Overdose Rates Research Articles

Comparing the effects of decreasing prescription opioid shipments and the release of an abuse deterrent OxyContin formulation on opioid overdose fatalities in WV: an interrupted time series study

IntroductionThe 2010 release of an abuse deterrent formulation (ADF) of OxyContin, a brand name prescription opioid, has been cited as a major driver for the reduction in prescription drug misuse and the associated increasing illicit opioid use and overdose rates. However, studies of this topic often do not account for changes in supplies of other prescription opioids that were widely prescribed before and after the ADF OxyContin release, including generic oxycodone formulations and hydrocodone. We therefore sought to compare the impact of the ADF OxyContin release to that of decreasing prescription opioid supplies in West Virginia (WV).MethodsOpioid tablet shipment and overdose data were extracted from The Washington Post ARCOS (2006–2014) and the WV Forensic Drug Database (2005–2020), respectively. Locally estimated scatterplot smoothing (LOESS) was used to estimate the point when shipments of prescription opioids to WV began decreasing, measured via dosage units and morphine milligram equivalents (MMEs). Interrupted time series analysis (ITSA) was used to compare the impact LOESS-identified prescription supply changes and the ADF OxyContin release had on prescription (oxycodone and hydrocodone) and illicit (heroin, fentanyl, and fentanyl analogues) opioid overdose deaths in WV. Model fit was compared using Akaike Information Criteria (AIC).ResultsThe majority of opioid tablets shipped to WV from 2006 to 2014 were generic oxycodone or hydrocodone, not OxyContin. After accounting for a 6-month lag from ITSA models using the LOESS-identified change in prescription opioid shipments measured via dosage units (2011 Q3) resulted in the lowest AIC for both prescription (AIC = -188.6) and illicit opioid-involved overdoses (AIC = -189.4), indicating this intervention start date resulted in the preferred model. The second lowest AIC was for models using the ADF OxyContin release as an intervention start date.DiscussionWe found that illicit opioid overdoses in WV began increasing closer to when prescription opioid shipments to the state began decreasing, not when the ADF OxyContin release occurred. Similarly, the majority of opioid tablets shipped to the state for 2006–2014 were generic oxycodone or hydrocodone. This may indicate that diminishing prescription supplies had a larger impact on opioid overdose patterns than the ADF OxyContin release in WV.

Impact of a Mobile App (LoAD Calc) on the Calculation of Maximum Safe Doses of Local Anesthetics: Protocol for a Randomized Controlled Trial.

Local anesthetics (LAs) are regularly used to alleviate pain during medical or surgical procedures. Their use is generally considered safe, but exceeding the maximum recommended doses can lead to LA systemic toxicity, a rare but potentially lethal complication. Determining maximum safe doses is therefore mandatory before performing local anesthesia, but rules are often unclear and the factors affecting dose calculation are numerous. Mobile health apps have been shown to help clinical decision-making, but most currently available apps present significant limitations. The Local Anesthetics Dose Calculator (LoAD Calc) app was designed to overcome these limitations by taking all relevant parameters into account. Before deploying this app in a clinical setting, it should be tested to determine its effectiveness and whether clinicians would be willing to use it. The primary objective will be to evaluate the effectiveness of the LoAD Calc app through written simulated cases. The secondary objective will be to determine whether physicians find this app easier, faster, and safer than the methods they generally use. We describe a parallel-group randomized controlled trial protocol. Anesthesiologists working at the Geneva University Hospitals will be invited to participate. Participants will be asked to compute the maximum dose of LA in 10 simulated clinical cases using 3 different LAs. The maximum safe dose will be determined manually using the same calculation rules that were used to develop LoAD Calc, without using the app itself. An overdose will be considered any dose higher than the correct dose, rounded to the superior integer, while an underdose will be defined as the optimal calculated dose minus 20%, rounded to the inferior integer. Randomization will be stratified according to current position (resident vs registrar). The participants allocated to the LoAD Calc (experimental) group will use the LoAD Calc app to compute the maximum safe LA doses. Those allocated to the control group will be asked to use the method they generally use. The primary outcome will be the overall overdose rate. Secondary outcomes will include the overdose rate according to ideal and actual body weight and to each specific LA, the overall underdose rate, and the time taken to complete these calculations. The app's usability will also be assessed. A sample size of 46 participants will be needed to detect a difference of 10% with a power of 90%. Thus, a target of 50 participants was set to allow for attrition and exclusion criteria. We expect recruitment to begin during the winter of 2023, data analysis in the spring of 2024, and results by the end of 2024. This study should determine whether LoAD Calc, a mobile health app designed to compute maximum safe LA doses, is safer and more efficient than traditional LA calculation methods. PRR1-10.2196/53679.

PROVIDENT: Development and Validation of a Machine Learning Model to Predict Neighborhood-level Overdose Risk in Rhode Island.

Drug overdose persists as a leading cause of death in the United States, but resources to address it remain limited. As a result, health authorities must consider where to allocate scarce resources within their jurisdictions. Machine learning offers a strategy to identify areas with increased future overdose risk to proactively allocate overdose prevention resources. This modeling study is embedded in a randomized trial to measure the effect of proactive resource allocation on statewide overdose rates in Rhode Island (RI). We used statewide data from RI from 2016 to 2020 to develop an ensemble machine learning model predicting neighborhood-level fatal overdose risk. Our ensemble model integrated gradient boosting machine and super learner base models in a moving window framework to make predictions in 6-month intervals. Our performance target, developed a priori with the RI Department of Health, was to identify the 20% of RI neighborhoods containing at least 40% of statewide overdose deaths, including at least one neighborhood per municipality. The model was validated after trial launch. Our model selected priority neighborhoods capturing 40.2% of statewide overdose deaths during the test periods and 44.1% of statewide overdose deaths during validation periods. Our ensemble outperformed the base models during the test periods and performed comparably to the best-performing base model during the validation periods. We demonstrated the capacity for machine learning models to predict neighborhood-level fatal overdose risk to a degree of accuracy suitable for practitioners. Jurisdictions may consider predictive modeling as a tool to guide allocation of scarce resources.

A novel, non-opioid, selective orexin-1 receptor antagonist for the treatment of substance use disorders

There is a pressing need for novel treatments for substance use disorders to address increasing rates of addiction and drug overdose. Preclinical studies have shown that the orexin (hypocretin) system in the brain, mediated primarily by the orexin 1 receptor, plays a role in reward-related behaviours and that selective blockade of this receptor is efficacious in rodent models of addiction for a wide range of substances including opioids, cocaine, nicotine, and alcohol. We report here the preclinical profile of C4X3256, a novel, selective oral antagonist of the orexin 1 receptor. In the rat, high levels of receptor occupancy were observed in the tenia tecta region of the brain for up to 8 h following oral dosing. Translation of brain receptor occupancy into pharmacological efficacy was demonstrated in rat models showing significantly reduced nicotine self-administration and diminished cue-induced reinstatement of nicotine seeking following an oral dose of 30 mg/kg C4X3256. In addition, C4X3256 significantly reduced reinstatement of cocaine seeking induced by presentation of tone/light cues in a rat model of relapse. In summary, the nonclinical profile of C4X3256 has supported the progression of this compound into human clinical trials as an investigational medicinal product for the treatment of substance use disorders.

Can Access to Non-Opioid Pain Management Therapies Reduce Overdose Rates? Evidence from Medical Cannabidiol Laws

Can Access to Non-Opioid Pain Management Therapies Reduce Overdose Rates? Evidence from Medical Cannabidiol Laws

A Preliminary Assessment of Short-Term Social and Substance Use-Related Outcomes Among Clients of Integrated Safer Opioid Supply Pilot Programs in Toronto, Canada

AbstractCanada is experiencing an ongoing overdose crisis, driven by a toxic unregulated drug supply. Integrated safer supply pilot programs offer pharmaceutical alternatives, coupled with comprehensive support services, to individuals using unregulated drug supply who are at high risk of overdose. We collected data from December 2020 to January 2023 on clients receiving safer opioid supply from five frontline service providers in Toronto, Canada, using interviewer-administered questionnaires. We assessed the incidence rate ratio of self-reported overdose comparing pre- and post-enrolment in the programs and examined changes in the prevalence of social and substance use outcomes post-enrolment. Forty-one participants were recruited, of whom 26 were followed up for a median of eight months (interquartile range, 5.0–11.7). The incidence rate ratio of overdose comparing post-enrolment to pre-enrolment was 0.20 (95% confidence interval, 0.09–0.43). Participants reported several positive social and substance use outcomes at follow-up, including a reduction in reliance on the unregulated supply and reduced criminal activity. Future implementation of integrated safer opioid supply pilot programs with larger sample sizes and rigorous epidemiological designs could help further illustrate the potential impacts of these programs in reducing overdose rates in Canada.

Rates of Opioid Overdose Among Racial and Ethnic Minority Individuals Released From Prison

This cross-sectional study examines opioid overdose patterns by race and ethnicity among individuals released from prison in Massachusetts.

Microbiome Depletion Increases Fentanyl Self-Administration and Alters the Striatal Proteome Through Short-Chain Fatty Acids.

Opioid use disorder (OUD) is a public health crisis currently being exacerbated by increased rates of use and overdose of synthetic opioids, primarily fentanyl. Therefore, the identification of novel biomarkers and treatment strategies to reduce problematic fentanyl use and relapse to fentanyl taking is critical. In recent years, there has been a growing body of work demonstrating that the gut microbiome can serve as a potent modulator of the behavioral and transcriptional responses to both stimulants and opioids. Here, we advance this work to define how manipulations of the microbiome drive fentanyl intake and fentanyl-seeking in a translationally relevant drug self-administration model. Depletion of the microbiome of male rats with broad spectrum antibiotics leads to increased drug administration on increased fixed ratio, progressive ratio, and drug seeking after abstinence. Utilizing 16S sequencing of microbiome contents from these animals, specific populations of bacteria from the gut microbiome correlate closely with levels of drug taking. Additionally, global proteomic analysis of the nucleus accumbens following microbiome manipulation and fentanyl administration to define how microbiome status alters the functional proteomic landscape in this key limbic substructure. These data demonstrate that an altered microbiome leads to marked changes in the synaptic proteome in response to repeated fentanyl treatment. Finally, behavioral effects of microbiome depletion are reversible by upplementation of the microbiome derived short-chain fatty acid metabolites. Taken together, these findings establish clear relevance for gut-brain signaling in models of OUD and lay foundations for further translational work in this space.

Willingness to utilize a mobile treatment unit in five counties at the epicenter of the US rural opioid epidemic

IntroductionUS federal policies are evolving to expand the provision of mobile treatment units (MTUs) offering medications for opioid use disorder (MOUD). Mobile MOUD services are critical for rural areas with poor geographic access to fixed-site treatment providers. This study explored willingness to utilize an MTU among a sample of people who use opioids in rural Eastern Kentucky counties at the epicenter of the US opioid epidemic. MethodsThe study analyzed Cross-sectional survey data from the Kentucky Communities and Researchers Engaging to Halt the Opioid Epidemic (CARE2HOPE) study covering five rural counties in the state. Logistic regression models investigated the association between willingness to utilize an MTU providing buprenorphine and naltrexone and potential correlates of willingness, identified using the Behavioral Model for Vulnerable Populations. ResultsThe analytic sample comprised 174 people who used opioids within the past six months. Willingness to utilize an MTU was high; 76.5 % of participants endorsed being willing. Those who had recently received MOUD treatment, compared to those who had not received any form of treatment or recovery support services, had six-fold higher odds of willingness to use an MTU. However, odds of being willing to utilize an MTU were 73 % lower among those who were under community supervision (e.g., parole, probation) and 81 % lower among participants who experienced an overdose within the past six months. ConclusionsThere was high acceptability of MTUs offering buprenorphine and naltrexone within this sample, highlighting the potential for MTUs to alleviate opioid-related harms in underserved rural areas. However, the finding that people who were recently under community supervision or had overdosed were significantly less willing to seek mobile MOUD treatment suggest barriers (e.g., stigma) to mobile MOUD at individual and systemic levels, which may prevent improving opioid-related outcomes in these rural communities given their high rates of criminal-legal involvement and overdose.

Baseline presentation of atypical anorexia nervosa in Singaporean adolescents: a retrospective cohort study

BackgroundWhile atypical anorexia nervosa (AAN) has been found to present with significant physical and psychological complications, the presentation of AAN has not been described in a multi-ethnic Singaporean population.MethodsThis retrospective cohort analysis aimed to characterize the baseline presentation of adolescents with anorexia nervosa (AN) (N = 317) and AAN (N = 141) in a Singaporean cohort that presented to a specialist paediatric eating disorder program between January 2010 and October 2020 for assessment.ResultsIn patients with AAN, there were increased proportions of males (16% vs. 7%) and of Malay ethnicity (11% vs. 4%) compared to AN. Compared to adolescents with AN, adolescents with AAN had lower rates of admission (61% vs. 81%), bradycardia (45% vs. 75%), and hypotension (7% vs. 21%) but had a higher rate of syncope (13% vs. 7%). Likewise, adolescents with AAN had higher rates of self-harm and drug overdose (14% vs. 1.5%) requiring admission, more purging (45.1% vs. 14.8%) and more shape concerns.ConclusionHighlighting the severity of the illness, Singaporean adolescents with AAN presented with physical complications of malnutrition and had more severe eating disorder psychopathology and a higher frequency of other psychological comorbidities than did adolescents with AN.

Quantifying a potential protective effect of buprenorphine on fatality risk during acute fentanyl exposures

IntroductionBuprenorphine is an important therapy for opioid use disorder and may also reduce the risk of fatal overdoses in fentanyl exposures. However, the role of buprenorphine in reducing this risk has not been quantified. This cross-sectional study examined the association between buprenorphine presence, decedent characteristics, and other factors with the predicted fentanyl concentrations in overdose deaths. MethodsThe study identified unintentional fentanyl overdose decedents (n = 3036) from the West Virginia Forensic Drug Database, 2011 through mid-2020. The main outcome was fentanyl concentrations in overdose deaths in the presence and absence of buprenorphine. A multiple linear regression model examined the association of fentanyl concentrations with buprenorphine presence based on the concentrations of the parent drug buprenorphine (B) and its metabolite norbuprenorphine (N), adjusting for demographics, toxicological characteristics (presence of multiple opioids, benzodiazepines, stimulants, marijuana, and alcohol), and comorbidities. We used a B/N concentration ratio < 1 as an indirect indicator of longer-term buprenorphine exposure prior to drug overdose death. ResultsThe median fentanyl concentration was 65 % higher when buprenorphine was present (N = 168) vs. absent (N = 2868) (0.028 vs. 0.017 μg/mL, p < 0.001). In the multivariable model, statistically significant associations occurred between buprenorphine presence and increased fentanyl concentrations (+28.7 %) with a B/N ratio < 1. Obesity, male sex, alcohol presence, and comorbid cardiovascular diseases were statistically significantly associated with lower (−11.3 % to −20.7 %) fentanyl concentrations, whereas marijuana presence and a history of substance use disorder were associated with statistically significant higher fentanyl concentrations (+8.8 % to +31.3 %). ConclusionsThese findings suggest that sustained or longer-term buprenorphine intake might exert some protective effect on fatalities resulting from fentanyl exposure as documented by the association of higher fentanyl blood concentrations with buprenorphine presence among fatal drug overdoses. As fentanyl availability and overdose rates increase nationally, buprenorphine is a vital tool for effective opioid use disorder treatment that might also reduce the risk of fatality in an acute fentanyl exposure.

The long-term impacts of opioid use before and after joint arthroplasty: matched cohort analysis of New Zealand linked register data.

Opioids are commonly used both before and after total joint arthroplasty (TJA). The objective of this study was to estimate the long-term effects of pre- and perioperative opioid use in patients undergoing TJA. We used linked population datasets to identify all (n =18,666) patients who had a publicly funded TJA in New Zealand between 2011 and 2013. We used propensity score matching to match individuals who used opioids either before surgery, during hospital stay, or immediately post-discharge with individuals who did not based on a comprehensive set of covariates. Regression analysis was used to estimate the effect of opioid use on health and socio-economic outcomes over 5 years. Opioid use in the 3 months prior to surgery was associated with significant increases in healthcare utilization and costs (number of hospitalizations 6%, days spent in hospital 14.4%, opioid scripts dispensed 181%, and total healthcare costs 11%). Also increased were the rate of receiving social benefits (2 percentage points) and the rates of opioid overdose (0.5 percentage points) and mortality (3 percentage points). Opioid use during hospital stay or post-discharge was associated with increased long-term opioid use, but there was little evidence of other adverse effects. Opioid use before TJA is associated with significant negative health and economic consequences and should be limited. This has implications for opioid prescribing in primary care. There is little evidence that peri- or post-operative opioid use is associated with significant long-term detriments.

Disparities in fatal and non-fatal opioid-involved overdoses among middle-aged non-Hispanic Black Men and Women.

The gap in fatal opioid overdose rates has been closing between non-Hispanic Black and non-Hispanic White individuals. The rising opioid-involved mortality rates among non-Hispanic Black adults has been identified by SAMHSA as a critical public health issue. However, further research is needed that utilizes comprehensive surveillance data on both fatal and non-fatal opioid-involved overdoses to better assess the changing trends and evaluate factors contributing to changing disparities. We conducted an analysis of medical examiner and hospital data for years 2016-2021 from the largest county in Illinois (Cook) to (1) evaluate disparities in non-fatal and fatal opioid-involved overdoses between middle-aged non-Hispanic Black adults and Black adults of other age groups stratified by sex, (2) to assess if disparities exist across middle-aged adults of different race-ethnicities specifically non-Hispanic White and Hispanic-Latino adults, and (3) evaluate factors contributing to the disparities. Fatal opioid overdose rates among middle-aged Black men 45-64 years old were on average 5.3 times higher than Black men of other age groups, and 6.2 times higher than middle-aged non-Black men. Similarly, fatal opioid overdose rates among middle-aged Black women were on average 5.0 times higher than Black women of other age groups, and 4.9 times higher than middle-aged non-Black women. Hospital utilization rates for opioid-involved overdoses showed similar disparities between age groups and race-ethnicities. Findings indicate that stark disparities in rates of opioid-involved overdoses among middle-aged Black men and women are likely attributed to exposure to more lethal opioids, drug variability in local markets, differences in concurrent drug exposures, and lower access to harm reduction, emergent and preventative health services.

Understanding Regional Patterns of Overdose Deaths Related to Opioids and Psychostimulants

Background As overdose rates increase for multiple substances, policymakers need to identify geographic patterns of substance-specific deaths. In this study, we describe county-level opioid and psychostimulant overdose patterns and how they correlate with county-level social vulnerability measures. Methods A cross-sectional observational study, we used nationwide 2016-2018 restricted access Centers for Disease Prevention and Control county-level mortality files for 1,024 counties. We estimated quartiles of opioid and psychostimulant overdose mortality and provided estimates of their association with county-level Social Vulnerability Index (SVI) percentile. Results There was high opioid and psychostimulant overdose mortality in the Middle Atlantic, South Atlantic, East North Central, and Mountain regions. The Central US had the lowest opioid and psychostimulant overdose mortality rates. Counties with higher SVI scores (i.e. higher social vulnerability) were significantly more likely to experience high opioid and high psychostimulant overdose (high-high) mortality. A 10-percentile increase in SVI score was associated with a 3.1 percentage point increase in the likelihood of being a high-high county (p < 0.001) in unadjusted models and a 1.5 percentage point increase (p < 0.05) in models adjusting for region. Conclusion Our results illustrated the heterogenous geographic distribution of the growing concurrent opioid and psychostimulant overdose crisis. The substantial regional variation we identified highlights the need for local data to guide policymaking and treatment planning. The association of opioid-psychostimulant overdose mortality with social vulnerability demonstrates the critical need in impacted counties for tailored treatment that addresses the complex medical and social needs of people who use both opioids and psychostimulants.

Removing PA requirements for buprenorphine did not increase prescriptions

A study of 23 states from 2015 to 2019 found that the removal of prior authorization (PA) requirements, thought to be a barrier to buprenorphine prescribing, in Medicaid programs did nothing to increase prescribing. The study, “Removal of Medicaid Prior Authorization Requirements and Buprenorphine Treatment for Opioid Use Disorder,” which published in JAMA Health Forum on Oct. 4, did show some association in increased prescribing in states with low prescribing levels at baseline, but not in states with higher baseline prescribing. The findings do not mean that prior authorization—a technique used by payers to control utilization—is not a barrier, but rather, that it is not the only barrier, and that other barriers must be removed in order to increase prescribing of buprenorphine. Study results showed that: 1) six states in the sample removed Medicaid PAs for at least one buprenorphine formulation; 2) states that kept their PA requirements had lower buprenorphine prescribing and lower Medicaid managed care penetration, but similar opioid overdose rates to states that removed the PA requirements; and 3) for states with below‐median baseline buprenorphine prescribing, PA removal was associated with increased buprenorphine prescriptions, while states with above‐median prescribing showed no change. The researchers concluded that more efforts are needed to increase availability of buprenorphine. The lead author is Paul J. Christine, M.D., Ph.D., of the University of Colorado School of Medicine.

Dynamic changes in methadone utilisation for opioid use disorder treatment: a retrospective observational study during the COVID-19 pandemic

ObjectivesOpioid use disorder (OUD) is a major public health concern in the USA, resulting in high rates of overdose and other negative outcomes. Methadone, an OUD treatment, has been shown...

Trends in non-fatal and fatal opioid overdoses during the first two years of the coronavirus disease–2019 pandemic

PurposeThis study assessed opioid-involved overdose rates by age, sex, and race-ethnicity across strict pandemic mitigation phases and how this varied across data systems. MethodsWe examined opioid-involved overdoses using medical examiner and hospital data for Cook County, Illinois between 2016-2021. Multivariable segmented regression was used to assess weekly overdose rates across subgroups of age, sex and race/ethnicity and strict pandemic mitigation phases. ResultsThe overall rate of weekly opioid-involved overdoses increased when assessing the medical examiner (β = 0.01; 95% CI = 0.01,0.02; P ≤ .001) and emergency department visits data sources (β = 0.15; 95% CI = 0.09,0.20; P ≤ .001) but not for the hospital admissions data source. We found differences in overdose rates across subgroups and phases of pandemic mandates. Fatal overdoses increased during lockdown-1 while admissions and emergency department (ED) visits for opioid-involved overdoses generally decreased across all phases of pandemic mitigation mandates except for the period following lockdown-1. Across pandemic mitigation phases, Hispanics and individuals under 25 years did not demonstrate any change in admissions and ED visits for overdoses. ConclusionsWe underscore the importance of utilizing multiple sources of surveillance to better characterize opioid-involved overdoses and for public health planning.

Opioid misuse and legislative responses in U.S. states: politics and lawmaking to address a public health crisis

ABSTRACT U.S. state legislators have increasingly adopted new laws in response to rising rates of fatal and non-fatal opioid overdoses. Legislative interventions vary in number and scope across states, prompting questions about the effects of problem severity, partisan politics, and population characteristics in formulating these opioid misuse policies. This study first identifies the geographic distribution and frequency of three types of opioid misuse laws enacted at a time when multiple waves of the opioid crisis converged (2015–2019): rescue drugs, provider training, and prescribing limits. Next, the study evaluates the roles of overdose problems, partisanship, and socio-demographic factors in contributing to a state legislature’s likelihood of enacting such legislation. The study finds that laws increasing access to drugs that reverse overdoses represent the most common type of legislative response. States with higher overdose death rates are more likely to proscribe an opioid misuse law, especially if these policies involve restricting opioid prescriptions or requiring more training for professionals who provide opioids. Economically advantaged states have increased odds of adopting prescribing limits. Results suggest a notable, but uneven responsiveness to this public health concern. The influence of problem severity relative to partisanship on legislative enactments, though, suggests a place for informed reform advocacy.

Stigma Toward Substance Dependence: Causes, Consequences, and Potential Interventions

Substance dependence is a prevalent and urgent public health problem. In 2021, 60 million Americans reported abusing alcohol within the month prior to being surveyed, and nearly 20 million Americans reported using illegal drugs (e.g., heroin) or prescription drugs (e.g., opioids) for nonmedical reasons in the year before. Drug-involved overdose rates have been steadily increasing over the past 20 years. This increase has been primarily driven by opioid and stimulant use. Despite its prevalence, drug dependence is one of the most stigmatized health conditions. Stigma has myriad negative consequences for its targets, including limiting their access to employment and housing, disrupting interpersonal relationships, harming physical and mental health, and reducing help-seeking. However, because research on stigma toward people with substance use disorders (SUDs) is relatively sparse compared with research on stigma toward other mental illnesses, the field lacks a comprehensive understanding of the causes and consequences of SUD stigma. Moreover, it remains unclear how, if at all, these factors differ from other types of mental illness stigma. The goal of this review is to take stock of the literature on SUD stigma, providing a clear set of foundational principles and a blueprint for future research and translational activity.

Removal of Medicaid Prior Authorization Requirements and Buprenorphine Treatment for Opioid Use Disorder

Buprenorphine treatment for opioid use disorder (OUD) is associated with decreased morbidity and mortality. Despite its effectiveness, buprenorphine uptake has been limited relative to the burden of OUD. Prior authorization (PA) policies may present a barrier to treatment, though research is limited, particularly in Medicaid populations. To assess whether removal of Medicaid PAs for buprenorphine to treat OUD is associated with changes in buprenorphine prescriptions for Medicaid enrollees. This state-level, serial cross-sectional study used quarterly data from 2015 through the first quarter (January-March) of 2019 to compare buprenorphine prescriptions in states that did and did not remove Medicaid PAs. Analyses were conducted between June 10, 2021, and August 15, 2023. The study included 23 states with active Medicaid PAs for buprenorphine in 2015 that required similar PA policies in fee-for-service and managed care plans and had at least 2 quarters of pre- and postperiod buprenorphine prescribing data. Removal of Medicaid PA for at least 1 formulation of buprenorphine for OUD. The main outcome was number of quarterly buprenorphine prescriptions per 1000 Medicaid enrollees. Between 2015 and the first quarter of 2019, 6 states in the sample removed Medicaid PAs for at least 1 formulation of buprenorphine and had at least 2 quarters of pre- and postpolicy change data. Seventeen states maintained buprenorphine PAs throughout the study period. At baseline, relative to states that repealed PAs, states that maintained PAs had lower buprenorphine prescribing per 1000 Medicaid enrollees (median, 6.6 [IQR, 2.6-13.9] vs 24.1 [IQR, 8.7-27.5] prescriptions) and lower Medicaid managed care penetration (median, 38.5% [IQR, 0.0%-74.1%] vs 79.5% [IQR, 78.1%-83.5%] of enrollees) but similar opioid overdose rates and X-waivered buprenorphine clinicians per 100 000 population. In fully adjusted difference-in-differences models, removal of Medicaid PAs for buprenorphine was not associated with buprenorphine prescribing (1.4% decrease; 95% CI, -31.2% to 41.4%). For states with below-median baseline buprenorphine prescribing, PA removal was associated with increased buprenorphine prescriptions per 1000 Medicaid enrollees (40.1%; 95% CI, 0.6% to 95.1%), while states with above-median prescribing showed no change (-20.7%; 95% CI, -41.0% to 6.6%). In this serial cross-sectional study of Medicaid PA policies for buprenorphine for OUD, removal of PAs was not associated with overall changes in buprenorphine prescribing among Medicaid enrollees. Given the ongoing burden of opioid overdoses, continued multipronged efforts are needed to remove barriers to buprenorphine care and increase availability of this lifesaving treatment.