Black clients in expansion states who used opioids were more likely to access medication for opioid use disorder after ACA implementation

MOUD use among Hispanic clients increased post-ACA, yet differed by heritage and geographic location

BACKGROUND

Overdose death rates for Hispanic people rose 2010-2022. Opioid overdose rates grew faster among Hispanic people than non-Hispanic White people ("White"). Medication for opioid use disorder (MOUD) is an effective but underutilized intervention for decreasing overdose risk. The Affordable Care Act ("ACA") should have increased MOUD use, but insurance and behavioral health reforms differed by state. We examined to what extent MOUD use increased post-ACA implementation and differed for Hispanic people (overall and by heritage group) compared to White people who used opioids ("clients").

METHODS

We analyzed first annual ambulatory care episodes (TEDS-A, 2009-2019) for working-age Hispanic (N= 76,591) and White (N=444,753) clients. We categorized Hispanic clients by heritage group (Puerto Rican, Mexican, or Other Hispanic). We grouped states by Medicaid expansion status (California, Other Expansion States, and Non-Expansion States). We used logistic regression to compare the odds of MOUD use pre/post ACA within racial/heritage groups, and, separately, between racial/heritage groups using pre-ACA White clients as a reference group. We used linear probability difference-in-differences to confirm changes in MOUD use between Hispanic and White clients.

RESULTS

Among Hispanic clients in ambulatory care, MOUD use was lowest in the Non-Expansion States and highest in California. Nationally, only Puerto Rican and Other Hispanic heritage clients had higher odds of MOUD post-ACA compared to pre-ACA. Nationally and in Other Expansion States, Hispanic and White clients had similar increases in MOUD use post-ACA.

CONCLUSIONS

MOUD use among Hispanic clients rose post-ACA, but differences remained between Hispanic heritage groups and between states.

State drug caps associated with fewer Medicaid-covered prescriptions for opioid use disorder, 2017-2022

The Medicaid program is the largest payer of opioid use disorder (OUD) treatment, including medications for OUD (MOUD). Because of budget neutrality requirements, some Medicaid programs use prescription drug caps to limit the monthly number of prescriptions an enrollee can fill. This study examined the association between Medicaid prescription drug caps and Medicaid-covered prescriptions for 2 forms of MOUD (buprenorphine and naltrexone) from 2017 to 2022 using fee-for-service and managed care data from Medicaid's State Drug Utilization Data. Ten states had monthly prescription drug caps, ranging from 3 to 6 prescriptions. Using multivariate linear regression, we estimated that enrollees in states with monthly drug caps filled 1489.3 fewer MOUD prescriptions per 100 000 enrollees. Further, compared with states with the smallest drug caps (3 drugs), enrollees in states with 4-, 5-, and 6-drug caps filled significantly more prescriptions per state-quarter (907.7, 562.6, and 438.9 more prescriptions, respectively). Our results were robust to sensitivity analyses. Monthly prescription drug caps were significantly associated with a reduction in Medicaid-covered MOUD prescriptions. Medicaid enrollees who need MOUD may be affected by indiscriminate prescription drug cap policies, potentially hindering ongoing efforts to mitigate the opioid crisis.

Expanding access to medication treatment for opioid use disorders: Findings from the Washington State hub and spoke effort

BACKGROUND

Opioid use disorder (OUD) is a leading cause of preventable death and injury nationwide. Efforts to increase the use of medication for opioid use disorder (MOUD) are needed. In 2017, Washington State implemented a Hub and Spoke (HS) model of care with the primary goal of expanding access to MOUD. We examined changes in MOUD utilization among Washington State Medicaid beneficiaries before and after HS implementation.

METHODS

We used Medicaid claims data to examine longitudinal changes in MOUD use for beneficiaries with OUD. We conducted a comparative interrupted time series analysis to examine the association between HS policy implementation and rates of MOUD utilization, overall and by type of medication.

RESULTS

Between 2016 and 2019, a period of increasing OUD prevalence, rates of MOUD utilization among Washington Medicaid beneficiaries increased overall from 39.7 to 50.5. Following HS implementation, rates of MOUD use grew at a significantly greater rate in the HS cohort than in the non-HS cohort (β=0.54, SE=0.02, p< 0.0001, 95% CI 0.49, 0.59). Analyses by medication type show that this rate increase was primarily due to buprenorphine use (β= 0.61, SE= 0.02, p< 0.0001, 95% CI 0.57, 0.65).

CONCLUSION

Improved systems of care are needed to make MOUD accessible to all patients in need. The Washington HS model is one strategy that may facilitate and expand MOUD use, particularly buprenorphine. Over the study period, Washington State saw increased use of buprenorphine, which was an emphasis of their HS model.

Is there a disparity in medications for opioid use disorder based on race/ethnicity and gender? A systematic review and meta-analysis

BACKGROUND

Access to medications for opioid use disorder (MOUD) among racial/ethnic minorities is a growing concern.

OBJECTIVES

Inequalities in receiving MOUD among gender and racial/ethnic groups were examined in this systematic review.

METHODS

Studies were retrieved by searching various databases and reference lists of reviews and selected full texts. Adjusted Odds Ratios (AORs) comparing MOUDs among racial/ethnic minorities to Whites were extracted or estimated from their findings. Meta-analysis was performed using STATA 17.

RESULTS

After screening 2438 records, 19 studies were included in this review in two categories. The first category consists of 11 studies comparing receiving MOUD between different races/ethnicities and genders at the individual level. The meta-analysis regarding AORs comparing Blacks, Hispanics, Asians, Native Americans/Alaska-Natives, Hawaiians, and mixed-race patients with Whites were 0.56 (95 % CI: 0.45-0.68), 0.72 (95 % CI: 0.55-0.94), 0.85 (95 % CI: 0.72-0.99), 0.88 (95%CI: 0.73-1.04), 0.27 (95 % CI: 0.03-2.18), and 0.97 (95 % CI: 0.81-1.16), respectively. The AOR of receiving MOUD for all minorities compared to Whites was 0.70 (95 % CI: 0.61-0.80). Overall AOR comparing MOUD for females to males was 0.95 (95 % CI: 0.87-1.04). The second category of articles compared buprenorphine and methadone treatment among ethnic/racial minorities and Whites.

CONCLUSIONS

Compared to Whites, Blacks, Hispanics, and Asians have limited access to MOUD. The findings suggest that methadone is the predominant medication for racial/ethnic minorities, while Whites and high-income communities receive buprenorphine more. It is crucial to re-design policies to bridge the gap in access to MOUD.

Mortality, incarceration and cost implications of fentanyl felonization laws: A modeling study

BACKGROUND

Opioid overdose continues to be a major cause of death in the United States. One effort to control opioid use has been to implement policies that enhance criminalization of opioid possession. Laws to further criminalize possession of fentanyl have been enacted or are under consideration across the country, including at the national level.

OBJECTIVE

Estimate the long-term effects on opioid death and incarceration resulting from increasingly strict fentanyl possession laws .

DESIGN

We built a Markov simulation model to explore the potential outcomes of a 2022 Colorado law which made possession of >1 g of drug with any amount of fentanyl a Level 4 drug felony (and escalation of the previous law, where >4 g of any drug with any amount of fentanyl in possession was considered a felony). The model simulates a cohort of people with fentanyl possession moving through the criminal justice system, exploring the probability of overdose and incarceration under different scenarios, including various fentanyl possession policies and potential interventions.

SETTING

Colorado PARTICIPANTS: A simulated cohort of people in possession of fentanyl.

MEASUREMENTS

Number of opioid overdose deaths, people incarcerated, and associated costs over 5 years.

RESULTS

When >4 g of a drug containing any amount of fentanyl is considered a felony in Colorado, the model predicts 5460 overdose deaths (95% CrI 410-9260) and 2,740 incarcerations for fentanyl possession (95% CrI: 230-10,500) over 5 years. When the policy changes so that >1 g possession of drug with fentanyl is considered a felony, opioid overdose deaths increase by 19% (95% CRI: 16-38%) and incarcerations for possession increase by 98% (CrI: 85-98%). Diversion programs and MOUD in prison help alleviate some of the increases in death and incarceration, but do not completely offset them.

LIMITATIONS

The mathematical model is meant to offer broad assessment of the impact of these policies, not forecast specific and exact numerical outcomes.

CONCLUSIONS

Our model shows that lowering thresholds for felony possession of fentanyl containing drugs can lead to more opioid overdose deaths and incarceration.

Impact of Medicaid expansion on inclusion of medications for opioid use disorder in homeless adults' treatment plans

INTRODUCTION

People experiencing homelessness (PEH) bear disproportionate opioid mortality. This article aims to determine how state Medicaid expansion under the Affordable Care Act impacted the inclusion of medications for opioid use disorder (MOUD) in treatment plans for housed versus homeless individuals.

METHODS

The Treatment Episodes Data Set (TEDS) provided data on 6,878,044 U.S. treatment admissions between 2006 and 2019. Difference-in-differences analysis compared MOUD treatment plans and Medicaid enrollment for housed versus homeless clients in states that did and did not expand Medicaid.

RESULTS

Medicaid expansion was associated with a 35.2 (95 % CI, 11.9 to 58.4) percentage point increase in Medicaid enrollment and an 8.51 (95 % CI, 1.13 to 15.9) percentage point increase in MOUD-inclusive treatment plans for housed and homeless clients alike. Yet the pre-existing MOUD disparity persisted, with PEH being 11.8 (95 % CI, -18.6 to -5.07) percentage points less likely to have MOUD-inclusive treatment plans.

CONCLUSIONS

Medicaid expansion may be an effective tool for increasing MOUD treatment plans for PEH in the 11 states that have not yet implemented the policy, but additional efforts to increase MOUD initiation for PEH will be necessary for closing their treatment gap.

Homelessness and Treatment Outcomes Among Black Adults With Opioid Use Disorder: A Secondary Analysis of X:BOT

OBJECTIVE

We sought to identify the sociodemographic and clinical characteristics associated with homelessnesss, and explore the relationship between homelessnesss and treatment outcomes among Black individuals.

METHODS

This is a secondary analysis of the subgroup of Black participants (n = 73) enrolled in "X:BOT," a 24-week multisite randomized clinical trial comparing the effectiveness of extended-release naltrexone versus sublingual buprenorphine-naloxone (n = 570). Outcomes included medication initiation, return to extramedical use of opioids assessed by both self-report and urine toxicology, and engagement in medications for opioid use disorder (MOUD) treatment at 28 weeks postrandomization. Descriptive statistics were performed.

RESULTS

Black participants were mostly unmarried and male, and about a third were aged 21-30 years. Among people experiencing homelessnesss, more were uninsured (45.5% [10/22] vs 19.6% [10/51]), unemployed (77.3% [17/22] vs 64.7% [33/51]), and reported alcohol (40.9% [9/22] vs 23.5% [12/51]) and sedative use (54.5% [12/22] vs 17.6% [9/51]) within the previous 30 days. Compared with housed Black individuals, a slightly higher proportion of Black individuals experiencing homelessnesss successfully initiated study medication (81.1% [18/22] vs 72.6% [37/51]); similar proportions returned to opioid use during the trial (68.2% [15/22] vs 68.6% [35/51]) and were engaged in MOUD at 28 weeks after trial entry (72.2% [13/18] vs 69.7% [23/33]) among participants located for follow-up.

CONCLUSIONS

These descriptive results among Black patients participating in a trial of MOUD suggest that efficacious MOUD is possible despite homelessnesss with additional clinical supports such as those provided by a clinical trial.

Racial Inequality in Receipt of Medications for Opioid Use Disorder

BACKGROUND

Since 2010, Black persons in the United States have had a greater increase in opioid overdose-related mortality than other groups, but national-level evidence characterizing racial and ethnic disparities in the use of medications for opioid use disorder (OUD) is limited.

METHODS

We used Medicare claims data from the 2016-2019 period for a random 40% sample of fee-for-service beneficiaries who were Black, Hispanic, or White; were eligible for Medicare owing to disability; and had an index event related to OUD (nonfatal overdose treated in an emergency department or inpatient setting, hospitalization with injection drug use-related infection, or inpatient or residential rehabilitation or detoxification care). We measured the receipt of medications to treat OUD (buprenorphine, naltrexone, and naloxone), the receipt of high-risk medications (opioid analgesics and benzodiazepines), and health care utilization, all in the 180 days after the index event. We estimated differences in outcomes according to race and ethnic group with adjustment for beneficiary age, sex, index event, count of chronic coexisting conditions, and state of residence.

RESULTS

We identified 25,904 OUD-related index events among 23,370 beneficiaries, with 3937 events (15.2%) occurring among Black patients, 2105 (8.1%) among Hispanic patients, and 19,862 (76.7%) among White patients. In the 180 days after the index event, patients received buprenorphine after 12.7% of events among Black patients, after 18.7% of those among Hispanic patients, and after 23.3% of those among White patients; patients received naloxone after 14.4%, 20.7%, and 22.9%, respectively; and patients received benzodiazepines after 23.4%, 29.6%, and 37.1%, respectively. Racial differences in the receipt of medications to treat OUD did not change appreciably from 2016 to 2019 (buprenorphine receipt: after 9.1% of index events among Black patients vs. 21.6% of those among White patients in 2016, and after 14.1% vs. 25.5% in 2019). In all study groups, patients had multiple ambulatory visits in the 180 days after the index event (mean number of visits, 6.6 after events among Black patients, 6.7 after events among Hispanic patients, and 7.6 after events among White patients).

CONCLUSIONS

Racial and ethnic differences in the receipt of medications to treat OUD after an index event related to this disorder among patients with disability were substantial and did not change over time. The high incidence of ambulatory visits in all groups showed that disparities persisted despite frequent health care contact. (Funded by the National Institute on Drug Abuse and the National Institute on Aging.).

Improving Research on Racial Disparities in Access to Medications to Treat Opioid Use Disorders

OBJECTIVES

The aims of the study are to review the current research on the association between access to medications for opioid use disorders (MOUD) and race, to identify gaps in research methods, and to propose new approaches to end racialized disparities in access to MOUD.

METHODS

We conducted a literature review of English language peer-reviewed published literature from 2010 to 2021 to identify research studies examining the association between race and use of, or access to, MOUD.

RESULTS

We reviewed 21 studies related to access to MOUD for Black and White populations. Of the 21 studies, 16 found that Black individuals had lower use of, or access to, MOUD than White individuals, 2 found the opposite among patients in specialty addiction treatment, 1 found that the difference changed over time, and 2 found that distance to opioid treatment programs was shorter for Black residents than for White residents.

CONCLUSIONS

To improve future research, we recommend that researchers (1) be clearer on how race is conceptualized and interpreted; (2) explicitly evaluate the intersection of race and other factors that may influence access such as income, insurance status, and geography; (3) use measures of perceived racism, unconscious bias, and self-identified race; (4) collect narratives to better understand why race is associated with lower MOUD access and identify solutions; and (5) evaluate the effect of policies, programs, and clinical training on reducing racial disparities. A multitude of studies find that Black individuals have lower access to MOUD. Researchers must now identify effective solutions for reducing these disparities.

Estimating the impact on initiating medications for opioid use disorder of state policies expanding Medicaid and prohibiting substance use during pregnancy

BACKGROUND

Medicaid expansion increased access to addiction treatment services for pregnant women. However, states' imposition of civil or criminal child abuse sanctions for drug use during pregnancy could inhibit access to treatment. We estimated the effects of Medicaid expansion on pregnant women's medications for opioid use disorder (MOUD) use, and its interaction with statutes that prohibit substance use during pregnancy.

METHODS

Using the Treatment Episode Dataset for Discharge (2010-2018), we identified the initial treatment episode of pregnant women with opioid use disorder (OUD). We described changes in MOUD use and estimated adjusted difference-in-differences and event study models to evaluate differences in changes in MOUD between states that prohibit substance use during pregnancy and states that do not.

FINDINGS

Among a total of 16,070 treatment episodes for pregnant women with OUD from 2010 to 2018, most (74%) were in states that expanded Medicaid. By one year post-expansion, the proportion of episodes receiving MOUD in states not prohibit substance use during pregnancy increased by 8.7% points (95% CI: 2.7, 14.7) from the pre-expansion period compared to a 5.6% point increase in states prohibiting substance use during pregnancy (95% CI: -3.3, 14.8). In adjusted event study analysis, the expansion was associated with an increase in MOUD use by 15.3% by year 2 in states not prohibiting versus 1.5% percentage points in states prohibiting substance use during pregnancy, respectively.

CONCLUSIONS

State policies prohibiting substance use during pregnancy may limit the salutary effects of Medicaid expansion for pregnant women who could benefit from MOUD treatment.