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Substance Use and Addiction Medicine

Use of Medications for Treatment of Opioid Use Disorder Among US Medicaid Enrollees in 11 States, 2014-2018

Educational Objective
To understand trends in the use of medications for opioid use disorder.

1 Credit CME

JAMA

Published Online: July 13, 2021

Original Investigation

Article Information and Disclosures

The Medicaid Outcomes Distributed Research Network (MODRN)

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Key Points

Question Did treatment of opioid use disorder (OUD) among Medicaid enrollees change from 2014 to 2018?

Findings In this exploratory serial cross-sectional study using data from 1 024 301 Medicaid enrollees in 11 states, the prevalence of medication treatment for OUD increased from 47.8% (138 918 of 290 638 enrollees with OUD) in 2014 to 57.1% (301 499 of 527 983) in 2018. There was substantial variation across and within states in any use and continuity (for 180 days) of medications for OUD by age, race/ethnicity, eligibility group, behavioral health comorbidity, and rural vs urban residence.

Meaning From 2014 through 2018, use of medications for opioid use disorder increased among Medicaid enrollees in 11 US states, but the pattern in the other states is not known.

Abstract

Importance There is limited information about trends in the treatment of opioid use disorder (OUD) among Medicaid enrollees.

Objective To examine the use of medications for OUD and potential indicators of quality of care in multiple states.

Design, Setting, and Participants Exploratory serial cross-sectional study of 1 024 301 Medicaid enrollees in 11 states aged 12 through 64 years (not eligible for Medicare) with International Classification of Diseases, Ninth Revision (ICD-9 or ICD-10) codes for OUD from 2014 through 2018. Each state used generalized estimating equations to estimate associations between enrollee characteristics and outcome measure prevalence, subsequently pooled to generate global estimates using random effects meta-analyses.

Exposures Calendar year, demographic characteristics, eligibility groups, and comorbidities.

Main Outcomes and Measures Use of medications for OUD (buprenorphine, methadone, or naltrexone); potential indicators of good quality (OUD medication continuity for 180 days, behavioral health counseling, urine drug tests); potential indicators of poor quality (prescribing of opioid analgesics and benzodiazepines).

Results In 2018, 41.7% of Medicaid enrollees with OUD were aged 21 through 34 years, 51.2% were female, 76.1% were non-Hispanic White, 50.7% were eligible through Medicaid expansion, and 50.6% had other substance use disorders. Prevalence of OUD increased in these 11 states from 3.3% (290 628 of 8 737 082) in 2014 to 5.0% (527 983 of 10 585 790) in 2018. The pooled prevalence of enrollees with OUD receiving medication treatment increased from 47.8% in 2014 (range across states, 35.3% to 74.5%) to 57.1% in 2018 (range, 45.7% to 71.7%). The overall prevalence of enrollees receiving 180 days of continuous medications for OUD did not significantly change from the 2014-2015 to 2017-2018 periods (−0.01 prevalence difference, 95% CI, −0.03 to 0.02) with state variability in trend (90% prediction interval, −0.08 to 0.06). Non-Hispanic Black enrollees had lower OUD medication use than White enrollees (prevalence ratio [PR], 0.72; 95% CI, 0.64 to 0.81; P < .001; 90% prediction interval, 0.52 to 1.00). Pregnant women had higher use of OUD medications (PR, 1.18; 95% CI, 1.11-1.25; P < .001; 90% prediction interval, 1.01-1.38) and medication continuity (PR, 1.14; 95% CI, 1.10-1.17, P < .001; 90% prediction interval, 1.06-1.22) than did other eligibility groups.

Conclusions and Relevance Among US Medicaid enrollees in 11 states, the prevalence of medication use for treatment of opioid use disorder increased from 2014 through 2018. The pattern in other states requires further research.

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Article Information

Corresponding Author: Julie M. Donohue, PhD, Health Policy and Management, University of Pittsburgh Graduate School of Public Health, 130 DeSoto St, A635, Pittsburgh, PA 15261 (jdonohue@pitt.edu).

Accepted for Publication: April 22, 2021.

The MODRN Group Writers: Julie M. Donohue, PhD; Marian P. Jarlenski, PhD; Joo Yeon Kim, MS; Lu Tang, PhD; Katherine Ahrens, PhD; Lindsay Allen, PhD; Anna Austin, PhD; Andrew J. Barnes, PhD; Marguerite Burns, PhD; Chung-Chou H. Chang, PhD; Sarah Clark, MPH; Evan Cole, PhD; Dushka Crane, PhD; Peter Cunningham, PhD; David Idala, MA; Stefanie Junker, MPH; Paul Lanier, PhD; Rachel Mauk, PhD; Mary Joan McDuffie, MA; Shamis Mohamoud, MA; Nathan Pauly, PhD; Logan Sheets, BA; Jeffery Talbert, PhD; Kara Zivin, PhD, MS, MA; Adam J. Gordon, MD, MPH; Susan Kennedy, MPP, MSW.

Affiliations of The MODRN Group Writers: Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania (Donohue, Jarlenski, Kim, Cole, Junker); Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania (Tang); Public Health Program, Muskie School of Public Service, University of Southern Maine, Portland (Ahrens); Health Policy, Management, and Leadership Department, School of Public Health, West Virginia University, Morgantown (Allen); Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (Austin); Department of Health Behavior and Policy, School of Medicine, Virginia Commonwealth University, Richmond (Barnes, Cunningham); Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin, Madison (Burns); Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania (Chang); Department of Pediatrics, University of Michigan Medical School, Ann Arbor (Clark); Ohio Colleges of Medicine Government Resource Center, The Ohio State University, Columbus (Crane, Mauk); The Hilltop Institute, University of Maryland Baltimore County, Baltimore (Idala, Mohamoud); School of Social Work, University of North Carolina at Chapel Hill (Lanier); Center for Community Research & Service, Biden School of Public Policy and Administration, University of Delaware, Newark (McDuffie); Health Sciences Center, School of Public Health, Health Affairs Department, School of Public Health, West Virginia University, Morgantown (Pauly); AcademyHealth, Washington, DC (Sheets, Kennedy); Division of Biomedical Informatics, College of Medicine, University of Kentucky, Lexington (Talbert); Department of Psychiatry, University of Michigan Medical School, Ann Arbor (Zivin); Department of Medicine and Department of Psychiatry, University of Utah School of Medicine, Salt Lake City (Gordon); Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City (Gordon).

Author Contributions: Dr Donohue 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: Donohue, Tang, Allen, Austin, Burns, Crane, Cunningham, Junker, Lanier, Mohamoud, Sheets, Talbert, Gordon, Kennedy.

Acquisition, analysis, or interpretation of data: Donohue, Jarlenski, Kim, Tang, Ahrens, Allen, Austin, Barnes, Burns, Chang, Clark, Cole, Crane, Cunningham, Idala, Lanier, Mauk, McDuffie, Mohamoud, Pauly, Talbert, Zivin, Gordon.

Drafting of the manuscript: Donohue, Tang, Gordon, Kennedy.

Critical revision of the manuscript for important intellectual content: Donohue, Jarlenski, Kim, Tang, Ahrens, Allen, Austin, Barnes, Burns, Chang, Clark, Cole, Crane, Cunningham, Idala, Junker, Lanier, Mauk, McDuffie, Mohamoud, Pauly, Sheets, Talbert, Zivin, Gordon.

Statistical analysis: Kim, Tang, Ahrens, Austin, Barnes, Cunningham, Idala, Lanier, McDuffie.

Obtained funding: Donohue, Crane.

Administrative, technical, or material support: Donohue, Jarlenski, Kim, Barnes, Burns, Cole, Crane, Cunningham, Junker, Lanier, Mohamoud, Pauly, Sheets, Talbert, Zivin, Gordon, Kennedy.

Supervision: Donohue, Chang, Crane, Zivin.

Conflict of Interest Disclosures: Dr Ahrens reported receiving support from the Maine Department of Health cooperative agreement. Dr Chang reported receiving grants from National Institutes of Health (NIH). Dr Cunningham reported receiving support from the Virginia Department of Medical Assistance contract to evaluate Addiction and Recovery Treatment Services program. Dr Mauk reported receiving grants from the NIH and support from the Ohio Department of Medicaid. Ms McDuffie reported receiving grants from the Delaware Division of Medicaid and Medical Assistance. Dr Gordon reported receiving institutional support from grants CIN 13-414 from the Department of Veterans Affairs' Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, and 1UG1DA049444-01 from the National Institute on Drug Abuse; serving on the board of directors (not compensated) for the American Society of Addiction Medicine (ASAM), the Association for Multidisciplinary Education and Research in Substance Use and Addiction (AMERSA), and the International Society of Addiction Journal Editors (ISAJE); and receiving royalties from the medical online reference, UpToDate. No other disclosures were reported.

Funding/Support: This study was supported by grant R01DA048029 from the National Institute on Drug Abuse (Drs Donohue, Allen, Cole, Crane, Cunningham, Mauk, Talbert, and Zivin and Ms Maohamoud and Mr Sheets).

Role of the Funder/Sponsor: The National Institute on Drug Abuse 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.

Collaborator Information: The MODRN Collaborators are listed in Supplement 2.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.