VCU news

By VCU News staff

Substantially more people in the United States with opioid use disorder are receiving evidence-based treatment for the disease, but there are still considerable gaps in care along racial lines, according to the largest analysis to date of opioid use disorder among Medicaid recipients.

The results, published today in the Journal of the American Medical Association, provide insights that policymakers and medical providers can act on to improve access to quality care for opioid use disorder, one of the leading causes of death in the U.S. The analysis was possible because of the Medicaid Outcomes Distributed Research Network, a unique network that partners academic institutions — including Virginia Commonwealth University — with state Medicaid programs to overcome barriers to data-sharing between states.

In its analysis published in JAMA — compiled by using standardized data from 11 states, including Virginia — the MODRN 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.

The study accounts for 16.3 million Medicaid members aged 12 through 64, or 22% of Medicaid’s enrollees nationally. Six of the 11 states, not including Virginia, rank among the highest in the nation for opioid overdose deaths.

“Virginia’s participation in this important research network enables us to build on the significant progress we have made over the past three years with our Addiction and Recovery Treatment Services benefit,” said Ellen Montz, chief deputy and chief health economist for the Virginia Department of Medical Assistance Services. “Opioid use disorder has visited immense destruction on families and communities across the commonwealth and the nation. Medicaid agencies are essential leaders in identifying solutions to this pressing challenge. Our partnership with Virginia Commonwealth University and other state Medicaid agencies and research institutions arms us with valuable context and recommendations that will bolster our ability to deliver effective, lifesaving care to our members.”

VCU has been leading the evaluation of Virginia’s state program to enhance Medicaid-sponsored treatment services for substance use disorders since 2017 and contributed data to the opioid treatment analysis.

“Medicaid plays an incredibly important role in our health system, and the population it serves overlaps with those most likely to have opioid use disorder. But Medicaid is 50-plus separate programs that can’t easily share data,” said Andrew Barnes, Ph.D., the study’s co-author and an associate professor of health behavior and policy at the VCU School of Medicine. “For the first time, we’ve pooled a large part of that data through partnerships between universities and Medicaid agencies, enabling us to draw powerful conclusions that could better enable our country to address the opioid epidemic, which has only grown more intense during the COVID-19 pandemic.”

Medicaid is the largest payor of medical and health-related services in the U.S., supplying health insurance to almost 80 million people, nearly a quarter of all Americans. To qualify for Medicaid, people must have low incomes. The Affordable Care Act expanded Medicaid by incentivizing states to allow access to people with incomes slightly above the federal poverty level, which 39 states, including Washington, D.C., adopted.

"Medicaid is 50-plus separate programs that can’t easily share data. For the first time, we’ve pooled a large part of that data through partnerships between universities and Medicaid agencies, enabling us to draw powerful conclusions that could better enable our country to address the opioid epidemic."

- Andrew Barnes, Ph.D.

“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, 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.”

The prevalence of opioid use disorder increased from 3.3% of Medicaid 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.

“This demonstrates that state Medicaid programs provided access to effective substance use treatment for a population that needed to be engaged in the health care system,” said Barnes. “Opioid use disorder can be treated, just like any other disease. That treatment is most successful when the patient has regular, unimpeded access to trained clinicians who can not only treat the disorder, but oftentimes also oversee the rest of their 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. They 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 clinicians hadn’t adequately reviewed their medical history.

There was great variability across states 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 in determining measures they were performing particularly well on, as well as areas where they could improve,” said Julie Donohue, Ph.D., the study’s co-author, principal lead on the MODRN project, and chair and professor of the University of Pittsburgh Graduate School of Public Health Department of Health Policy and Management.

“And 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,” Donohue said. “Improved understanding of factors driving increased use of medications for opioid use disorder is crucial to closing remaining treatment gaps.”

This research was funded by National Institute for Drug Abuse grant R01DA048029.