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Disparities in buprenorphine use persist years after approval
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Though the 2002 approval of buprenorphine lead to an increase in the number of U.S. Medicaid enrollees receiving medication treatment for opioid use disorder, the rate at which treatment with these medications rose varied by county, race/ethnicity and income years later, researchers found.
“Increasing use of medication treatment for individuals with opioid use disorders with medications like methadone and buprenorphine is a critical piece of the nation’s response to the opioid crisis,” Bradley D. Stein, MD, PhD, from the RAND Corporation, and the department of psychiatry, University of Pittsburgh School of Medicine, told Healio Psychiatry.
“Buprenorphine was approved by the FDA in 2002 for treatment of opioid use disorders, but there was little information about to what extent buprenorphine’s approval increased the number of Medicaid enrollees who received medication treatment in the years following FDA approval, or to what extent receipt of such treatment was equitable across communities,” he continued. “The more we know about this, the better we are able to take actions and make sure effective treatment for opioid use disorder is reaching the individuals who can benefit from it.”
Using Medicaid claims data from non-dually eligible adults with opioid use disorder enrolled in Medicaid between 2002 and2009, researchers assessed changes in methadone, buprenorphine and any other medication treatment use. The investigators also examined the link between treatment use and county-level indicators of poverty, race/ethnicity and urbanicity. They measured county-level aggregate counts of medication treatment by year (n = 7,760 county-years), then estimated count data models to determine links between treatment and county characteristics.
“The good news is that we found that from 2002 to 2009, there was a substantial increase in the number of adult Medicaid enrollees receiving medication treatment, with the bulk of the increase coming from individuals receiving buprenorphine,” Stein said. “However, we also learned that the increases in medication treatment were substantially lower in counties with populations that historically have been disadvantaged with respect to health care access and quality.”
Analysis showed that the number of Medicaid enrollees with opioid use disorders who received medication treatment rose 62% between 2002 and 2009, with the number of enrollees who received methadone increasing 20% and the remaining increase resulted from buprenorphine.
In 2002, when almost all people received methadone, urban counties had higher rates of medication therapy than rural counties (IRR = 9.54; P < .001), but there were no significant differences across counties by concentration of black race or poverty, whereas counties with higher concentrations of Hispanic residents in 2002 had higher rates of medication treatment regardless of poverty than those with a low concentration of Hispanic residents and poverty. By 2009, people in counties with a low percentage of black residents and a low poverty rate were significantly more likely to receive medication treatment than those living in all other types of counties.
Both in 2002 and 2009, urban county residents remained more likely to receive opioid use disorder treatment than residents from rural counties (IRR = 1.94; P < .01). Residents of counties with a low percentage of Hispanics and a low poverty rate were significantly more likely to receive medication treatment than residents from all other types of counties by 2009.
“It is critically important that efforts to increase access to medication treatment work to ensure that access is equitably distributed across society so that it reaches disadvantaged individuals who may be at higher risk of suffering from opioid use disorder,” Stein told Healio Psychiatry. – by Savannah Demko
Disclosure: This study was supported by The National Institute on Drug Abuse of the NIH.
Perspective
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Adam Bisaga, MD
A significant number of patients diagnosed with opioid use disorder (OUD), perhaps as much as 80%, do not receive evidence-based treatment with medications, even though many of them are interested in treatment. Of the three medications approved by FDA for treatment of OUD, methadone and buprenorphine are offered most commonly, with the extended release naltrexone offered to 5% of patients treated with medications. While treatment methadone may be on average more effective than treatment with buprenorphine, it is highly regulated and inflexible, requiring many months of daily visits to the clinics for supervised administration, and therefore it may not be a best match for some patients. On the contrary, buprenorphine can be as effective as methadone for many patients and it is highly flexible, with minimal requirements for clinic visits for patients that do not need it, and therefore it is more attractive than methadone for many patients. Ideally, all medication treatments should be available in all treatment settings, so that the patient and physician would decide on the best medication for the given patient, rather than making choice based on which medication is available at that program.
The addiction treatment gap has not narrowed over the past 15 years despite the alarming increases in annual rates of opioid overdose deaths. One of the reasons for the gap is poor access to evidence-based medical care and while treatment capacity has expanded, this expansion did not catch up with the increasing needs that were present in most communities. Most of the increases in medical treatment of OUD were due to the expansion of office-based treatment with buprenorphine. However, studies evaluating trends in expanding treatment capacity in various geographic areas show that the treatment gap was not closing equitably for all affected individuals. The present study, one of the largest of its kind, shows that a traditionally disadvantaged patient population — patients living in areas with high rates of poverty and high percentage of black residents — was less likely to benefit from the expansion of access to treatment with buprenorphine as compared to treatment with methadone.
Several reasons for this disparity have been proposed, with one possibly related to the way that medical care is reimbursed. Fewer medical providers offering buprenorphine are willing to accept to their care publicly-insured patients in contrast to patients from high-income, largely white areas, who may be more likely to have private insurance or are able to pay in cash. Buprenorphine providers tend to be addiction specialists and see patients in private practice while there are few economic incentives for specialists or other providers to practice in the public sectors and offer buprenorphine.
These findings highlight the importance of policies that specifically focus on barriers to care that may be different for various communities. Once such barriers are identified, these could be remediated with targeted efforts. One of the major efforts should be directed at assuring that all three FDA-approved medications are available in areas of the country that have been traditionally disadvantaged, including the areas with high level of poverty and underfunded medical care, as these individuals may be at higher risk for the disorder, for poor treatment outcome, and in turn high rates of overdose deaths. Assuring that treatment in those areas is available and accessible, appropriate to the needs of patients and attractive will encourage more individuals to take advantage of treatment and begin turning the rising tide of overdoses.
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