Jeffrey D. Baxter

The Evidence Doesn’t Justify Steps By State Medicaid Programs To Restrict Opioid Addiction Treatment With Buprenorphine

Many state Medicaid programs restrict access to buprenorphine, a prescription medication that relieves withdrawal symptoms for people addicted to heroin or other opiates. The reason is that officials fear that the drug is costlier or less safe than other therapies such as methadone. To find out if this is true, we compared spending, the use of services related to drug-use relapses, and mortality for 33,923 Massachusetts Medicaid beneficiaries receiving either buprenorphine, methadone, drug-free treatment, or no treatment during the period 2003-07. Buprenorphine appears to have significantly expanded access to treatment because the drug can be prescribed by a physician and taken at home compared with methadone, which by law must be administered at an approved clinic. Buprenorphine was associated with more relapse-related services but

Predictors of prenatal and postpartum care adequacy in a medicaid managed care population.

1,330 lower mean annual spending than methadone when used for maintenance treatment. Mortality rates were similar for buprenorphine and methadone. By contrast, mortality rates were 75 percent higher among those receiving drug-free treatment, and more than twice as high among those receiving no treatment, compared to those receiving buprenorphine. The evidence does not support rationing buprenorphine to save money or ensure safety.

Beyond health plans: behavioral health disorders and quality of diabetes and asthma care for Medicaid beneficiaries

PURPOSE To examine factors affecting prenatal and postpartum care for an insured, but vulnerable, population. METHODS Individual-level data on three measures of care adequacy were obtained for Massachusetts Medicaid Managed Care women who met the National Committee on Quality Assurances Healthcare Effectiveness Data and Information Set denominator criteria for the prenatal and postpartum care measures in 2007 (n = 1,882). We modeled individual compliance with each measure separately as a binomial logistic function with individual and neighborhood characteristics, provider type, and health plan as explanatory variables. FINDINGS In our sample, 85% of women initiated care in the first trimester, but only 62% met the goal of receiving more than 80% of the recommended number of prenatal visits. Just 60% had a timely postpartum care visit. Having a diagnosis of substance abuse or dependence reduced the odds of meeting all measures. Women with disabilities were less likely to attain two of the three measures of adequate care, as were women with other children in the household. Women who enrolled in Medicaid in the first trimester were more likely to receive the recommended number of prenatal visits than those who were enrolled before pregnancy. CONCLUSION Given the importance of prenatal and postpartum care for maternal and child health and the recent national declining trend in timely care, initiatives to improve rates of timely and adequate care are crucial and must include components tailored toward particularly vulnerable subpopulations.

Responses of State Medicaid Programs to Buprenorphine Diversion Doing More Harm Than Good

Background:Most health insurance plans monitor ambulatory care quality using the Healthcare Effectiveness Data and Information Set (HEDIS), publicly reporting results at the plan level. Plan-level comparisons obscure the influence of patients served or settings where care is delivered. Mental illness, substance abuse, and other physical comorbidities, particularly prevalent among Medicaid beneficiaries, can impact adherence to recommended care. We analyzed individual-level HEDIS measures for diabetes and asthma from 5 Medicaid managed care plans to understand how these factors contribute to quality. Methods:We used claims and medical records to study HEDIS measures for persistent asthma (n = 9103) and diabetes (n = 1790) among beneficiaries enrolled in Massachusetts’ Medicaid program during 2004 and 2005. Logistic regression models included patient-level demographic and health factors, provider type, region, and managed care plan. Results:Alcohol and drug use disorders and emergency department use were associated with lower quality care for most measures. Glycemic control was better for patients with diabetes and severe mental illness. Patients with higher illness burden and with more frequent ambulatory visits received higher quality care for both conditions. Younger adults received recommended care less often than older adults. Quality varied across plans. Conclusions:Additional efforts to improve quality of care for asthma and diabetes for Medicaid beneficiaries are needed for individuals with substance use disorders and young adults. Although evidence of higher quality for patients with multiple conditions is encouraging, improving quality for comparatively healthier individuals might also produce significant long-term benefits.

Risk Factors for Relapse and Higher Costs Among Medicaid Members with Opioid Dependence or Abuse: Opioid Agonists, Comorbidities, and Treatment History

Abuse of prescription opioids is an increasing national concern. Recent reports point to growing rates of overdose, addiction, emergency department visits, and death attributable to nonmedical use of prescription pain medications.1,2 Opioid misuse and addiction has an especially important impact on Medicaid programs; rates of drug abuse among covered individuals exceed those of other insured populations.3 Opioid agonist treatment with methadone hydrochloride or buprenorphine hydrochloride is the most effective way to treat opioid addiction.4 Medicaid programs in most states cover methadone treatment and in al l states cover buprenorphine, but there is concern that either medication can be abused. As a consequence, daily on-site dosing is required for most patients who are prescribed methadone. Buprenorphine carries a lower risk of sedation and overdose; it can more safely be dispensed for unsupervised use at home. Prescriptions f o r t h e l e a d i n g s u b l i n g u a l b u p r e n o r p h i n e hydrochloride–naloxone hydrochloride product (Suboxone; Reckitt-Benckiser) have risen sharply since 2002, when the US Food and Drug Administration (FDA) approved its use for treatment of opioid addiction. At present, more than 20 000 physicians are certified to prescribe buprenorphine. Patients filled an estimated 9 million prescriptions for buprenorphine in 2012. For a typical patient, the medication costs about

The Quality of Asthma Care Among Adults With Substance-Related Disorders and Adults With Mental Illness

325 a month. Reported increases in buprenorphine diversion have raised concern about unsupervised and nonmedical use. Emergency department visits involving buprenorphine increased almost 10-fold from 2005 to 2010; half of the 30 135 emergency department visits in 2010 were for nonmedical use.2 Of particular note are case reports of accidental ingestion by children, including some deaths.5 Citing concerns about safety and costs, several states have implemented stricter controls on the use of buprenorphine in their Medicaid programs. Almost all states now require prior authorization before buprenorphine is prescribed; some impose additional restrictions. Eleven states now impose lifetime limits on the duration of buprenorphine therapy, which range from 12 to 36 months. States with these stringent restrictions include Arkansas, Delaware, Illinois, Maine, Michigan, Mississippi, Montana, Utah, Virginia, Washington, and Wyoming. Patients who cannot continue to take buprenorphine could theoretically be treated with methadone or without medication. Unfortunately, access to methadone maintenance programs is severely limited in many locations, and the requirement for on-site dosing creates challenges for work and family life. In addition, compared with opioid agonist treatment, drugfree treatment has higher relapse rates, higher costs, poorer treatment retention, and higher mortality.4,6 Given typical patterns of opioid addiction and recovery, lifetime limits on buprenorphine treatment may make opioid addiction worse. Most people make repeated treatment attempts before achieving sustained recovery. When not in treatment, they face a substantially greater risk of overdose and death. Medicationassisted treatment has saved many lives since its introduction, yet it is still not widely accepted by the public, or even by some physicians. Oversimplified views that treatment with medications is not effective because it does not immediately end drug dependence or because it substitutes one opioid for another may be appealing. And there are examples of people who quit using opioids on their own. But for most people, choosing drugfree opioid treatment increases their risk of relapse and death.4,6 From a policy perspective, severe restrictions on buprenorphine place patients at substantial risk. A more sensible approach to the availability of buprenorphine would weigh the potential harm from diversion against the consequences of forcing patients to end treatment arbitrarily or to switch to less effective alternatives. Compared with methadone and many commonly used drugs, buprenorphine is relatively safe. Poison centers and emergency departments report that, among adults, fewer emergency visits related to buprenorphine reflect life-threatening situations and result in hospital admission than visits related to the use of heroin, methadone, or oxycodone.7 Accidental ingestion by children is more dangerous but less common.7 Despite the increase in emergency department visits, deaths associated with buprenorphine are rare.2,7 One study8 found that having limited access to buprenorphine treatment was the strongest predictor of using buprenorphine that had been diverted by another patient. Although some individuals report abusing it, buprenorphine is not the drug of choice for most recreational users or addicts. Sources of diverted buprenorphine vary, but those with legitimate prescriptions seem to supply about half of the drugs used illicitly. This suggests that they receive prescribed doses high enough to avoid withdrawal themselves and to share or sell a portion of their supply.9 Diversion has increased in proportion to the growing supply of buprenorphine.9 Necessary measures are careful screening of patients to document opioid addiction, clinical evaluations to ensure that minimum effective doses are used, monitorVIEWPOINT

Adherence to Buprenorphine Treatment Guidelines in a Medicaid Program

Clinical trials show that opioid agonist therapy (OAT) with methadone or buprenorphine is more effective than behavioral treatments, but state policymakers remain ambivalent about covering OAT for long periods. We used Medicaid claims for 52,278 Massachusetts Medicaid beneficiaries with a diagnosis of opioid abuse or dependence between 2004 and 2010 to study associations between use of methadone, buprenorphine or other behavioral health treatment without OAT, and time to relapse and total healthcare expenditures. Cox Proportional Hazards ratios for patients treated with either methadone or buprenorphine showed approximately 50% lower risk of relapse than behavioral treatment without OAT. Expenditures per month were from

Patterns of health care utilization for asthma treatment in adults with substance use disorders.

153 to

Co-occurring risk factors for arrest among persons with opioid abuse and dependence: implications for developing interventions to limit criminal justice involvement

233 lower for OAT episodes compared to other behavioral treatment. Co-occurring alcohol abuse/dependence quadrupled the risk of relapse, other non-opioid abuse/dependence doubled the relapse risk and severe mental illness added 80% greater risk compared to those without each of those disorders. Longer current treatment episodes were associated with lower risk of relapse. Relapse risk increased as prior treatment exposure increased but prior treatment was associated with slightly lower total healthcare expenditures. These findings suggest that the effectiveness of OAT that has been demonstrated in clinical trials persists at the population level in a less controlled setting and that OAT is associated with lower total healthcare expenditures compared to other forms of behavioral treatment for patients with opioid addiction. Co-occurring other substance use and mental illness exert strong influences on cost and risk of relapse, suggesting that individuals with these conditions need more comprehensive treatment.

The Surgeon General's Facing Addiction Report: An Historic Document for Healthcare

OBJECTIVE The purpose of this study was to investigate whether the presence of substance-related disorders or mental illness may affect the quality of medication management in asthma care. METHODS Claims from 1999 for adult Medicaid patients with persistent asthma from five states were analyzed. Sample sizes ranged from 1,207 to 5,815. The adjusted odds of meeting two quality-of-care measures for asthma were calculated: the Health Effectiveness Data and Information Set (HEDIS) measure of filling a single prescription for a controller medication and a non-HEDIS measure of achieving a ratio of long-term controller medications to total asthma medications of > or = .5. RESULTS Odds of achieving the HEDIS measure were lower for patients with substance-related or schizophrenia disorders in two states (range of odds ratio [OR]=.69, 95% confidence interval [CI]=.53-.90, to OR=.81, 95% CI=.69-.96), but the odds increased for patients with depressive disorders in two states (OR=1.34, CI= 1.12-1.61; OR=1.37, CI=1.05-1.77) and for patients with bipolar disorder in one state (OR=1.69, CI=1.13-2.55). Odds of achieving the ratio measure were lower for patients with substance-related disorders in four states (range of OR=.63, CI=.47-.88, to OR=.75, CI=.62-.92) and higher for patients with depressive disorders, although only in one state (OR=1.25, CI=1.03-1.53). CONCLUSIONS Patients with substance-related disorders and those with schizophrenia disorders may be receiving lower-quality asthma care, whereas patients with some other forms of mental illness may be receiving higher-quality care. Further studies are needed to identify the determinants of high-quality asthma care and the validity of quality measures based on administrative data in these populations.