Prescriptions for Opioid Addiction Treatments Increase, but Access Is Uneven

Prescription rates for buprenorphine were significantly higher in 2018 in states that had expanded Medicaid coverage.(CRAIG F. WALKER/THE BOSTON GLOBE/GETTY IMAGES)

MILLIONS OF prescriptions have been filled in recent years for buprenorphine, but not all patients have equal access to the opioid addiction treatment drug, a new analysis indicates.Buprenorphine, commonly sold as Suboxone, is one of three drugs approved by the Food and Drug Administration to treat opioid addiction – along with methadone and naltrexone – but the only medication covered by all state Medicaid programs. The drugs blunt opioid cravings and are commonly paired with counseling, an approach called medication-assisted treatment.Health experts say expanding access to such treatment, especially among Medicaid enrollees, is key to curbing the nation's opioid epidemic, which claimed 47,600 lives in 2017. Yet researchers estimate that only between 20% and 40% of people with opioid use disorder have been treated for the condition in recent years.

Even so, the number of buprenorphine prescriptions that were filled and covered by Medicaid surged nearly fivefold between 2011 and 2018, from 1.3 million to 6.2 million, according to the new analysis from the Urban Institute, an economic and social policy think tank based in the nation's capital. Last year, 77.2% of these prescriptions were in states that had expanded Medicaid coverage by early 2014.

"We're seeing large-scale differences in prescribing that are hard to justify," says Lisa Clemans-Cope, the study's lead author and a principal research associate and health economist in the Health Policy Center at the Urban Institute. Viewed as a rate per 1,000 Medicaid enrollees, buprenorphine prescription rates rose from 40 to 138 among expansion states and from 16 to 41 in non-expansion states during that time period, the study found. State-level rates ranged from 1,210 in Vermont to 5 in Arkansas.Some states may have more people who are addicted to opioids than others, the study says, and prescribing practices for medications like buprenorphine may differ by region. But Clemans-Cope says it's unlikely those factors would be significant enough to merit the wide variation in buprenorphine prescription rates by state. Additionally, "states really do need to assess whether patients are getting the most effective treatment – even when they are getting treatment," she says.Some states have taken more aggressive approaches to combating the opioid crisis than others, including Vermont, where officials have ramped up the state's addiction treatment infrastructure under its expanded Medicaid program. Its "hub-and-spoke" model, which offers addiction treatment integrated into regular primary care settings across the state, has resulted in significantly more patients receiving treatment. Since late 2017, opioid use disorder treatment has been available in the state on-demand, with no waiting lists.Providers in Vermont also may be prescribing higher dose levels of buprenorphine, the study notes, which may reflect "clinically effective dosing." As of 2015, the American Society of Addiction Medicine recommends that buprenorphine doses should range from 8 mg to 24 mg per day, depending on the patient. "These numbers imply that the people who are being treated for opioid use disorder with buprenorphine (in Vermont) are getting about 30 prescriptions per year, or about 2.5 prescriptions per month," Clemans-Cope says. "That's a lot higher than the other states."With a buprenorphine prescribing rate of 827 per 1,000 among Medicaid enrollees in 2018, West Virginia saw the second-highest rate in the U.S. The study notes, however, that the wide gap between treatment levels in Vermont and West Virginia – Vermont's rate was 46% higher in 2018 – indicate the Mountain State may not be fully meeting its residents' needs."Even in states that expanded Medicaid, they probably want to take a look at the effectiveness of the treatments that they're offering," Clemans-Cope says. "They should look at whether higher buprenorphine dosing … and offering on-demand treatment could help increase retention and recovery and better outcomes for patients and their families." Meanwhile, the study says states that have not expanded Medicaid and have seen low buprenorphine prescribing rates and high opioid death rates – such as Florida, Missouri, South Carolina and Tennessee – should consider implementing policies to improve access to and quality of treatment. Research from the Urban Institute published earlier this year found that many states improved access to opioid use disorder medications in recent years, but that Medicaid expansion states saw the biggest gains. As of August 2019, 14 states had not adopted Medicaid expansion, according to the Kaiser Family Foundation. Utah, Idaho and Nebraska have adopted but not yet implemented expansion. The new study indicates that sealing health insurance coverage gaps in non-expansion states, as well as ensuring patients are receiving adequate addiction treatment across the country, are perhaps the most vital steps that states can take to curb the most devastating consequences of the U.S. opioid epidemic."It's really an imperative that states that haven't expanded Medicaid do so to close these gaps in treatment," Clemans-Cope says. "It's really causing harm to have people untreated for opioid use disorder during this enormous crisis."

Gaby Galvin is a staff writer at U.S. News & World Report

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