of patients and visits. CONCLUSIONS Psychosocial services are concentrated in a few locations, thereby reducing geographic accessibility of providers. Providers should be incentivized to offer care in more locations and to accept more Medicaid-insured patients.
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Affiliation(s)
- Pravara M Harati
- 1372122529 H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Janet R Cummings
- 1371 Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Nicoleta Serban
- 1372122529 H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, GA, USA
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Pro G, Utter J, Haberstroh S, Baldwin JA. Dual mental health diagnoses predict the receipt of medication-assisted opioid treatment: Associations moderated by state Medicaid expansion status, race/ethnicity and gender, and year. Drug Alcohol Depend 2020; 209:107952. [PMID: 32172130 PMCID: PMC7537819 DOI: 10.1016/j.drugalcdep.2020.107952] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 02/26/2020] [Accepted: 02/28/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Mental health diagnoses (MHD) are common among those with opioid use disorders (OUD). Methadone/buprenorphine are effective medication-assisted treatment (MAT) strategies; however, treatment receipt is low among those with dual MHDs. Medicaid expansions have broadly increased access to OUD and mental health services over time, but MAT uptake may vary depending on multiple factors, including MHD status, state Medicaid expansion decisions, and race/ethnicity and gender. Examining clinical and policy approaches to promoting MAT uptake may improve services among marginalized groups. METHODS MAT treatment discharges were identified using the Treatment Episodes Dataset-Discharges (TEDS-D; 2014-2017) (n = 1,400,808). We used multivariate logistic regression to model MAT receipt using interactions and adjusted for several potential confounders. RESULTS Nearly one-third of OUD treatment discharges received MAT. Dual MHDs in both expansion and non-expansion states were positively associated with MAT uptake over time. Dual MHDs were negatively associated with MAT receipt only among American Indian/Alaska Native women residing in Medicaid expansion states (aOR = 0.58, 95 % CI = 0.52-0.66, p < 0.0001). CONCLUSION Disparities in MAT utilization are nuanced and vary widely depending on dual MHD status, Medicaid expansion, and race/ethnicity/gender. Medicaid is beneficial but not a universal treatment panacea. Clinical decisions to initiate MAT are dependent on multiple factors and should be tailored to meet the needs of high-risk, historically disadvantaged clients.
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Affiliation(s)
- George Pro
- Northern Arizona University, Center for Health Equity Research, 1395 South Knoles Drive, Flagstaff, AZ, 86011, USA.
| | - Jeff Utter
- University of Colorado, Department of Family Medicine, Colorado University Anschutz, 12631 East 17th Avenue, Aurora, CO, 80045, USA.
| | - Shane Haberstroh
- Northern Arizona University, Department of Educational Psychology, 801 South Knoles Drive, Flagstaff, AZ, 86011, USA.
| | - Julie A Baldwin
- Northern Arizona University, Center for Health Equity Research, 1395 South Knoles Drive, Flagstaff, AZ, 86011, USA.
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Abraham AJ, Andrews CM, Harris SJ, Friedmann PD. Availability of Medications for the Treatment of Alcohol and Opioid Use Disorder in the USA. Neurotherapeutics 2020; 17:55-69. [PMID: 31907876 PMCID: PMC7007488 DOI: 10.1007/s13311-019-00814-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Despite high mortality rates due to opioid overdose and excessive alcohol consumption, medications for the treatment of alcohol and opioid use disorder have not been widely used in the USA. This paper provides an overview of the literature on the availability of alcohol and opioid used disorder medications in the specialty substance use disorder treatment system, other treatment settings and systems, and among providers with a federal waiver to prescribe buprenorphine. We also present the most current data on the availability of alcohol and opioid use disorder medications in the USA. These estimates show steady growth in availability of opioid use disorder medications over the past decade and a decline in availability of alcohol use disorder medications. However, overall use of medications in the USA remains low. In 2017, only 16.3% of specialty treatment programs offered any single medication for alcohol use disorder treatment and 35.5% offered any single medication for opioid use disorder treatment. Availability of buprenorphine-waivered providers has increased significantly since 2002. However, geographic disparities in access to buprenorphine remain. Some of the most promising strategies to increase availability of alcohol and opioid use disorder medications include the following: incorporating substance use disorder training in healthcare education programs, educating the substance use disorder workforce about the benefits of medication treatment, reducing stigma surrounding the use of medications, implementing medications in primary care settings, implementing integrated care models, revising regulations on methadone and buprenorphine, improving health insurance coverage of medications, and developing novel medications for the treatment of substance use disorder.
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Affiliation(s)
- Amanda J. Abraham
- School of Public and International Affairs, University of Georgia, 280F Baldwin Hall, 355 S. Jackson Street, Athens, GA 30602 USA
| | - Christina M. Andrews
- College of Social Work, University of South Carolina, 1512 Pendleton St., Room 309, Columbia, SC 29208 USA
| | - Samantha J. Harris
- School of Public and International Affairs, University of Georgia, 280F Baldwin Hall, 355 S. Jackson Street, Athens, GA 30602 USA
| | - Peter D. Friedmann
- University of Massachusetts Medical School Baystate, 280 Chestnut St., Springfield, MA 01199 USA
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Predictors of availability of long-acting medication for opioid use disorder. Drug Alcohol Depend 2019; 204:107586. [PMID: 31593871 PMCID: PMC6910228 DOI: 10.1016/j.drugalcdep.2019.107586] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 08/07/2019] [Accepted: 08/08/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND The U.S. Food and Drug Administration has approved three long-acting medications for opioid use disorder (MOUD): extended-release naltrexone (XR-NTX) in 2010, a subdermal buprenorphine implant in 2016, and a depot buprenorphine injection in 2017. Long-acting MOUD options may improve adherence while reducing diversion, but their availability compared to daily-dosing MOUD has not been well-characterized. The objective of this analysis was to characterize the availability of long-acting MOUD in substance use disorder treatment settings in the United States. METHODS Using the 2017 National Survey on Substance Abuse Treatment Services (N-SSATS) and state-level opioid overdose mortality, we examined associations between state- and facility-level factors and offering long-acting MOUD, which included XR-NTX and the buprenorphine implant. We constructed multivariable mixed logistic regression models for both types of long-acting MOUD. RESULTS Nationwide, 38% (n = 5141) of substance use treatment facilities provided any kind of MOUD (daily or long-acting). Of these, 62% provided XR-NTX, whereas only 3% offered the buprenorphine implant. Facilities in the East North Central, East South Central, West North Central and Mountain regions had higher odds of offering XR-NTX, as did federally-funded facilities, and facilities in states with the highest opioid overdose mortality rates. CONCLUSIONS In 2017, XR-NTX was available at most of the minority of facilities offering MOUD, but the buprenorphine implant was not. Increasing the availability of MOUD, including long-acting options, is necessary to address unmet need for opioid use disorder treatment.
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Mulia N, Lui CK, Ye Y, Subbaraman MS, Kerr WC, Greenfield TK. U.S. alcohol treatment admissions after the Mental Health Parity and Addiction Equity Act: Do state parity laws and race/ethnicity make a difference? J Subst Abuse Treat 2019; 106:113-121. [PMID: 31451310 DOI: 10.1016/j.jsat.2019.08.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 07/11/2019] [Accepted: 08/10/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND The U.S. Mental Health Parity and Addiction Equity Act (MHPAEA) was a landmark federal policy aimed at increasing access to substance use treatment, yet studies have found relatively weak impacts on treatment utilization. The present study considers whether there may be moderating effects of pre-existing state parity laws and differential changes in treatment rates across racial/ethnic groups. METHODS We analyzed data from SAMHSA'S Treatment Episode Data Set (TEDS) from 1999 to 2013, assessing changes in alcohol treatment admission rates across states with heterogeneous, pre-existing parity laws. NIAAA's Alcohol Policy Information System data were used to code states into five groups based on the presence and strength of states' pre-MHPAEA mandates for insurance coverage of alcohol treatment and parity (weak; coverage no parity; partial parity if coverage offered; coverage and partial parity; strong). Regression models included state fixed effects and a cubic time trend adjusting for state- and year-level covariates, and assessed MHPAEA main effects and interactions with state parity laws in the overall sample and racial/ethnic subgroups. RESULTS While we found no significant main effects of federal parity on alcohol treatment rates, there was a significantly greater increase in treatment rates in states requiring health plans to cover alcohol treatment and having some pre-existing parity. This was seen overall and in all three racial/ethnic groups (increasing by 25% in whites, 26% in blacks, and 42% in Hispanics above the expected treatment rate for these groups). Post-MHPAEA, the alcohol treatment admissions rate in these states rose to the level of states with the strongest pre-existing parity laws. CONCLUSION The MHPAEA was associated with increased alcohol treatment rates for diverse racial/ethnic groups in states with both alcohol treatment coverage mandates and some prior parity protections. This suggests the importance of the local policy context in understanding early effects of the MHPAEA.
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Affiliation(s)
- Nina Mulia
- Alcohol Research Group, Public Health Institute, 6001 Shellmound St., Suite 450, Emeryville, CA 94608, USA.
| | - Camillia K Lui
- Alcohol Research Group, Public Health Institute, 6001 Shellmound St., Suite 450, Emeryville, CA 94608, USA
| | - Yu Ye
- Alcohol Research Group, Public Health Institute, 6001 Shellmound St., Suite 450, Emeryville, CA 94608, USA
| | - Meenakshi S Subbaraman
- Alcohol Research Group, Public Health Institute, 6001 Shellmound St., Suite 450, Emeryville, CA 94608, USA
| | - William C Kerr
- Alcohol Research Group, Public Health Institute, 6001 Shellmound St., Suite 450, Emeryville, CA 94608, USA
| | - Thomas K Greenfield
- Alcohol Research Group, Public Health Institute, 6001 Shellmound St., Suite 450, Emeryville, CA 94608, USA
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Shover CL, Abraham A, D'Aunno T, Friedmann PD, Humphreys K. The relationship of Medicaid expansion to psychiatric comorbidity care within substance use disorder treatment programs. J Subst Abuse Treat 2019; 105:44-50. [PMID: 31443890 DOI: 10.1016/j.jsat.2019.07.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 05/31/2019] [Accepted: 07/22/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Co-occurring mental health disorders are common among substance use disorder (SUD) patients. Medicaid expansion aimed to reduce barriers to SUD and mental health care and thereby improve treatment outcomes. METHODS We estimated change in the proportion of United States SUD treatment sites offering treatment for psychiatric comorbidities following Medicaid expansion as part of implementation of the Affordable Care Act (ACA) in 2014. Using panel data from the 2013-2014, n = 660, and 2016-2017, n = 638, waves of the National Drug Abuse Treatment System Survey (NDATSS), we estimated change in the proportion of sites offering antidepressant medication, other psychiatric medication, behavioral treatment, or any combination thereof for treatment of mental health comorbidities (i.e., beyond services focused on SUD). We modeled the impact of Medicaid expansion as an interaction between year and date of Medicaid expansion. We constructed a mixed-effects linear regression model for each outcome, with the interaction variable as the main exposure, site as a random effect, and site's average duration of treatment, proportion of clients with psychiatric comorbidities, average caseload per treatment prescribing-clinician on staff, type of facility and geographic region as covariates, to estimate a difference-in-differences (D-I-D) equation. RESULTS The adjusted D-I-D analysis indicated that the proportion of SUD treatment sites offering antidepressants for psychiatric treatment increased 10% (95% CI 1%, 18%) in the Medicaid expansion sites compared to non-expansion sites. The D-I-D for other psychiatric medications was also 10% (95% 1%, 19%). No significant changes were observed in behavioral treatment or the combination measure. The strongest association between Medicaid expansion and offering medication for mental health comorbidities was the 34% increase observed for residential treatment settings (95% CI 10%, 59%). CONCLUSION Availability of psychiatric medication treatment in SUD treatment settings increased following Medicaid expansion, particularly in residential SUD facilities. This policy change has facilitated integrated treatment for the substantial share of SUD treatment patients with mental health comorbidities, with the greatest benefit for patients receiving SUD treatment in residential programs.
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Affiliation(s)
- Chelsea L Shover
- Stanford University, Department of Psychiatry, 401 N. Quarry Rd., Stanford, CA 94305, United States of America.
| | - Amanda Abraham
- University of Georgia, School of Public and International Affairs, 280F Baldwin Hall, Athens, GA 30602, United States of America.
| | - Thomas D'Aunno
- New York University, Wagner Graduate School of Public Service, 295 Lafayette St., New York, NY 10012, United States of America.
| | - Peter D Friedmann
- University of Massachusetts Medical School - Baystate, Office of Research, 3601 Main St., Springfield, MA 01107, United States of America.
| | - Keith Humphreys
- Stanford University, Department of Psychiatry, 401 N. Quarry Rd., Stanford, CA 94305, United States of America; Veterans Affairs Palo Alto Health Care System, 795 Willow Rd., Menlo Park, CA 94025, United States of America.
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