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Try out PMC Labs and tell us what you think. Learn More. West Virginia is the epicenter of a national opioid crisis. We examine trends in treatment for opioid use disorder OUD among individuals enrolled in the West Virginia Medicaid expansion program under the Affordable Care Act using — claims data.

Expanding Medicaid could provide services to populations that may ly have had limited access to OUD treatment. We thus sought to understand trends over time in OUD diagnosis and treatment, especially with medications. About 5. Mean annual duration of filled buprenorphine increased from days in to days inand most individuals filling buprenorphine also received counseling and drug testing during the study period. The growing use of medication treatment for OUD in the West Virginia Medicaid expansion provides an opportunity to reduce overdose deaths.

West Virginia is the epicenter of a national opioid overdose crisis. InWest Virginia had a fatal opioid overdose rate of Given the high uninsured and poverty rates in West Virginia that preceded the Affordable Care Act ACAMedicaid expansion could be one tool to address the opioid crisis. The expansion provided Medicaid eligibility for the first time to many adults with incomes below percent of the federal poverty level, a population that has elevated burden of substance use disorders. West Virginia was one of the 25 states plus the District of Columbia that implemented the optional Medicaid expansion starting in January By earlythere wereindividuals enrolled in the West Virginia Medicaid expansion, 4 compared to the pre-ACA monthly Medicaid average of5.

Substance use disorder treatment is a required benefit in ACA Medicaid expansion programs, but states have leeway in defining the benefit package. Naltrexone is most commonly administered as a long-acting injection.

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It requires individuals to be fully withdrawn from opioids to begin treatment, which limits the of individuals able to initiate it. This study examines patterns of service use related to treatment for OUD, including initiation and duration of pharmacologic and nonpharmacologic treatment, in the West Virginia Medicaid expansion program.

It builds upon recent national studies that leverage data from across expansion and non-expansion states. A recent study using national survey data found that the ACA increased the of low-income people with Medicaid coverage in substance use disorder treatment, but did not increase overall entry to treatment. In sum, existing literature suggests that Medicaid expansion is picking up a growing share of the cost for OUD medication treatment in expansion states and that Medicaid may in particular be driving an increase in buprenorphine treatment.

There may also be constraints, however, such as benefit de limitations or lack of adequate supply of prescribing providers, that hinder greater receipt of medication treatment among newly Medicaid-eligible individuals. Moreover, it is unknown how much of the Medicaid expansion is funding medication treatment for OUD versus other treatment modalities e.

Questions also remain regarding how individuals are navigating treatment on the ground, such as what barriers exist to ongoing Woman want sex Millwood West Virginia treatment following initiation. Our study uses longitudinal claims data from West Virginia Medicaid and considers multiple treatment approaches e.

A clearer analysis of these factors can be useful for policymakers seeking to build upon the Medicaid expansion. Through a data use agreement with the West Virginia Department of Health and Human Resources, we obtained the full sample of Medicaid-reimbursed inpatient, outpatient and pharmacy claims for all individuals enrolled in the West Virginia Medicaid program under ACA eligibility criteria for calendar years — The Medicaid expansion population is defined in the claims data using specific eligibility codes and thus encompasses only individuals who are newly eligible specifically under ACA provisions in Until the third quarter ofWest Virginia Medicaid expansion enrollees were primarily enrolled in Medicaid fee-for-service, after which the state transitioned to managed care.

X in any position on at least one claim. For buprenorphine and naltrexone of any formulationwe identified therapeutic groups using the First Data Bank three-digit hierarchical ingredient code HIC3 classification.

Finally, using diagnosis codes we also created indicators for 14 common chronic conditions hypertension, hyperlipidemia, atherosclerosis, asthma, chronic obstructive pulmonary disease, arthritis, diabetes, depression, anxiety disorder, bipolar disorder, hepatitis C, HIV, alcohol use disorder, and chronic pain.

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For our primary analysis, we aggregated data into person years. To define servicewe looked for clinically meaningful groupings of procedure codes. Specifically, we identified claims for behavioral health counseling e. Using the of prescriptions and days supplied, we calculated the of days individuals had a filled prescription for buprenorphine or naltrexone. As noted, methadone for OUD was not reimbursed by Medicaid during this time period. Using adapted Census-based19 we also identified whether individuals reside in a metropolitan county counties that contains a core citya county adjacent to a metropolitan area suburban countiesand counties not in a metropolitan area rural counties.

We conducted both month-level and aggregated annual analyses. For annual measures, we restricted to individuals enrolled for at least 10 months of the calendar year.

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For month-level analyses, we did not impose the 10 month continuous enrollment requirement and examined the of individuals who had a diagnosis of OUD in a month and the of individuals filling buprenorphine and naltrexone. We calculated summary statistics of all other utilization and spending measures on an annual basis, and for continuous measures calculated means and medians. To further examine predictors of treatment utilization, we pooled person-year data from the three years and estimated separate logistic regression models where the outcomes were fills for buprenorphine, fills for naltrexone, and utilization of counseling treatment without buprenorphine or naltrexone among individuals in the calendar year in which individuals had an OUD diagnosis note that individuals could appear in both the buprenorphine and naltrexone models if they filled prescriptions for both medications in the study period.

The medications are separately considered because they have different clinical profiles and may be administered to different populations. Several limitations should be considered. First, data from West Virginia do not necessarily generalize to other state Medicaid expansion programs. West Virginia was the focus of this study because of both the high pre-ACA uninsured rates and because of the severity Woman want sex Millwood West Virginia the opioid crisis, making it likely that large s of individuals in the expansion population would need OUD treatment.

However, West Virginia did not cover methadone maintenance during the study period, which is likely to be an important pathway into treatment in other states. West Virginia is among the most rural states, and care-seeking patterns are likely to be different in more urban states. Second, we do not have a comparison group, such as individuals not eligible for Medicaid expansion or eligible individuals who did not enroll, preventing us from drawing causal inferences about the likely effect of Medicaid expansion on use of treatment or quality of care.

Furthermore, we were unable to obtain contemporaneous data on other populations e. Relatedly, without pre-Medicaid enrollment data we cannot determine whether our study population had insurance coverage, access to treatment, or received any treatment, prior to the expansion. This precludes any pre-post comparison. However, it is reasonable to assume that the large majority of individuals in the ACA expansion population were ly uninsured as has been found using national data Our study findings have descriptive value as relatively little is known about treatments used by people enrolled in the ACA Medicaid expansion.

Third, because we focus only on services with an OUD diagnosis code, we may miss services provided to individuals in this population for related conditions that may have also treated OUD e. Finally, we are inherently limited by claims data in our ability to examine clinically important treatment markers such as rates of abstinence and health-related quality of life.

On average, in the first three years of Medicaid expansion, 5. Notes : Rural-urban status is determined using the urban-rural continuum code scores. Each observation in this table represents a unique individual with at least 10 months of data during one of the three years from to P-value for pairwise t-test between people diagnosed with opioid use disorder and those without opioid use disorder diagnosis.

They were ificantly less likely than other enrollees to have diagnosed cardiovascular diseases than those without OUD, such as hypertension Exhibit 2 shows monthly trends from to in the percentage of enrollees who had a claim with a diagnosis of OUD in each month and the percentages receiving buprenorphine and naltrexone.

Of note, rates for month-level calculations will be lower than annual rates because they pertain to individuals using services specifically in the particular study month rather than any time in the year. A gray box is overlaid on the second half of when the state transitioned to managed care on July 1. There appears to be underreporting of outpatient claims during this time, but data become more consistent in early Diagnosed monthly prevalence of OUD more than doubled during the study period from 1.

The monthly prevalence of buprenorphine use increased sixfold, from 0. The monthly percentage of people with OUD receiving naltrexone increased from 0. Notes : Monthly average are calculated as the percentage of all Medicaid expansion enrollees in the month with either a claim that included a diagnosis for an opioid use disorder, a prescription filled for buprenorphine, or a prescription filled for naltrexone. The gray box indicates the period when the state transitioned the Medicaid expansion population from fee-for-service to managed care. Exhibit 3 provides information on the service utilization characteristics of individuals with diagnosed OUD overall, and the subgroups who used either any buprenorphine or any naltrexone in — It also provides p-values for tests of ificant time trends in means over the three-year period.

Inindividuals with OUD received an average of 6. However, these data are skewed by high utilizers as the median for each of these measures is only 0 or 1 service received. The mean of counseling sessions did not ificantly change. Notes : Drug Woman want sex Millwood West Virginia, counseling sessions, and physician visits defined using procedure codes. Medication fills determined using three-level hierarchical ingredient code HIC3 codes. Each observation in these tables is a person year with at least 10 months of enrollment in the Medicaid expansion.

Inindividuals who received any buprenorphine received an average of At the mean, these individuals also received The mean of days ificantly increased to Individuals using naltrexone had shorter average duration of medication use: at the mean they only received about This ificantly decreased over the study period to They received an average of These indicators did not ificantly change during the study period.

Exhibit 4 provides odds ratios from logistic regression models predicting fills of buprenorphine, fills of naltrexone, and utilization of counseling without medication, in each calendar year where individuals had a diagnosis of OUD, combining data across the three study years. Separate models were estimated to predict the odds of fills of buprenorphine and naltrexone and receipt of counseling without medication. Among individuals with OUD, odds of filling buprenorphine were ificantly lower among Hispanics and Non-Hispanic blacks compared to non-Hispanic whites and were ificantly lower among older individuals versus those age 25— Odds of filling buprenorphine were ificantly lower among people with hypertension, hyperlipidemia, arthritis, depression, anxiety disorder, bipolar disorder, alcohol use disorder, and chronic pain, compared to people without these conditions.

Compared to people in urban areas, people in suburban and rural areas were ificantly more likely to fill prescriptions for buprenorphine. Odds of filling naltrexone were ificantly higher among Hispanics and non-Hispanic blacks compared to non-Hispanic whites. Compared to individuals age 25—34, older individuals were ificantly less likely to fill naltrexone. Odds of filling naltrexone were ificantly lower for people with comorbid arthritis and chronic pain, but ificantly higher for people with depression, bipolar disorder, hepatitis C, and alcohol use disorder compared to people without these conditions.

Compared to people in urban areas, people in rural areas were ificantly less likely to fill naltrexone. Odds of receiving counseling without medication were ificantly higher for Hispanic individuals compared to non-Hispanic whites. Odds of receiving counseling without medication were ificantly lower for individuals with comorbid hypertension and chronic pain, and higher for depression, anxiety disorder, bipolar disorder, and alcohol use disorder.

Finally, odds were ificantly lower for individuals in rural areas compared to those in urban areas. We examined trends Woman want sex Millwood West Virginia utilization of OUD treatment among individuals enrolled in the West Virginia Medicaid expansion. We found that the diagnosed prevalence of OUD steadily grew during the — study period. Underscoring the scope of the West Virginia opioid crisis, the annual diagnosed OUD prevalence in the sample was 5. This is dramatically higher than ly-reported rates reported for Medicaid enrollees with claims data where the national average was 0.

The share of individuals with an OUD diagnosis filling buprenorphine also increased during the study period: increasing from under one-third of individuals with an OUD diagnosis in the month in early to around three-quarters by late We also found that individuals were filling buprenorphine for slightly longer periods of time per year by Naltrexone fill rates were consistently lower than buprenorphine.

While naltrexone fill rates increased substantially during the study period, average duration among people using naltrexone actually decreased over time.

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