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Changes in Buprenorphine-Naloxone and Opioid Pain Reliever Prescriptions After the Affordable Care Act Medicaid Expansion

Educational Objective
To understand how Medicaid expansion influenced buprenorphine treatment for opioid use disorder.
1 Credit CME
Key Points

Question  Did Medicaid expansion under the US Affordable Care Act change prescription fills for buprenorphine with naloxone, a treatment for opioid use disorder, and opioid pain relievers?

Findings  In this cohort study using difference-in-differences analysis of all-payer prescription fill data from 5 states, Medicaid expansion was associated with a significant overall increase in people filling prescriptions for buprenorphine with naloxone. Expansion was not associated with changes in fills per 100 000 county residents of opioid pain relievers overall, but significantly more people filled prescriptions for opioid pain relievers paid for specifically by Medicaid.

Meaning  Medicaid expansion may increase the role of states in providing opioid use disorder treatment and in paying for opioid pain relievers for pain management.


Importance  Expanding Medicaid eligibility could affect prescriptions of buprenorphine with naloxone, an established treatment for opioid use disorder, and opioid pain relievers (OPRs).

Objective  To examine changes in prescriptions of buprenorphine with naloxone and OPRs after the US Affordable Care Act Medicaid expansion.

Design, Setting, and Participants  In this cohort study, longitudinal, patient-level, retail pharmacy claims were extracted from IQVIA real-world data from an anonymized, longitudinal, prescription database. The sample included 11.9 million individuals who filled 2 or more prescriptions for a prescription opioid during at least 1 year between January 1, 2010, and December 31, 2015, from California, Maryland, and Washington (expansion states) and Florida and Georgia (nonexpansion states). Data analysis was conducted from August 1, 2017, to May 31, 2018. Data were aggregated to county-year observations (N = 2082) and linked to county-level covariates. For each outcome, a difference-in-differences regression model was estimated comparing changes before and after expansion in expansion vs nonexpansion counties. Models were adjusted for county demographics, uninsured rate, and overdose mortality in the baseline year (2010).

Exposures  Presence of Medicaid expansion in the year.

Main Outcomes and Measures  For buprenorphine with naloxone and OPRs, rates per 100 000 county residents were calculated separately for any prescriptions overall and by different payment sources. Mean days of medication per county among people filling prescriptions for these agents were also determined.

Results  The study sample included 11.9 million individuals (expansion states: 40.9% men; mean [SD] age, 44.1 [13.8] years; nonexpansion states: 41.0% men; mean [SD] age, 43.7 [13.7] years). In expansion counties, 68.8 individuals per 100 000 county residents filled buprenorphine with naloxone and 5298.3 filled OPR prescriptions in 2010. After expansion, buprenorphine with naloxone fills per 100 000 county residents increased significantly in expansion relative to nonexpansion counties (8.7; 95% CI, 1.7 to 15.7). Opioid pain reliever fills per 100 000 county residents did not significantly change in expansion counties relative to nonexpansion counties (327.4; 95% CI −202.5 to 857.4). The rate of OPRs per 100 000 county residents paid for by Medicaid significantly increased (374.0; 95% CI, 258.3 to 489.7). There were no significant changes in days per 100 000 county residents of either medication after expansion.

Conclusions and Relevance  Medicaid expansion significantly increased buprenorphine with naloxone prescriptions per 100 000 county residents in expansion counties, suggesting that expansion improved access to opioid use disorder treatment. Expansion did not significantly increase the overall rate per 100 000 county residents of OPR prescriptions, but increased the population with OPRs paid for by Medicaid. This finding therefore suggests the growing importance of Medicaid in pain management and addiction prevention.

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Article Information

Accepted for Publication: June 7, 2018.

Published: August 17, 2018. doi:10.1001/jamanetworkopen.2018.1588

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2018 Saloner B et al. JAMA Network Open.

Corresponding Author: Brendan Saloner, PhD, Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Room 344, Baltimore, MD 21205 (bsaloner@jhu.edu).

Author Contributions: Dr Saloner had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Saloner, Jones.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Saloner, Levin.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Saloner, Levin, Chang, Jones.

Obtained funding: Saloner.

Administrative, technical, or material support: Saloner, Alexander.

Supervision: Saloner.

Conflict of Interest Disclosures: Dr Alexander is chair of the US Food and Drug Administration’s Peripheral and Central Nervous System Advisory Committee; has served as a paid consultant to IQVIA; holds an equity share in MesaRx Innovations; holds equity in Monument Analytics, a health care consultancy whose clients include the life sciences industry as well as plaintiffs in opioid litigation; and serves as a paid member of OptumRx’s P&T Committee. This arrangement has been reviewed and approved by Johns Hopkins University in accordance with its conflict of interest policies. No other disclosures were reported.

Funding/Support: This study was funded by the internal Lipitz Grant at the Johns Hopkins Bloomberg School of Public Health. Dr Saloner also acknowledges funding support from the National Institute on Drug Abuse grant K01 DA042139.

Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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