an estimated 82,998 people died of an opioid overdose in the US last year. a new study Published Friday in JAMA Health Forum shows how lack of access to life-saving drugs could be contributing to these preventable deaths.
The study is the most comprehensive Medicaid analysis of opioid addiction to date, analyzing a national claims dataset with 76 million patient data points between 2016 and 2018. Medicaid patients are already at a disproportionate risk of opioid overdose, nearly four times higher than patients with commercial insurance. Accordingly, Medicaid is one of the top payers of opioid addiction treatment in the US almost 40% of adults under 65 with this chronic disease.
“It’s a vulnerable segment of the population,” said Elizabeth Armstrong, an assistant professor of social work at the University of Maine, who was not involved in the study. “People’s socioeconomic status, as well as access to safe and stable housing, food security, mental health issues; they are all challenges that tend to cluster together.”
But insurance coverage doesn’t automatically mean patients have access to treatments like methadone, buprenorphine or naltrexone — the three FDA-approved drugs for treating opioid addiction. Both methadone and buprenorphine activate opioid receptors at safer levels to reduce cravings and are associated with a reduced risk of death. Overall, the study found that 55% of Medicaid enrollees with opioid dependence nationwide received some medication treatment.
In New England, about 75%-80% of these patients received drug treatment. But in most Midwestern and Southern states, less than 40% of Medicaid patients diagnosed with opioid addiction were receiving medication. “The variability suggests problems with quality of care,” said Dennis McCarty, a study co-author and professor emeritus of public health at Oregon Health and Science University. “It reveals missed opportunities to intervene.”
Patrick Marshalek, an associate professor of behavioral medicine and psychiatry at West Virginia University who was not involved in the study, said that while the findings are intriguing, it equates to “the first shot of a grainy video” — meaning it hasn’t yet happened. it is clear how to interpret some results. For example, during the study period, states varied widely in their coverage of methadone treatment, reimbursement rates, and whether or not they expanded Medicaid under the Affordable Care Act, making it difficult to directly compare state drug rates or learn lessons.
For example, the study found that 83% of patients with opioid dependence in Maine received drug treatment – the highest percentage of any state. But Armstrong thinks this is simply because Maine hadn’t expanded Medicaid at the time, meaning the state insured a much smaller patient population. “So there may have been less of a gap between the population seeking treatment and the availability of treatment for that study period.”
Health economist Stephan Lindner, the lead author of this study and an associate professor of emergency medicine at Oregon Health and Science University, also noted that the research team was unable to analyze race or ethnicity because of data quality concerns. But given known demographic differences in terms of access to opioid addiction treatment, Armstrong suggests that Maine’s relatively homogeneous population is approx 94% of the inhabitants are white — could also help explain the state’s high drug rates.
The most pressing question is what states can do to close disparities in treatment. “We are failing people by not providing adequate treatment to people with opioid use disorder who are enrolled in Medicaid,” Lindner said.
Marshalek points to telemedicine as a powerful way to expand access to opioid addiction treatment, especially given that many regulatory barriers were relaxed during the Covid-19 pandemic and may soon become permanent.
Marshalek also said West Virginia’s hub-and-spoke model serves as an example of how to expand access: Instead of expecting patients to drive hours to the main hospital to get medications, experts at the WVU hub in Morgantown are training physicians at primary care clinics and federally qualified health centers across the state to help them spread opioid addiction treatment within their own communities.
Similarly, Armstrong recommends providing opioid addiction treatment within school clinics and expanding access to non-students and family members, as Medicaid already pays for behavioral health services at school. However, Armstrong says that in the long run, the US needs more people capable of providing integrated behavioral health care. Professional Opioid Workforce Response Program to train social workers in opioid addiction and create a network of providers throughout Maine.
Lindner also stressed the need for further research. By using Medicaid claims data, the study is inevitably unable to capture patients who have not interacted with the healthcare system. “They fly under the radar, but, very importantly, they’re still there,” Lindner said, “and eventually they’ll show up in the overdoses.”
Ultimately, combining different streams of data — including Medicaid claims, overdose deaths, national surveys, and first responder data — could shed more light on the human toll of opioid addiction. From hopelessness to isolation to despair, “there’s a fire burning with this addiction epidemic,” Marshalek said, “and it’s really not that discriminatory when it comes to looking for fuel.”