Residential treatment and medication treatment for opioid use disorder: The role of state Medicaid innovations in advancing the field.

Background: Mortality due to opioid use continues to increase; effective strategies to improve access to treatment for opioid use disorder (OUD) are needed. While OUD medications exist, they are used infrequently and often not available in residential addiction treatment settings. CMS provides expanded opportunities for Medicaid reimbursement of treatment in residential facilities and requires states that request Medicaid SUD Waivers to provide a full continuum of care including medication treatment. The objective of this study was to assess how states facilitate access to OUD medications in residential settings and whether Medicaid requirements play a role. Methods: Using a legal mapping framework, across the 50 states and DC, we abstracted data from state regulations in 2019 - 2020 and Medicaid Section 1115(a) demonstration applications. We examined the temporal relationship between state regulations regarding medication-assisted treatment for OUD in residential settings and Section 1115(a) demonstrations. Results: We identified variation in regulations regarding medication treatment for OUD in residential settings and possible spillover effects of the CMS requirements for Medicaid SUD Waivers. In 18 states with relevant regulations, regulatory approaches include identifying opioid medication treatment as a right, requiring access to OUD medication treatment, and establishing other requirements. 25 of 30 states with approved Section 1115(a) demonstrations included explicit requirements for OUD medication treatment access. Four states updated OUD medication treatment regulations for residential treatment settings within a year of applying for a Section 1115(a) demonstration. Conclusions: State regulations and Medicaid program requirements are policy levers to facilitate OUD medication treatment access.

Adverse events among adult Medicaid enrollees with opioid use disorder and co-occurring substance use disorders.

BACKGROUND: It is common for adults with opioid use disorder (OUD) to misuse additional substances, and these individuals may be particularly at risk for adverse events, including mortality. Less is known about how continued receipt of prescription opioids or risk of adverse events (e.g., suicidality, overdose, poisoning) differs for people with co-occurring OUD and additional substance use disorders (SUDs). METHODS: We conducted a retrospective study using IBM® MarketScan® Multi-State Medicaid Database enrollment/claims data. We used logistic regression to measure the association between sample characteristics and our dependent variables. The sample consisted of non-Medicare-eligible adults aged 18-64 years who were continuously enrolled in Medicaid in 2016-2017 with an OUD diagnosis on at least one claim in 2016. RESULTS: Adults with OUD and a co-occurring SUD were more likely than adults with OUD only to have an opioid-related poisoning event (odds ratio [OR] = 1.488, p = .0052), all-cause poisoning (OR = 1.756, p < .0001), or suicidal ideation (OR = 1.796, p < .0001) but not to receive ongoing opioid prescriptions (OR = 0.973, p = .1626). Adverse events varied by OUD-SUD combination. For example, adults with OUD and cocaine use disorder had the highest odds of all-cause (OR = 2.393, p < .0001) or opioid-related (OR = 1.890, p = .0027) poisoning among those with a drug-specific diagnosis and were most likely to be diagnosed with suicidal ideation (OR = 2.465, p < .0001). CONCLUSIONS: This study provides evidence that adults with OUD and a co-occurring additional SUD have increased risk for several adverse events. Multisubstance use should be screened for and identified to determine the most appropriate course of treatment.

Utilization of treatment by Medicaid enrollees with opioid use disorder and co-occurring substance use disorders.

BACKGROUND: Multiple substance use is common among adults who misuse opioids. Adverse consequences of drugs are more severe among multisubstance users than among single drug users. This study sought to determine whether adults with opioid use disorder (OUD) and at least one other substance use disorder (SUD) are less likely than adults with OUD only to receive certain services. METHODS: We conducted a retrospective longitudinal study using the IBM® MarketScan® Multi-State Medicaid Database. We used logistic regression to measure associations between clinical characteristics and service utilization. The sample included non-Medicare-eligible adults aged 18-64 years with at least one claim in 2016 with a primary diagnosis of OUD who were continuously enrolled in Medicaid in 2016 and 2017. RESULTS: Of the 58,745 Medicaid enrollees with an initial OUD diagnosis in 2016, 29,267 had one or more additional SUD diagnoses. In the year following diagnosis, these adults were less likely than adults with OUD only to receive OUD medication treatment (OR = 0.88, p < .0001). This was true for all specifically diagnosed co-occurring SUDS. Adults with OUD and a co-occurring SUD, however, were more likely than those with OUD only to use any type of high-intensity services. CONCLUSIONS: Adults with OUD and at least one co-occurring SUD received more intensive services, which may reflect severity and lack of OUD medication treatment before misuse escalation. Programs should account for barriers to connecting these individuals to appropriate OUD treatment.

Rural-Nonrural Differences in Telemedicine Use for Mental and Substance Use Disorders Among Medicaid Beneficiaries.

OBJECTIVE: This study investigated recent rural-nonrural trends in the prevalence and amount of mental and substance use disorder telemedicine received by adult Medicaid beneficiaries. METHODS: An analysis of 2012-2017 claims data from the IBM MarketScan Multi-State Medicaid Database for adult beneficiaries ages 18-64 years with mental and substance use disorder diagnoses (N= 1,603,066) identified telemedicine services by using procedure modifier codes and ICD-9 and ICD-10 diagnosis codes. Unadjusted trends in telemedicine use were examined, and multivariate regression models compared the prevalence and amount of telemedicine and in-person outpatient treatment received by rural (N=428,697) and nonrural (N= 1,174,369) beneficiaries and by diagnosis. RESULTS: Rates of telemedicine treatment for mental and substance use disorders among Medicaid beneficiaries increased during the study period but remained low. Among rural beneficiaries, there was a 5.9 percentage point increase in telemedicine for mental disorders and a 1.9 percentage point increase in telemedicine for substance use disorders. After control for other individual characteristics, rural beneficiaries were more likely than nonrural beneficiaries to receive any telemedicine for mental disorder (2.2 percentage points more likely) or substance use disorder (0.6 percentage points) treatment. Receipt of telemedicine was associated with receipt of more in-person outpatient services by rural beneficiaries (11.2 more visits for mental disorders and 8.2 more for substance use disorders). CONCLUSIONS: Although provision of telemedicine for mental and substance use disorders increased during the study period and was somewhat more common among rural Medicaid beneficiaries, it remains an underused resource for addressing care shortages in rural areas.

Opioid Use Disorder and Prescribed Opioid Regimens: Evidence from Commercial and Medicaid Claims, 2005-2015.

INTRODUCTION: In response to the US opioid crisis, interventions are being implemented to lower opioid prescribing to reduce opioid misuse and overdose. As opioid prescribing falls, opioid misuse may shift from prescriptions to other, possibly illicit, sources. We examined how the percentage of patients with an opioid use disorder (OUD) diagnosis in a given year without a current opioid prescription changed over a decade among commercially insured enrollees and Medicaid beneficiaries. We also examined how the percentages differed by enrollee demographic factors. METHODS: We used commercial and Medicaid claims from the IBM MarketScan® databases from 2005 to 2015 to identify enrollees with and without current opioid prescriptions who have been diagnosed with OUD. We measured the percentage of enrollees with OUD without a current opioid prescription by year and demographic factors. RESULTS: We identified 99,396 enrollee-years with OUD covered by commercial insurance and 60,492 enrollee-years with OUD covered by Medicaid. Among enrollees with OUD, the percentage without a current opioid prescription increased from 37% in 2005 to 49% in 2012 before falling back to 39% in 2015 in the commercial population, and increased from 32% in 2005 to 38% in 2015 in the Medicaid population. Differences in percentages were observed by age, sex, race, and region, particularly among young people where 70 to 89% had OUD without a current prescription. CONCLUSIONS: Most enrollees with OUD in the data had current opioid prescriptions, suggesting that continuing efforts to reduce misuse of prescribed opioids among patients with prescriptions may be effective. However, a substantial percentage of enrollees with OUD may be obtaining opioids via other, likely illegitimate, channels, particularly younger people, which suggests an opportunity for targeted efforts to reduce opioid diversion.

Family member opioid prescriptions and opioid use disorder.

It is recognized that family members are a major source of diverted opioids. Yet it is not known how family member opioid prescriptions predict the development of an opioid use disorder (OUD).We conducted an observational study using commercial health care claims to investigate the association between a family member opioid prescription and an individual having an OUD-related claim in a large sample of patients with commercial insurance. We found that individuals had higher odds of having an OUD when a family member had an opioid prescription. This effect was magnified in spouses and employees compared with adolescents and young adult dependents. In addition, adult dependents with a pre-existing non-OUD substance use disorder had higher odds of having an OUD when a family member also had an opioid prescription. Given the high risk of opioid-related morbidity and mortality, more attention should be given to safeguard opioid diversion and to facilitate appropriate disposal of unused opioids.

The importance of identification when measuring performance in addiction treatment.

Background: Identifying and effectively treating individuals with substance use disorders (SUDs) is an important priority for state Medicaid programs, given the enormous toll that SUDs take on individuals, their families, and their communities. In this paper, we describe how the Healthcare Effectiveness Data and Information Set (HEDIS) measure "Identification of Alcohol and Other Drug Services" can be used, along with eligible population prevalence rates, to expand states' ability to track how well their Medicaid programs identify enrollees with SUDs and link them with treatment (measured by initiation and engagement performance measures). Methods: We use the 2009 Medicaid MAX data on utilization and enrollment along with information from the National Survey of Drug Use and Health (NSDUH) to obtain state-level estimates of alcohol and drug abuse and dependence among Medicaid beneficiaries for 7 illustrative states. We calculate identification, initiation, and engagement measures using specifications from the National Committee on Quality Assurance (NCQA). Results: NSDUH data showed that the eligible population prevalence rate (the average rate of alcohol or drug abuse or dependence) among the 7 states was 10.0%, whereas the average identification rate was 2.9%. The gap between the prevalence and identification rates ranged from 5.1% to 11.0% among the 7 states. The initiation rates ranged from 36.9% to 57.1%. The states' engagement rates ranged from 11.8% to 31.1%, although rates differ by age, gender, and race/ethnicity in some states. Conclusion: Including identification along with initiation and engagement measures allows states to determine how well they are performing in a more complete spectrum from need, to recognition and documentation of enrollees with SUDs, to initiation of treatment, to continuation of early treatment.

Opioid Prescribing to Adolescents in the United States From 2005 to 2016.

OBJECTIVE: This study assessed trends in days' supply for opioid prescriptions filled by adolescents with commercial insurance and Medicaid. METHODS: IBM MarketScan commercial and Medicaid pharmacy claims data were used to measure days' supply among adolescents (2005-2016) and to determine whether there were differences between patients with commercial insurance or Medicaid coverage. RESULTS: The 2-3 days' supply decreased from 50.5% (2005) to 36.7% of fills (2016), while 4-5 days' supply increased from 30.2% to 37.7%. Fills of 6-7 and 8-15 days increased slightly. Fills of over 30 days remained near 0.0%, and one-day fills remained at 1.0-2.0% until 2016, when they increased to 3.6% Conclusions: For adolescents, fills of prescription opioids generally exceeded three days. Efforts to reduce opioid prescribing through guidelines, prescription drug monitoring programs, and limits on days' supply do not appear to have affected prescribing for adolescents as much as desired.

Prescribing of benzodiazepines and opioids to individuals with substance use disorders.

BACKGROUND: Benzodiazepines are recommended for short-term use due to risk of dependence. This study examined characteristics associated with benzodiazepine and opioid dispensing of 7+ days in a Medicaid population with substance use disorder (SUD). METHODS: Using 2014 MarketScan® data, we performed zero-inflated negative binomial regression to ascertain characteristics associated with longer-term use of these medications. RESULTS: Nearly 14% of those with SUDs received 1+ fills of benzodiazepines of 7+ days. The highest rates were among those aged 45-64 (IRR=2.38, p<0.0001) and with non-alcohol SUDs (IRR=1.12, p<0.0001). Individuals with co-occurring psychiatric disorders, particularly anxiety and depression (IRR=1.41, p<0.0001), had high rates of benzodiazepine fills. Receiving a 7+ day oral opioid fill (IRR=1.30, p<0.0001) coincided with increased benzodiazepine dispensing. Similar results occurred for longer-term prescribing of opioids, with higher rates among those with non-alcohol SUDs (IRR=1.23, p< 0.0001). CONCLUSIONS: For many people with SUDs, receiving a benzodiazepine or opioid prescription of 7+ days is not a single occurrence; patients in our sample were more likely to receive 2+ fills than to receive one. Longer-term prescribing is most pronounced among those with co-occurring anxiety disorders. This suggests that anxiety in those with SUD should preferentially not be treated using benzodiazepines. Longer-term polypharmacy with benzodiazepines and opioids coincided. Overdoses among those using both drugs are growing and this study provides evidence that attention to the opioid epidemic should include attention to polypharmacy that includes benzodiazepines.

Off-Label Prescribing of Psychotropic Medication, 2005-2013: An Examination of Potential Influences.

OBJECTIVE: This study examined rates of psychotropic prescriptions for various on- and off-label uses in 2005 and 2013 in the context of changes in labeled indications. METHODS: The National Disease and Therapeutic Index, a survey of nationally representative office-based physicians that identifies the diagnosis attached to each prescription, was used to capture the number of psychiatric medications prescribed for a particular diagnosis in 2005 (N=4,120) and 2013 (N=4,140). Labeled indications for each year were abstracted, and the association of prescribing patterns and changes in labeled indications was evaluated. RESULTS: Expanded labeling was associated with increased use of antidepressants for anxiety (an increase of 3.4 percentage points); antipsychotics for depression (8.3), bipolar disorder (3.4), and tic disorders, autism, and related disorders (1.5); and anxiolytics for anxiety disorders (5.5). Use of antidepressants for depression decreased, by 5.6 percentage points, as did use of antipsychotics (4.6) and anxiolytics (.7) for dementia-related disorders and of antipsychotics for attention-deficit and related disorders (2.7), likely reflecting black box warnings and evidence of side effects. Off-label use of antidepressants for attention deficit and related disorders and anxiolytics for bipolar disorders increased by 1.1 and 1.3 percentage points, respectively. CONCLUSIONS: FDA labeling plays an important but imperfect role in influencing how providers select medications. Prescribing increases for medications with new indications. Conversely, black box warnings of potentially dangerous side effects result in decreased prescribing. However, labeled indications often lag the science, and prescribing patterns should be tracked to inform the need for more education, research, and labeling changes.

Testing for clinical inertia in medication treatment of bipolar disorder.

BACKGROUND: Clinical inertia has been defined as lack of change in medication treatment at visits where a medication adjustment appears to be indicated. This paper seeks to identify the extent of clinical inertia in medication treatment of bipolar disorder. A second goal is to identify patient characteristics that predict this treatment pattern. METHOD: Data describe 23,406 visits made by 1815 patients treated for bipolar disorder during the STEP-BD practical clinical trial. Visits were classified in terms of whether a medication adjustment appears to be indicated, and also whether or not one occurred. Multivariable regression analyses were conducted to find which patient characteristics were predictive of whether adjustment occurred. RESULTS: 36% of visits showed at least 1 indication for adjustment. The most common indications were non-response to medication, side effects, and start of a new illness episode. Among visits with an indication for adjustment, no adjustment occurred 19% of the time, which may be suggestive of clinical inertia. In multivariable models, presence of any indication for medication adjustment was a predictor of receiving one (OR=1.125, 95% CI =1.015, 1.246), although not as strong as clinical status measures. LIMITATIONS: The associations observed are not necessarily causal, given the study design. The data also lack information about physician-patient communication. CONCLUSIONS: Many patients remained on the same medication regimen despite indications of side effects or non-response to treatment. Although lack of adjustment does not necessarily reflect clinical inertia in all cases, the reasons for this treatment pattern merit further examination.

Intermediate Services After Behavioral Health Hospitalization: Effect on Rehospitalization and Emergency Department Visits.

OBJECTIVE: This study examined the effect of intermediate service use on behavioral health inpatient readmissions and subsequent emergency department (ED) visits among Medicaid enrollees. METHODS: Data were from fee-for-service inpatient admissions from the 2008 Medicaid Analytic eXtract files for adults with a primary diagnosis of a mental or substance use disorder. A multivariate survival analysis estimated the association between posthospital services-particularly intermediate services (residential, partial hospital, intensive outpatient, and other rehabilitative services)-and time to readmission or ED visit. A propensity score-matched sample was used to examine the relationship between time to readmission and ED visit in the nondisabled and disabled populations more closely. RESULTS: The sample included 32,037 adults (nondisabled, 27.6%; disabled, 72.4%). Only 2.5% of nondisabled adults and 5.4% of disabled adults used intermediate services within seven days of hospital discharge. In the multivariate analysis, significant associations were found between intermediate service use and readmissions and ED visits in the nondisabled population (hazard ratio [HR]=.71, p=.04, and HR=.68, p<.01, respectively), but not in the disabled population. Significant associations were also found between use of other health care in the seven-day posthospitalization period and decreased time to readmission and ED visits in the nondisabled population and increased time to readmission and ED visits in the disabled population. In the propensity score--matched analysis, use of intermediate services was not significant in either population. CONCLUSIONS: The low use of intermediate services may reflect limited availability as well as Medicaid coverage limits. Research is needed to determine the optimal number and type of intermediate services for this population to minimize the need for additional hospital services.

Projected Spending on Psychotropic Medications 2013-2020.

Spending on psychotropic medications has grown rapidly in recent decades. Using national data on drug expenditures, patent expirations, future drug development and expert interviews, we project that spending will grow more slowly over the period 2012-2020. The average annual increase is projected to be just 3.0 % per year, continuing the steady deceleration in recent years. The main drivers of this expected deceleration include slower development of new drugs, upcoming patent expirations which will lower prices, and payers' growing ability to manage utilization and promote generic use. The slowdown will relieve some cost pressures on payers, particularly Medicare and Medicaid.

The diminished pipeline for medications to treat mental health and substance use disorders.

OBJECTIVE: Psychotropic drug development is perceived to be lagging behind other pharmaceutical development, even though there is a need for more effective psychotropic medications. This study examined the state of the current psychotropic drug pipeline and potential barriers to psychotropic drug development. METHODS: The authors scanned the recent academic and "grey" literature to evaluate psychotropic drug development and to identify experts in the fields of psychiatry and substance use disorder treatment and psychotropic drug development. On the basis of that preliminary research, the authors interviewed six experts and analyzed drugs being studied for treatment of major psychiatric disorders in phase III clinical trials. RESULTS: Interviews and review of clinical trials of drugs in phase III of development confirmed that the psychotropic pipeline is slim and that a majority of the drugs in phase III trials are not very innovative. Among the barriers to development are incentives that encourage firms to focus on incremental innovation rather than take risks on radically new approaches. Other barriers include human brain complexity, failure of animal trials to translate well to human trials, and a drug approval threshold that is perceived as so high that it discourages development. CONCLUSIONS: Drivers of innovation in psychotropic drug development largely parallel those for other drugs, yet crucial distinctions have led to slowing psychotropic development after a period of innovation and growth. Various factors have acted to dry up the pipeline for psychotropic drugs, with expert opinion suggesting that in the near term, this trend is likely to continue.

Performance measurement: a proposal to increase use of SBIRT and decrease alcohol consumption during pregnancy.

Alcohol consumption during pregnancy has negative implications for maternal and child health. Appropriate early universal Screening, Brief Intervention and Referral to Treatment (SBIRT) for pregnant women is necessary to identify women at risk and reduce the likelihood of continued drinking. Because SBIRT is not consistently used, the development and use of performance measures to assure implementation of SBIRT are key steps towards intervention and reduction of alcohol consumption during pregnancy. Practice guidelines provide ample support for specific instruments designed for SBIRT in prenatal care. An examination of existing performance measures related to alcohol consumption during pregnancy, however, reveals no comprehensive published performance measure designed to quantify the use of SBIRT for alcohol use in prenatal care. Process performance measures were developed that can determine the proportion of pregnant women who are screened during the course of prenatal care and the proportion of women requiring either brief intervention or referral to substance use disorder treatment who received those interventions. The measures require use of screening instruments validated for use with pregnant women. The two proposed measures would represent a significant step in efforts to assure appropriate intervention for women who drink during pregnancy, hold accountable providers who do not employ SBIRT, and provide a basis from which necessary systemic changes might occur. Pregnancy is a time when many women are motivated to stop drinking. That opportunity should be seized, with timely intervention offering assistance for pregnant women who have not stopped drinking of their own accord.

The Washington circle engagement performance measures' association with adolescent treatment outcomes.

BACKGROUND: For adolescents, substance use disorder (SUD) treatment outcomes (e.g., abstinence, problematic behaviors) often cannot be measured soon enough to influence treatment trajectory. Although process measures (e.g., treatment engagement) can play an important role, it is essential to demonstrate their association with outcomes. This study explored the extent to which engagement in outpatient treatment was associated with outcomes and whether demographic/clinical characteristics moderated these relationships. METHODS: This is a prospective study of adolescents (N=1491) who received outpatient treatment for SUDs at one of 28 treatment sites taking part in a national evidence-based practice implementation initiative. Information from the Global Appraisal of Individual Needs interviews at intake and six-month follow-up, as well as encounter data, were used. Adjusted hierarchical logistic models were used to estimate effects of engagement on six-month outcomes. RESULTS: Sixty-one percent of adolescents engaged in outpatient treatment. Adolescents engaging in treatment had significantly lower likelihoods of reporting any substance use (OR 0.60, 95% CI 0.41, 0.87), alcohol use (OR 0.63, 95% CI 0.45, 0.87), heavy alcohol use (OR 0.53, 95% CI 0.33, 0.86), and marijuana use (OR 0.64, 95% CI 0.45, 0.93). This association of engagement with abstinence outcomes was not limited to any particular group. Treatment engagement, however, was not associated with adolescents' self-report of illegal activity or trouble controlling behavior at follow-up. CONCLUSION: At the individual level, the Washington Circle engagement measure was a predictor of some positive outcomes for adolescents in outpatient treatment. Efforts to better engage adolescents in treatment could improve quality of care.

Ego-dystonic pregnancy and prenatal consumption of alcohol among first-time mothers.

This study examines predictors of drinking during pregnancy among first-time mothers, in order to distinguish those in need of targeted screening and intervention. Data from the prenatal panel of the Parenting for the First Time study were used in hierarchical linear regressions to determine likelihood of prenatal alcohol consumption among a sample of 645 women. African-American women and those of race/ethnicities other than White were less likely to drink, regardless of age or level of education. Among all women, being in school was associated with abstention (P = 0.05). Among teens, endorsing a perception of feeling "pushed around" was a significant indicator of prenatal alcohol consumption (P = 0.05), as was not having plans for infant feeding shortly before delivery (P = 0.05). Among adults with some level of college education, having a first prenatal visit after the fourth month of pregnancy was a significant predictor of drinking (P = 0.01). This study indicates that women who evidence behaviors or attitudes indicating an ego-dystonic pregnancy (one that is psychologically or emotionally uncomfortable), may be more likely to self-medicate and cope via avoidance through drinking. These behaviors and attitudes may be indicators of the need for targeted screening and intervention, as well as indicators of underlying problems to be targeted in treatment. Further, among all women for whom continued education is a possibility, retaining the ability to attend school during the pregnancy can be protective.

Adolescent treatment initiation and engagement in an evidence-based practice initiative.

This study examined client and program factors predicting initiation and engagement for 2,191 adolescents at 28 outpatient substance abuse treatment sites implementing evidence-based treatments. Using Washington Circle criteria for treatment initiation and engagement, 76% of the sample initiated, with 59% engaging in treatment. Analyses used a 2-stage Heckman probit regression, accounting for within-site clustering, to identify factors predictive of initiation and engagement. Adolescents treated in a pay-for-performance (P4P) group were more likely to initiate, whereas adolescents in the race/ethnicity category labeled other (Native American, Asian, Pacific Islander, Native Alaskan, Native Hawaiian, mixed race/ethnicity), or who reported high truancy, were less likely to initiate. Race/ethnicity groups other than Latinos were equally likely to engage. Among White adolescents, each additional day from first treatment to next treatment reduced likelihood of engagement. Although relatively high initiation and engagement rates were achieved, the results suggest that attention to program and client factors may further improve compliance with these performance indicators.