State Laws Banning Prior Authorization For Medications For Opioid Use Disorder Increased Substantially, 2015-23.

IMPORTANCEMedicaid is a key policy lever to improve opioid use disorder treatment, covering approximately 40% of Americans with opioid use disorder. Although approximately 70% of Medicaid beneficiaries are enrolled in comprehensive managed care organization (MCO) plans, little is known about coverage and prior authorization (PA) policies for medications for opioid use disorder (MOUD) in these plans.OBJECTIVETo compare coverage and PA policies for buprenorphine, methadone, and injectable naltrexone across Medicaid MCO plans and fee-for-service (FFS) programs and across states.DESIGN, SETTING, AND PARTICIPANTSThis cross-sectional study analyzed MOUD data from 266 Medicaid MCO plans and FFS programs in 38 states and the District of Columbia in 2018.MAIN OUTCOMES AND MEASURESFor each medication, the percentages of MCO plans and FFS programs that covered the medication without PA, covered the medication with PA, and did not cover the medication were calculated, as were the percentages of MCO, FFS, and all (MCO and FFS) beneficiaries who were covered with no PA, covered with PA, and not covered. In addition, MCO plan coverage and PA policies were mapped by state. Analyses were conducted from January 1 through May 31, 2022.RESULTSCoverage and PA policies were compared for MOUD in 266 MCO plans and 39 FFS programs, representing approximately 70 million Medicaid beneficiaries. Overall, FFS programs had more generous MOUD coverage than MCO plans. However, a higher percentage of FFS programs imposed PA for the 3 medications (47.0%) than did MCOs (35.9%). Furthermore, although most Medicaid beneficiaries were enrolled in a plan that covered MOUD, 53.2% of all MCO- and FFS-enrolled beneficiaries were subject to PA. Results also showed wide state variation in MCO plan coverage and PA policies for MOUD and the percentage of Medicaid beneficiaries subject to PA.CONCLUSIONS AND RELEVANCEThis cross-sectional study found variation in MOUD coverage and PA policies across Medicaid MCO plans and FFS programs and across states. Thus, Medicaid beneficiaries’ access to MOUD may be heavily influenced by their state of residency and the Medicaid plan in which they are enrolled. Left unaddressed, PA policies are likely to remain a barrier to MOUD access in the nation’s Medicaid programs.

Research objective Medications for opioid use disorder (MOUDs) – including methadone, buprenorphine, and naltrexone – are the most effective treatments for opioid use disorder (OUD). Historically, insurers have required prior authorization for MOUD, but prior authorization is often reported as a key barrier to MOUD prescribing. Some states have passed laws prohibiting MOUD prior authorization requirements. We sought to identify the frequency of MOUD prior authorization prohibitions in state laws and to categorize types of prohibitions. Methods We searched for regulations and statutes present in all U.S. states and Washington DC between 2005 and 2019 using MOUD-related terms in Westlaw legal software. In qualitative software, we coded laws discussing MOUD prior authorization using template analysis – a mixed deductive/inductive approach. Finally, we used coded laws to identify frequencies of states with prior authorization prohibitions, including changes over time. Results No states had laws prohibiting MOUD prior authorization between 2005 and 2015, with the first prohibition appearing in 2016. By 2019, fifteen states had MOUD prior authorization prohibitions. States varied significantly in their approach to prohibiting MOUD prior authorization. In 2019, it was more common for states to have MOUD prior authorization prohibitions applying to all insurers (n = 10 states) than to only Medicaid (n = 7 states) or only non-Medicaid insurers (n = 1 state). In 2019, general prior authorization prohibitions (n = 10 states) were more common than prohibitions only applicable to medications on the formulary, prohibitions only applicable to medications on the preferred drug list, prohibitions only applicable during the first 5 days of treatment, and prohibitions only applicable during the first 30 days of treatment. Conclusions The number of states with an MOUD prior authorization law prohibition increased in recent years. Such laws could help expand access to life-saving OUD treatments by making it easier for clinicians to prescribe MOUD. KEY MESSAGES No states had MOUD prior authorization prohibitions between 2005 and 2015 in state statutes or regulations, and only one state had such a prohibition in 2016. By 2019, fifteen states had an MOUD prior authorization prohibition law. States varied significantly in their approach to prohibiting MOUD prior authorization, including with respect to the insurer type, duration of the prohibition, and applicable medication.

Background: People who inject drugs (PWID) are especially vulnerable to harms from opioid use disorder (OUD). Medications for OUD (MOUD) effectively reduce overdose and infectious disease transmission risks. Objective: We investigate whether state Medicaid coverage for methadone and buprenorphine is related to past-year MOUD use among PWID using cross-sectional, multilevel analyses with individual-level data on PWID from the Centers for Disease Control and Prevention’s 2018 National HIV Behavioral Surveillance. The sample included 8,142 PWID aged 18-64 who reported daily opioid use from 22 U.S. metropolitan areas. Our outcome was any self-reported MOUD use in the past 12 months. Exposures were state Medicaid coverage and prior authorization requirements for methadone and buprenorphine. We interacted these exposures with PWID race/ethnicity, insurance status, and spatial access to treatment and harm reduction resources. Results: Compared with PWID in states without Medicaid methadone coverage, odds of past-year MOUD use were 73% (p<0.05) higher among PWID in states with methadone coverage requiring prior authorization and 80% (p<0.05) higher among PWID in states with coverage without prior authorization. Insured PWID were twice as likely to report MOUD use than uninsured PWID, with no statistically significant differences between Medicaid versus other insurance. Medicaid prior authorization requirements for buprenorphine were not significantly associated with MOUD use. Non-Hispanic Black PWID were significantly less likely to use MOUD than non-Hispanic White and Hispanic PWID. Conclusions: State Medicaid methadone coverage was strongly associated with higher odds that PWID utilized MOUD, suggesting that expanding methadone insurance coverage could improve MOUD treatment in a vulnerable population.

Medication for opioid use disorder (MOUD) reduces harms associated with opioid use disorder (OUD), including risk of overdose. Understanding how variation in MOUD duration influences overdose risk is important as health-care payers increasingly remove barriers to treatment continuation (e.g. prior authorization). This study measured the association between MOUD continuation, relative to discontinuation, and opioid-related overdose among Medicaid beneficiaries. Retrospective cohort study using landmark survival analysis. We estimated the association between treatment continuation and overdose risk at 5 points after the index, or first, MOUD claim. Censoring events included death and disenrollment. Medicaid programs in 11 US states: Delaware, Kentucky, Maryland, Maine, Michigan, North Carolina, Ohio, Pennsylvania, Virginia, West Virginia and Wisconsin. A total of 293 180 Medicaid beneficiaries aged 18-64 years with a diagnosis of OUD and had a first MOUD claim between 2016 and 2017. MOUD formulations included methadone, buprenorphine and naltrexone. We measured medically treated opioid-related overdose within claims within 12 months of the index MOUD claim. Results were consistent across states. In pooled results, 5.1% of beneficiaries had an overdose, and 67% discontinued MOUD before an overdose or censoring event within 12 months. Beneficiaries who continued MOUD beyond 60 days had a lower relative overdose hazard ratio (HR) compared with those who discontinued by day 60 [HR = 0.39; 95% confidence interval (CI) = 0.36-0.42; P < 0.0001]. MOUD continuation was associated with lower overdose risk at 120 days (HR = 0.34; 95% CI = 0.31-0.37; P < 0.0001), 180 days (HR = 0.31; 95% CI = 0.29-0.34; P < 0.0001), 240 days (HR = 0.29; 95% CI = 0.26-0.31; P < 0.0001) and 300 days (HR = 0.28; 95% CI = 0.24-0.32; P < 0.0001). The hazard of overdose was 10% lower with each additional 60 days of MOUD (95% CI = 0.88-0.92; P< 0.0001). Continuation of medication for opioid use disorder (MOUD) in US Medicaid beneficiaries was associated with a substantial reduction in overdose risk up to 12 months after the first claim for MOUD.

Methadone and buprenorphine discontinuation among postpartum women with opioid use disorder

BackgroundProblem-solving courts have the potential to help reduce harms associated with the opioid crisis. However, problem-solving courts vary in their policies toward medications for opioid use disorder (MOUD), with some courts discouraging or even prohibiting MOUD use. State laws may influence court policies regarding MOUD; thus, we aimed to identify and describe state laws related to MOUD in problem-solving courts across the US from 2005 to 2019.MethodsWe searched Westlaw legal software for regulations and statutes (collectively referred to as “state laws”) in all US states and D.C. from 2005 to 2019 and included laws related to both MOUD and problem-solving courts in our analytic sample. We conducted a modified iterative categorization process to identify and analyze categories of laws related to MOUD access in problem-solving courts.ResultsSince 2005, nine states had laws regarding MOUD in problem-solving courts. We identified two overarching categories of state laws: 1) laws that prohibit MOUD bans, and 2) laws potentially facilitating access to MOUD. Seven states had laws that prohibit MOUD bans, such as laws prohibiting exclusion of participants from programs due to MOUD use or limiting the type of MOUD, dose or treatment duration. Four states had laws that could facilitate access to MOUD, such as requiring courts to make MOUD available to participants.DiscussionRelatively few states have laws facilitating MOUD access and/or preventing MOUD bans in problem-solving courts. To help facilitate MOUD access for court participants across the US, model state legislation should be created. Additionally, future research should explore potential effects of state laws on MOUD access and health outcomes for court participants.

“Sick and tired of being sick and tired”: Exploring initiation of medications for opioid use disorder among people experiencing homelessness

Racial‒Ethnic Disparities of Buprenorphine and Vivitrol Receipt in Medicaid

Background: Criminal problem-solving courts and civil dependency courts often have participants with substance use disorder (SUD), including opioid use disorder (OUD). These courts refer participants to treatment and set treatment-related requirements for court participants to avoid incarceration or to regain custody of children. Medications for opioid use disorder (MOUD) are the most effective treatment for OUD but are underutilized by court system participants. Little is known about variation in court policies for different MOUDs. Also, more information is needed about types of policies for each MOUD, including whether participants may begin MOUD, continue previously begun MOUD, or complete the court program with MOUD. Methods: An online survey was distributed to criminal problem-solving and civil dependency judges in Florida in 2019 and 2020, yielding data from 58 judges (a 24% response rate). We used nonparametric statistics to test hypotheses with ordinal data. A Friedman's test for related samples or Cochran's Q was used to make within-group comparisons between policies and MOUDs. Results: We found considerable policy variation, with more permissive policies for naltrexone than buprenorphine or methadone, and more permissive policies for continuing MOUD than for initiating MOUD or completing a court program with MOUD. For each medication, less than one quarter of judges indicated their court always permits MOUD, with most indicating that MOUD is permitted sometimes or usually. Conclusion: Because respondents rarely chose “never” or “always” for any MOUD policy, most courts appear to be making MOUD decisions on a case-by-case basis. A clearer understanding of this decision-making process is needed. Some court participants may be required to discontinue MOUD before completing a court program, even if they were permitted to start or continue MOUD treatment. Discontinuation of MOUD without medical justification is contrary to the standard of care for individuals with OUD and increases their risk of overdose.

Transitions of care between jail-based medications for opioid use disorder and ongoing treatment in the community: A retrospective cohort study

Factors associated with receipt of medication for opioid use disorder among pregnant individuals entering treatment programs in the U.S.

Back to table of contents Previous article Next article Clinical & ResearchFull AccessDocument Provides Inpatient Guidelines for Medication Treatment of Opioid Use DisorderAbhisek Chandan Khandai, M.D., Josie Francois, M.D.Abhisek Chandan KhandaiSearch for more papers by this author, M.D., Josie FrancoisSearch for more papers by this author, M.D.Published Online:21 Dec 2022https://doi.org/10.1176/appi.pn.2023.01.1.39AbstractA new resource document will help strengthen psychiatrists’ capabilities to be team leaders in the treatment of hospitalized patients with opioid use disorder. This article is one of a series coordinated by APA’s Council on Consultation-Liaison Psychiatry and the Academy of Consultation-Liaison Psychiatry.The prevalence, morbidity, mortality, and costs of opioid use disorder have dramatically increased over the past 20 years. While there are several effective and evidence-based medications for opioid use disorder (MOUD), less than 20% of Americans with opioid use disorder receive MOUD. The inpatient general hospital setting represents a critical point of access to MOUD, given the significant medical comorbidities of patients with opioid use disorder and the increased time to engage patients in treatment, better monitoring capabilities, and opportunities to reduce the monetary impact of the disorder on the health care system.Psychiatrists are an integral part of the hospital treatment team. However, they are often excluded for many reasons, including stigma toward opioid use disorder, lack of consultation-liaison (C-L) psychiatry services, and discomfort with managing opioid use disorder.To help address this care gap, APA’s Council on C-L Psychiatry, in collaboration with the Council on Addiction Psychiatry, convened a multispecialty expert workgroup to prepare a resource document related to the medication treatment of patients with opioid use disorder. The workgroup discussed several barriers to medication treatment and factors limiting the involvement of psychiatrists in the treatment of opioid and other substance use disorders in the inpatient hospital setting. Among the barriers they identified were stigma associated with substance use disorders (SUD) and a knowledge gap among psychiatrists regarding SUD treatment. The workgroup then created a resource document that seeks to address these barriers and guide general psychiatrists.The document includes an overview of OUD and its management in adults, explores the pharmacology of MOUD, describes barriers to care and specialty-specific concerns, and provides approaches to reducing stigma. The resource document also compares current medications to treat patients with opioid use disorder (naltrexone, buprenorphine, and methadone), walks psychiatrists through the medications’ initiation and titration in the general hospital setting, and provides recommendations on how to transition patients taking these medications from inpatient to outpatient settings.The resource guide is designed to educate and empower psychiatrists to take a larger role in MOUD in the general hospital setting to save more lives at reduced cost. Psychiatrists are in a strong position to oversee the use of MOUD in hospital settings and are best equipped to lead MOUD treatment and reduce stigma, given our relative expertise in the area of SUDs, comorbid psychiatric illnesses, and harm reduction strategies. As such, it is important that psychiatrists stay up to date on evidence-based MOUD and work with other specialties to promote psychiatric involvement in the care of those with opioid use disorder in the general hospital setting. ■Resource Document on the Treatment of Opioid Use Disorder in the General HospitalAbhisek Chandan Khandai, M.D., is a consultation-liaison psychiatry attending at UT Southwestern Medical Center and a member of APA’s Committee on Consultation-Liaison Psychiatry.Josie Francois, M.D., is a first-year psychiatry resident at Brigham and Women’s Hospital. ISSUES NewArchived

BackgroundThe Veterans Health Administration has made strides to improve access to medications for opioid use disorder overall. However, quality improvement methods to assess treatment gaps may not sufficiently detect differences in medication access by intersecting patient factors, which may have multiplicative rather than additive effects. This study aimed to determine whether race/ethnicity and legal involvement interact in receipt of medications for opioid use disorder among Veterans Health Administration patients.MethodsUsing national electronic health record data from Fiscal Years 2021–2022, we examined the receipt of medications for opioid use disorder among veterans diagnosed with opioid use disorder who received healthcare at Veterans Health Administration facilities (n = 65,883). We conducted a mixed effects multivariable logistic regression model to examine an interaction effect of race/ethnicity and legal involvement with receipt of any medications for opioid use disorder, both unadjusted and adjusted for patient and facility characteristics.ResultsIn an adjusted logistic regression model, the interaction effect indicated that non-Hispanic Black veterans with legal involvement had the lowest odds of medications for opioid use disorder receipt compared to non-Hispanic White veterans without legal involvement (adjusted odds ratio = 0.67, 95% confidence interval = 0.59–0.77, p <.0001). Non-Hispanic American Indian/Alaska Native patients without legal involvement (adjusted odds ratio = 0.85, 95% confidence interval = 0.73–0.99, p =.04) also had lower odds of receipt of medications for opioid use disorder compared to non-Hispanic White patients without legal involvement. Non-Hispanic White veterans with legal involvement (adjusted odds ratio = 1.07, 95% confidence interval = 1.01–1.14, p =.03) had higher odds of receipt of medications for opioid use disorder compared to non-Hispanic White patients without legal involvement.ConclusionsVeterans Health Administration quality improvement efforts should monitor interacting racial and legal status factors and understand and address patient, clinical, and regulatory barriers to medications for opioid use disorder among Black veterans with legal involvement.

Non-prescribing clinicians' treatment orientations and attitudes toward treatments for opioid use disorder: Rural differences

Thousands of pregnant people with opioid use disorder (OUD) enter US jails annually, yet their access to medications for OUD (MOUD) that meet the standard of care (methadone and/or buprenorphine) is unknown. To assess the availability of MOUD for the treatment of pregnant individuals with OUD in US jails. In this cross-sectional study, electronic and paper surveys were sent to all 2885 identifiable US jails verified in the National Jails Compendium between August 19 and November 7, 2019. Respondents were medical and custody leaders within the jails. The primary outcome was the availability of MOUD (methadone and/or buprenorphine) for the treatment of pregnant people with OUD in US jails. Availability of MOUD was assessed based on (1) continuation of MOUD for pregnant incarcerated individuals (if the individual was receiving MOUD before incarceration), with or without initiation of MOUD; (2) both initiation and continuation of MOUD for pregnant individuals; (3) only continuation of MOUD for pregnant individuals; and (4) management of opioid withdrawal for pregnant individuals. Secondary outcomes included MOUD availability during the postpartum period and logistical factors associated with the provision of MOUD. Multivariate logistic regression analysis was used to assess factors associated with MOUD availability during pregnancy. Among 2885 total surveys sent, 1139 (39.5%) were returned; of those, 836 surveys (73.4%; 29.0% of all surveys sent) could be analyzed, with similar proportions from metropolitan (399 jails [47.7%]) and rural (381 jails [45.6%]) settings. Overall, 504 jails (60.3%) reported that MOUD was available for medication continuation, with or without medication initiation, during pregnancy. Of those, 267 jails (53.0%; 31.9% of surveys included in the analysis) both initiated and continued MOUD, and 237 jails (47.0%; 28.3% of surveys included in the analysis) only continued MOUD; 190 of 577 jails (32.9%; 22.7% of surveys included in the analysis) reported opioid withdrawal as the only management for pregnant people with OUD. Among the 504 medication-providing jails, only 120 (23.8%) continued to provide MOUD during the postpartum period. Methadone was more commonly available at jails that only continued MOUD (84 of 123 jails [68.3%]), whereas buprenorphine was more commonly available at jails that both initiated and continued MOUD (73 of 119 jails [61.3%]). In an adjusted model, jails with higher odds of MOUD availability were located in the Northeast (odds ratio [OR], 10.72; 95% CI, 2.43-47.36) or metropolitan areas (OR, 1.92; 95% CI, 1.31-2.83), had private health care contracts (OR, 1.49; 95% CI, 1.03-2.14) and a higher number of women (≥70) reported in the female census (OR, 1.69; 95% CI, 1.02-2.80), and provided pregnancy testing within 2 weeks of arrival at the jail (OR, 2.66; 95% CI, 1.69-4.17). In this cross-sectional study, a substantial proportion of US jails did not provide access to MOUD to pregnant people with OUD. Although most jails reported continuing to provide MOUD to individuals who were receiving medication before incarceration, few jails initiated MOUD, and most medication-providing jails discontinued MOUD during the postpartum period. These results suggest that many pregnant and postpartum people with OUD in US jails do not receive medication that is the standard of care and are required to endure opioid withdrawal, signaling an opportunity for intervention to improve care for pregnant people who are incarcerated.