Although more people with opioid use disorder in the United States are receiving treatment for their disorder, gaps in health care persist along racial lines, according to the largest analysis of opioid use disorder among Medicaid recipients to date.
The analysis was possible because of the Medicaid Outcomes Distributed Research Network (MODRN), a unique collaboration that partners academic institutions with state Medicaid programs to overcome barriers to data sharing between states. Researchers hope that insights from MODRN will help policymakers and medical providers improve access to quality health care for opioid use disorder, a leading cause of death in the U.S. The Journal of the American Medical Association (JAMA) published the results of the analysis on July 13, 2021.
“Medicaid is an incredibly important part of our health systems in the United States, and it involves more than 50 separate programs,” said co-author Paul Lanier, Ph.D. (pictured), associate professor at the University of North Carolina at Chapel Hill School of Social Work and lead MODRN investigator for North Carolina. “Unfortunately, those programs don’t share data very easily.
“The MODRN team has been able to pool a large part of that data, for the first time ever,” Lanier continued. “Our analysis of that data led to powerful conclusions that can help us address the growing opioid epidemic and some disparities in health care, especially for minority populations.”
Medicaid is the largest payor of medical and health-related services supplying health insurance to almost 80 million people, nearly a quarter of all Americans. Typically, to qualify for Medicaid, people must have low incomes. The Affordable Care Act (ACA) expanded Medicaid by incentivizing states to allow access to people with incomes slightly above the federal poverty level; although 38 states adopted this expansion, North Carolina did not.
For this analysis, MODRN obtained de-identified, standardized data from 11 states, including North Carolina as well as the six states that rank among the highest for opioid overdose deaths, accounting for 16.3 million people aged 12 through 64, or 22% of Medicaid’s enrollees. (With 17.9 deaths per 100,000 people, North Carolina ranks 14th in the nation for opioid overdose deaths, according to National Institute on Drug Abuse statistics.)
“The impact these timely, multi-state findings can have on Medicaid policy decision making, and ultimately the lives of millions of Medicaid enrollees, is immeasurable,” said Susan Kennedy, MPP, MSW, director of the Evidence-Informed State Health Policy Institute at AcademyHealth, which supports MODRN. “MODRN’s collaborative involvement with Medicaid policymakers extended beyond the review of utilization and outcomes results and cultivated rich discussions on state policy differences that may influence outcomes, helping to bridge states together in their individual efforts to address the opioid epidemic.”
Increase in enrollees with opioid use disorder
The prevalence of opioid use disorder increased from 3.3% of enrollees in 2014 to 5% in 2018. Notably, the share of enrollees with opioid use disorder enrolled in Medicaid due to the ACA expansion grew from 27.3% to 50.7% in the same time period.
“We can see from the data that, when states adopted Medicaid expansion, they really increased access to health care for individuals who desperately needed those services for opioid use disorder,” said co-author Anna Austin, Ph.D., assistant professor at the Gillings School of Global Public Health and a member of the MODRN team at UNC. “Opioid use disorder is treatable — but treatment is most successful when people have regular access to health care.”
There are several medications — buprenorphine, methadone, and naltrexone — to treat opioid use disorder. These medications work best when taken continuously, so the MODRN team looked at several indicators of quality of care, including at least one period of 180 days of continuous medication, at least one order for a urine drug test, and at least one claim for behavioral health counseling.
The MODRN team also looked into whether people with opioid use disorder were being prescribed other controlled substances associated with increased risk of overdose, such as benzodiazepines, which would indicate that a clinician hadn’t adequately reviewed an enrollee’s medical history.
The team found that Black enrollees were considerably less likely than white enrollees to be treated with medications for their opioid use disorder and were less likely to have continuity of such treatment.
In contrast, pregnant women with opioid use disorder were far more likely than the average person with opioid use disorder to receive continuous medication-assisted treatment. This is likely because the women were actively engaged in care due to their pregnancy and motivated to continue treatment.
State data varied significantly in the quality measures of behavioral health counseling, urine testing, and controlled substance prescribing. The MODRN team shared information with each state’s Medicaid managers.
“State Medicaid officials were very engaged — not only could they see where improvement was possible, but they could also talk with other state officials and learn about successful programs and practices,” said co-author Julie Donohue, Ph.D., principal lead on the MODRN project, who is chair and professor of the University of Pittsburgh Graduate School of Public Health Department of Health Policy and Management. “Improved understanding of factors driving increased use of medications for opioid use disorder is crucial to closing remaining treatment gaps.”
Members of MODRN are listed in the JAMA manuscript. In North Carolina, MODRN collaborators include UNC School of Social Work, Gillings School of Global Public Health, the Cecil G. Sheps Center for Health Services Research, and the North Carolina Department of Health and Human Services.
This research was funded by National Institute for Drug Abuse grant R01DA048029.