Abstract
Medications for opioid use disorder, including buprenorphine hydrochloride and methadone hydrochloride, are highly effective at improving outcomes for individuals with the disorder. For pregnant women, use of these medications also improves pregnancy outcomes, including the risk of preterm birth. Despite the known benefits of medications for opioid use disorder, many pregnant and nonpregnant women with the disorder are not receiving them. To determine whether pregnancy and insurance status are associated with a woman's ability to obtain an appointment with an opioid use disorder treatment clinician. In this cross-sectional study with random assignment of clinicians and simulated-patient callers (performed in "secret shopper" format), outpatient clinics that provide buprenorphine and methadone were randomly selected from publicly available treatment lists in 10 US states (selected for variability in opioid-related outcomes and policies) from March 7 to September 5, 2019. Pregnant vs nonpregnant woman and private vs public insurance assigned randomly to callers to create unique patient profiles. Simulated patients called the clinics posing as pregnant or nonpregnant women to obtain an initial appointment with a clinician. Appointment scheduling, wait time, and out-of-pocket costs. A total of 10 871 unique patient profiles were assigned to 6324 clinicians. Among all women, 2312 of 3420 (67.6%) received an appointment with a clinician who prescribed buprenorphine, with lower rates among pregnant vs nonpregnant callers (1055 of 1718 [61.4%] vs 1257 of 1702 [73.9%]; relative risk, 0.83; 95% CI, 0.79-0.87). For clinicians who prescribed methadone, there was no difference in appointment access for pregnant vs nonpregnant callers (240 of 271 [88.6%] vs 237 of 265 [89.4%]; relative risk, 0.99; 95% CI, 0.93-1.05). Insurance was frequently not accepted, with 894 of 3420 buprenorphine-waivered prescribers (26.1%) and 174 of 536 opioid treatment programs (32.5%) granting appointments only when patients agreed to pay cash. Median wait times did not differ between pregnant and nonpregnant callers among buprenorphine prescribers (3 days [interquartile range, 1-7 days] vs 3 days [interquartile range, 1-7 days]; P = .43) but did differ among methadone prescribers (1 day [interquartile range, 1-4 days] vs 2 days [interquartile range, 1-6 days]; P = .049). For patients agreeing to pay cash, the median out-of-pocket costs for initial appointments were $250 (interquartile range, $155-$300) at buprenorphine prescribers and $34 (interquartile range, $15-$120) at methadone prescribers. In this cross-sectional study with random assignment of clinicians and simulated-patient callers, many women, especially pregnant women, faced barriers to accessing treatment. Given the high out-of-pocket costs and lack of acceptance of insurance among many clinicians, access to affordable opioid use disorder treatment is a significant concern.
Highlights
Opioid use during pregnancy,[1,2] diagnoses of opioid use disorder (OUD) among pregnant women,[3,4,5] and neonatal complications from in utero opioid exposure have increased substantially during the past 2 decades.[3,5,6,7,8] Untreated OUD among pregnant women is associated with adverse pregnancy outcomes, including overdose death and preterm birth.[9]
Script Development In the initial phase, we developed a script for women with OUD by interviewing treatment clinician staff and calling several buprenorphine-waivered prescribers and opioid treatment programs (OTPs) to better understand what information would be needed to make an appointment to obtain MOUD treatment
Among OTPs, acceptance of Medicaid ranged from 2 of 26 (7.7%) in Tennessee to 73 of 83 (88.0%) in Massachusetts (P < .001) (Figure 2). In this cross-sectional study with random assignment of clinicians and simulated-patient callers, we found many barriers to women successfully accessing MOUDs; these barriers were more substantial for pregnant women
Summary
Opioid use during pregnancy,[1,2] diagnoses of opioid use disorder (OUD) among pregnant women,[3,4,5] and neonatal complications from in utero opioid exposure have increased substantially during the past 2 decades.[3,5,6,7,8] Untreated OUD among pregnant women is associated with adverse pregnancy outcomes, including overdose death and preterm birth.[9].
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