Changes in Buprenorphine Treatment After Medicaid Expansion

Treatment setting and buprenorphine discontinuation: an analysis of multi-state insurance claims

BACKGROUND

Potential differences in buprenorphine treatment outcomes across various treatment settings are poorly characterized in multi-state administrative data. We thus evaluated the association of opioid use disorder (OUD) treatment setting and insurance type with risk of buprenorphine discontinuation among commercial insurance and Medicaid enrollees initiated on buprenorphine.

METHODS

In this observational, retrospective cohort study using the Merative MarketScan databases (2006-2016), we analyzed buprenorphine retention in 58,200 US adults with OUD. Predictor variables included insurance status (Medicaid vs commercial) and treatment setting, operationalized as substance use disorder (SUD) specialty treatment facility versus outpatient primary care physicians (PCPs) versus outpatient psychiatry, ascertained by linking physician visit codes to buprenorphine prescriptions. Treatment setting was inferred based on timing of prescriber visit claims preceding prescription fills. We estimated time to buprenorphine discontinuation using multivariable cox regression.

RESULTS

Among enrollees with OUD receiving buprenorphine, 26,168 (45.0%) had prescriptions from SUD facilities without outpatient buprenorphine treatment, with the remaining treated by outpatient PCPs (n = 23,899, 41.1%) and psychiatrists (n = 8133, 13.9%). Overall, 50.6% and 73.3% discontinued treatment at 180 and 365 days respectively. Buprenorphine discontinuation was higher among enrollees receiving prescriptions from SUD facilities (aHR = 1.03[1.01-1.06]) and PCPs (aHR = 1.07[1.05-1.10]). Medicaid enrollees had lower buprenorphine retention than those with commercial insurance, particularly those receiving buprenorphine from SUD facilities and PCPs (aHR = 1.24[1.20-1.29] and aHR = 1.39[1.34-1.45] respectively, relative to comparator group of commercial insurance enrollees receiving buprenorphine from outpatient psychiatry).

CONCLUSION

Buprenorphine discontinuation is high across outpatient PCP, psychiatry, and SUD treatment facility settings, with potentially lower treatment retention among Medicaid enrollees receiving care from SUD facilities and PCPs.

Changes in buprenorphine waivered provider supply after Virginia Medicaid implements the addiction and recovery treatment services program and Medicaid expansion

BACKGROUND

Shortages of providers authorized to prescribe buprenorphine may limit access to buprenorphine, which studies have shown to be effective in the treatment of opioid use disorder (OUD).

OBJECTIVE

To examine whether two state Medicaid policies in Virginia-the Addiction and Recovery Treatment Services (ARTS) program in 2017, and Medicaid expansion in 2019-increased the number of buprenorphine waivered providers (BWP) in Virginia, compared to other southern states in the United States that did not expand Medicaid.

METHODS

The study population includes providers authorized to prescribe buprenorphine. We compute the number of BWP per 100,000 people for the study states, overall and for different waiver limits (30, 100 or 275). Using difference-in-difference regression models, we examine changes in BWP rates for Virginia relative to nonexpansion states in the US South between 2015 and 2020.

RESULTS

The rate of increase in BWP was higher in Virginia after implementation of ARTS and Medicaid expansion (148 %), compared to southern nonexpansion states over the same time period (115 %). Relative to nonexpansion states in the South, BWP with patient limits of 100 or 275 increased by 7 % in Virginia after ARTS implementation in 2017, and by an additional 22 % after Medicaid expansion in 2019 (p < 0.05 each).

CONCLUSIONS

The findings suggest that public policies that expand access to OUD treatment services-including buprenorphine treatment-may also increase the supply of providers authorized to prescribe buprenorphine, helping to alleviate shortages of BWP providers and further increasing access to care.

Differences in medicaid expansion effects on buprenorphine treatment utilization by county rurality and income: A pharmacy data claims analysis from 2009-2018

Background

Although use of buprenorphine for treating opioid use disorder increased over the past decade, buprenorphine utilization remains limited in lower-income and rural areas. We examine how the Affordable Care Act Medicaid expansion influenced buprenorphine initiation rates by county income and evaluate how associations differ by county rural-urban status.

Methods

This study used nationwide 2009-2018 IQVIA retail pharmacy data and a comparative interrupted time series framework-a hybrid framework combining regression discontinuity and difference-in-difference approaches. We used piecewise linear estimation to quantify changes in buprenorphine initiation rates before and after Medicaid expansion.

Results

The sample included observations from 376,704 county-months. We identified 5,227,340 new buprenorphine treatment episodes, with an average of 9.2 new buprenorphine episodes per month per 100,000 county residents. Among urban counties, those with the lowest median incomes experienced significantly larger increases in buprenorphine initiation rates associated with Medicaid expansion than counties with higher median incomes (5-year rates difference est=3525.3, se=1695.3, p = 0.04). However, among rural counties, there was no significant association between buprenorphine initiation rates and county median income after Medicaid expansion (5-year rates difference est=979.0, se=915.8, p = 0.29).

Conclusions

Medicaid expansion was associated with a reduction in income-related buprenorphine disparities in urban counties, but not in rural counties. To achieve more equitable buprenorphine access, future policies should target low-income rural areas.

The impact of Medicaid expansion on mental health and substance use related inpatient visits

OBJECTIVE

Under the Affordable Care Act, many states expanded their Medicaid eligibility, allowing individuals living at or below 138% of the Federal Poverty Level to receive insurance coverage. As a result, forty states and the District of Columbia have expanded Medicaid to date. Although Medicaid expansion is expected to increase access to care in general, it is not evident if it has helped increase access to mental health and substance use-related healthcare, especially in inpatient settings. Therefore, this study examines the impact of Medicaid expansion on mental health and substance use- (MHSU) related inpatient visits and the variation in payer mix.

METHODS

This study utilizes state-level quarterly inpatient visit data from the Healthcare Cost and Utilization Project's Fast Stats Database from 2005 to 2019 and performs difference-in-differences regression analyses to compare MHSU-related inpatient visit data in expansion and non-expansion states for all visits and by payer. Analyses controlled for state-level socio-demographic and health policy variables.

RESULTS

Findings indicate that Medicaid expansion did not significantly affect overall MHSU-related inpatient visits. However, Medicaid expansion was associated with 22.74% increase (P < 0.01; 95% CI: 17.76, 27.71) in the Medicaid share of MHSU-related inpatient visits, 18.31% reduction (P < 0.01; 95% CI: -22.54, -14.09) in the uninsured share of MHSU-related inpatient visits, and 4.42% reduction (P < 0.05; 95% CI: -7.83, -1.01) in the privately insured share of MHSU-related inpatient visits in expansion states compared with non-expansion states.

CONCLUSIONS

Findings show that Medicaid expansion significantly affects the payer mix associated with MHSU-related inpatient visits while it has no significant impact on the overall MHSU-related inpatient visits.

State Policy and the Breadth of Buprenorphine-Prescriber Networks in Medicaid Managed Care

Provider networks in Medicaid Managed Care (MMC) play a crucial role in ensuring access to buprenorphine, a highly effective treatment for opioid use disorder. Using a difference-in-differences approach that compares network breadth across provider specialties and market segments within the same state, we investigated the association between three Medicaid policies and the breadth of MMC networks for buprenorphine prescribers: Medicaid expansion, substance use disorder (SUD) network adequacy criteria, and SUD carveouts. We found that both Medicaid expansion and SUD network adequacy criteria were associated with substantially increased breadth in buprenorphine-prescriber networks in MMC. In both cases, we found that the associations were largely driven by increases in the network breadth of primary care physician prescribers. Our findings suggest that Medicaid expansion and SUD network adequacy criteria may be effective strategies at states' disposal to improve access to buprenorphine.

National Trends in Buprenorphine Treatment for Opioid Use Disorder From 2007 to 2018

BACKGROUND

Buprenorphine is a key medication to treat opioid use disorder (OUD). Since its approval in 2002, buprenorphine access has grown markedly, spurred by major federal and state policy changes. This study characterizes buprenorphine treatment episodes during 2007 to 2018 with respect to payer, provider specialty, and patient demographics.

METHODS

In this observational cohort study, IQVIA Real World pharmacy claims data were used to characterize trends in buprenorphine treatment episodes across four time periods: 2007-2009, 2010-2012, 2013-2015, and 2016-2018.

RESULTS

In total, we identified more than 4.1 million buprenorphine treatment episodes among 2 540 710 unique individuals. The number of episodes doubled from 652 994 in 2007-2009 to 1 331 980 in 2016-2018. Our findings indicate that the payer landscape changed dramatically, with the most pronounced growth observed for Medicaid (increased from 17% of episodes in 2007-2009 to 37% of episodes in 2016-2018), accompanied by relative declines for both commercial insurance (declined from 35 to 21%) and self-pay (declined from 27 to 11%). Adult primary care providers (PCPs) were the dominant prescribers throughout the study period. The number of episodes among adults older than 55 increased more than 3-fold from 2007-2009 to 2016-2018. In contrast, youth under age 18 experienced an absolute decline in buprenorphine treatment episodes. Buprenorphine episodes increased in length from 2007-2018, particularly among adults over age 45.

CONCLUSIONS

Our findings demonstrate that the U.S. experienced clear growth in buprenorphine treatment-particularly for older adults and Medicaid beneficiaries-reflecting some key health policy and implementation success stories. Yet, since the prevalence of OUD and fatal overdose rate have also approximately doubled during this period, the observed growth in buprenorphine treatment did not demonstrably impact the pronounced treatment gap. To date, only a minority of individuals with OUD currently receive treatment, indicating continued need for systemic efforts to equitably improve treatment uptake.

Exploring the Association of State Policies and the Trajectories of Buprenorphine Prescriber Patient Caseloads

BACKGROUND

Increasing buprenorphine access is critical to facilitating effective opioid use disorder treatment. Buprenorphine prescriber numbers have increased substantially, but most clinicians who start prescribing buprenorphine stop within a year, and most active prescribers treat very few individuals. Little research has examined state policies' association with the evolution of buprenorphine prescribing clinicians' patient caseloads.

METHODS

Our retrospective cohort study design derived from 2006 to 2018 national pharmacy claims identifying buprenorphine prescribers and the number of patients treated monthly. We defined persistent prescribers based on results from a k-clustering approach and were characterized by clinicians who did not quickly stop prescribing and had average monthly caseloads greater than 5 patients for much of the first 6 years after their first dispensed prescription. We examined the association between persistent prescribers (dependent variable) and Medicaid coverage of buprenorphine, prior authorization requirements, and mandated counseling policies (key predictors) that were active within the first 2 years after a prescriber's first observed dispensed buprenorphine prescription. We used multivariable logistic regression analyses and entropy balancing weights to ensure better comparability of prescribers in states that did and did not implement policies.

RESULTS

Medicaid coverage of buprenorphine was associated with a smaller percentage of new prescribers becoming persistent prescribers (OR = 0.72; 95% CI = 0.53, 0.97). There was no evidence that either mandatory counseling or prior authorization was associated with the odds of a clinician being a persistent prescriber with estimated ORs equal to 0.85 (95% CI = 0.63, 1.16) and 1.13 (95% CI = 0.83, 1.55), respectively.

CONCLUSIONS

Compared to states without coverage, states with Medicaid coverage for buprenorphine had a smaller percentage of new prescribers become persistent prescribers; there was no evidence that the other state policies were associated with changes in the rate of clinicians becoming persistent prescribers. Because buprenorphine treatment is highly concentrated among a small group of clinicians, it is imperative to increase the pool of clinicians providing care to larger numbers of patients for longer periods. Greater efforts are needed to identify and support factors associated with successful persistent prescribing.

Oral buprenorphine utilization, concomitant benzodiazepines and opioid analgesics, and payment source: Trends from 2015 to 2019

INTRODUCTION

This study describes utilization patterns of oral buprenorphine products indicated for the treatment of opioid use disorder with a focus on patterns consistent with prescribing guidelines and the safe use conditions during induction and maintenance treatment outlined by the Risk Evaluation and Mitigation Strategy (REMS) Program, including trends over time.

METHODS

Using an anonymized longitudinal patient-level dataset that captures information on medical and pharmacy claims in the United States (October 1, 2014 through March 31, 2020), buprenorphine prescriptions, days' supply, and daily dose were described overall and stratified by induction (month 1) vs. maintenance (month 2-6) treatment, along with duration of concomitant benzodiazepines or opioid analgesics.

RESULTS

Overall, there were 1.5 million buprenorphine treatment episodes initiated between January 1, 2015 to September 30, 2019 (2015: 258,899; 2019: 351,378). Treatment episodes included an average of 6.8 buprenorphine prescriptions (standard deviation [SD] = 6.7), 16.8 days' supply per prescription (SD = 10.5), 94.2 total days' supply per treatment episode (SD = 71.4), and a mean daily dose of 13.6 mg (SD = 6.3), with the number of prescriptions and total days' supply per treatment episode declining over the study period. There was a lower mean number of days' supply per prescription in the first month of treatment compared to months 2-6 (month 1: 15.8 [SD = 11.0]; month 2-6: 19.0 [SD = 10.1]) and daily dose per prescription (month 1: 13.3 mg [SD = 6.4]; months 2-6: 14.3 mg [SD = 6.2]), and a higher mean number of prescriptions per month (month 1: 2.5 per month [SD = 1.7]; months 2-6: 1.8 per month [SD = 1.2]). From 2015 to 2019, there appeared to be a shift in payer mix, with increases in Medicaid/Medicare and declines in cash and commercial insurance. Concomitant benzodiazepine and opioid analgesic use declined over time; in 2019, 16.6 % and 14.3 % of treatment episodes had any concomitant benzodiazepine or opioid analgesic, respectively, and <5 % had chronic (>90 overlapping days) concomitant use (3.0 % and 0.4 %, respectively).

CONCLUSIONS

The number of oral buprenorphine treatment episodes increased over the study period, and prescribing was generally consistent with the REMS and other treatment guidelines. There was a decline in concomitant buprenorphine and benzodiazepine or opioid analgesics, and chronic concomitant use was rare.

Endogenous opiates and behavior: 2021

This paper is the forty-fourth consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2021 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonizts and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

Medicaid Managed Care: Access To Primary Care Providers Who Prescribe Buprenorphine

Medicaid managed care insurers play a crucial role in facilitating access to buprenorphine to treat opioid use disorder. Using a novel set of provider directory and prescription claims data, we examined variation in access to in-network buprenorphine-prescribing primary care providers among Medicaid managed care enrollees. Approximately 32.2 percent of enrollees had fewer than one in-network buprenorphine prescriber per 100,000 county residents. On average, there were a greater number of in-network buprenorphine-prescribing primary care providers in states with higher compared with lower overdose death rates. However, most enrollees lived in areas with a shortage of these providers. We found that a 25 percent higher network participation rate by prescribers compared with nonprescribers could improve the probability that enrollees see a prescriber by approximately 25 percent. Policies to improve access within Medicaid managed care include using primary care provider assignment algorithms to match patients with buprenorphine prescribers and requiring that networks include a minimum number of buprenorphine prescribers.