This week, I am reading a new study published by researchers at the Urban Institute on state variation in Medicaid prescriptions for buprenorphine to treat opioid use disorder (OUD) from 2011 to 2018.

The Urban Institute Health Policy Center’s State Variation in Medicaid Prescriptions for Opioid Use Disorder from 2011 to 2018

The study from the Urban Institute analyzed data from the Medicaid State Drug Utilization Dataset (SDUD) to assess patterns in Medicaid prescriptions of buprenorphine maintenance treatment—in combination with buprenorphine-naloxone, where naloxone is added to deter misuse—across the period of 2011 to 2018. Buprenorphine is one of the three FDA-approved medications used in OUD pharmacotherapy (the other two are methadone and naltrexone). Researchers cross-referenced their findings with the Medicaid Statistical Information System (MSIS) data, and trends were examined across time, across states and by Medicaid-expansion status.

The researchers acknowledge some study limitations.  For example, the SDUD dataset excludes any prescriptions furnished by safety net providers like Federally Qualified Health Centers (FQHCs), which if included would increase the total number of buprenorphine prescriptions. Furthermore, the study cannot parse out new Medicaid enrollees in comparison to prior enrollees to explore trends in buprenorphine maintenance treatment across prior and new Medicaid enrollees.

What it finds

• Results indicate the number of Medicaid-covered buprenorphine prescriptions to treat OUD increased five-fold nationally from 2011 to 2018 (from 1.3 million to 6.2 million); with 77.2% (or 4.8 million prescriptions) in states that expanded Medicaid by early 2014.
• The prescribing rate increased nationally from 36 per 1,000 Medicaid enrollees (ages 12 and older) in 2011 to 124 per 1,000 in 2018; rates differed by expansion status with the non-expanders rate increasing from 16 to 41 and the rate among expanders increasing from 40 to 138 per 1,000.
• There were sizeable differences among states in the prescribing rate. The states with the highest prescribing rate (at or above the 90^th percentile) are: Ohio (438), Montana (588), Kentucky (662), West Virginia (827), and Vermont (1,210); with Vermont’s rate being 200 times greater than the rate of 5 in Arkansas. The states with the lowest prescribing rates (at or below the 10^th percentile) are: Arkansas (5), Texas (8), South Dakota (11), Florida (12), and Kansas (14).
• Regional trends were examined as well with the prescribing rate highest in New England and parts of Appalachia in 2011, and by 2018, the Middle Atlantic, East North Central and Northern Pacific states also had increasing prescribing rates.

Spotlight on Vermont:

• Vermont led the way in buprenorphine maintenance treatment with 1,210 prescriptions per 1,000 Medicaid enrollees in 2018, 46% higher than the next highest rated state.
• Researchers indicate that Vermont’s high prescribing rate is likely connected to the greater treatment needs among Vermont residents and that Vermont significantly increased its OUD treatment capacity and coverage under the Medicaid expansion, eliminated wait lists for treatment, and implemented a new “hub-and-spoke” treatment system.
• Another potential cause for the high buprenorphine prescribing rate increase in Vermont could be that Vermont is now prescribing ‘clinically-effective dosing’ in accordance with the American Society of Addiction Medicine’s national guidelines reporting that a typical dose of 16mg a day be taken as two 8mg tablets, and increasing evidence suggesting that higher doses are more effective than lower doses in treatment of OUD.

Why it matters

• Non-expansion states have the opportunity to better address OUD treatment barriers and support retention by:
  1. expanding Medicaid under the ACA,
  2. increasing treatment capacity, and
  3. improving treatment effectiveness.
• Researchers call for continued study of the extent to which state differences in pharmacotherapy may or may not be associated with mortality rates and claims-based outcomes, such as medication continuation, emergency department visits, and hospitalizations related to drug use.
• As the opioid crisis continues in America, many states are still experiencing high death rates associated with opioid-related overdose deaths. It is critical to ensure people with OUD have access to Medicaid coverage and evidence-based OUD treatment so that people with OUD have the tools they need to both recover and maintain their recovery.