(32) Buprenorphine Treatment Disparities: The Role of the Specialty System and Insurance Status

Background: The U.S. system of specialty treatment for substance use disorders, also known as “rehab,” comprises more than 15,000 facilities offering acute residential care and provides a large proportion of addiction treatment in the country. There is concern about inadequate use of buprenorphine in opioid use disorder (OUD) specialty facilities, which predominantly cater to Medicaid enrollees. In this study, we evaluated the association of OUD treatment setting (specialty versus office-based) with treatment retention in Medicaid- and commercially-insured patients.

Methods: In this retrospective cohort study, we used the IBM MarketScan databases (2011-2016) and identified individuals (n=157,408) seeking treatment for OUD. The primary outcome variable was retention in treatment at 180 days. The primary predictor variables were insurance status (Medicaid versus Commercial) and treatment setting (specialty versus office-based, based on procedure codes). The risk of treatment discontinuation was estimated using multivariate logistic regression with adjustment for age, sex, and race.

Results: Among commercial insurance beneficiaries (n=70,291), 76% received buprenorphine during enrollment, in comparison to 36% of Medicaid beneficiaries (p <.001). Medicaid enrollees were primarily seen in the specialty setting (64%), in comparison to only 4% of commercially insured patients receiving treatment in specialty facilities (p <.001). Among Medicaid beneficiaries (n=87,117), 36.5% (95% CI: 34.5-38.7%) of those who received any office-based counseling were retained in buprenorphine treatment at 180 days, compared with 28.5% (27.8-29.1%) of those who never received counseling and 11.5% (10.4-12.6%) of those who received any specialty counseling. Among commercial insurance beneficiaries,180-day buprenorphine retention for those who received any office-based counseling, those who received no counseling, and those who received specialty counseling was 45.3% (44.2-46.4%), 38.4% (28.0-38.8%), and 29.5% (38.0-38.8%), respectively.

Conclusions: This is the first large administrative data study to examine the association of OUD treatment setting with treatment delivery and outcomes in Medicaid and commercially-insured patients, and to compare specialty and office-based treatments and outcomes side-by-side in a multi-state cohort. Our study finds that Medicaid beneficiaries with OUD overwhelmingly use the specialty treatment system, where they are less likely to receive buprenorphine and more likely to experience treatment discontinuation.

References: 1. Beetham, T, Saloner, B, Gaye, M, Wakeman, SE, Frank, RG, & Barnett, ML. (2020). Therapies offered at residential addiction treatment programs in the United States. JAMA, 324(8): 804–806.
2. Presnall NJ, Wolf DAPS, Brown DS, Beeler-Stinn S, & Grucza RA. (2019). A comparison of buprenorphine and psychosocial treatment outcomes in psychosocial and medical settings. J Subst Abuse Treat, 104:135-143.
3. Beetham TB. Saloner B, Wakeman SE, Gaye M, & Barnett ML. (2019). Access to office-based buprenorphine treatment in areas with high rates of opioid-related mortality: An audit study. Ann Int Med, 171(1):1-9.

Diversity, Equity, and Inclusion: Medicaid provides health care access to millions of low-income people in the U.S. who have been severely impacted by the opioid crisis. Our study illustrates that Medicaid enrollees are predominantly using specialty treatment facilities where they are undertreated with buprenorphine relative to office based settings . As the specialty system has heavily expanded amid the present overdose crisis, our study calls attention to disparities in treatment access facing a psychosocially and medically vulnerable patient population.