Who Gets Medication-assisted Treatment for Opioid Use Disorder, and Does It Reduce Overdose Risk? Evidence from the Rhode Island All-payer Claims Database 
Medication-assisted treatment (MAT) for opioid use disorder (OUD) consists of administering methadone, buprenorphine, or naltrexone in conjunction with behavioral therapy. Despite strong support in the medical and public health communities for MAT, fewer than 10 percent of US patients with diagnosed OUD receive this treatment, according to some estimates. Rhode Island has adopted robust and innovative policies to promote comprehensive care for OUD that includes MAT, and the available evidence suggests that the state has an above-average rate of MAT uptake; nevertheless, the opioid-related mortality rates in Rhode Island—and on average in the United States—remain elevated. This situation prompts questions about the ability of recent policy measures to achieve sufficient increases in the uptake of MAT and about the practical efficacy of MAT in reducing overdose risk. Using the all-payer claims database for Rhode Island (known as HealthFacts RI), this paper studies (1) the effectiveness of MAT as practiced in Rhode Island in preventing opioid overdoses, (2) the factors at the patient level that either inhibit or facilitate the uptake of MAT, and (3) the impact that federal policies implemented in 2016 have had on buprenorphine prescribing patterns in Rhode Island.
Key Findings
- Among opioid use disorder (OUD) patients in Rhode Island who suffered an initial (nonfatal) overdose, those who had received medication-assisted treatment (MAT) in the preceding three months were significantly less likely to experience a second overdose.
- Among patients diagnosed with opioid dependence, women are less likely to receive MAT (either methadone or buprenorphine) than men are, and individuals with comorbid alcohol use disorder are less likely to be treated with methadone than other patients.
- Buprenorphine treatment is less likely, but methadone more likely, among individuals residing in Zip codes with elevated poverty rates.
- Compared with non-Medicaid OUD patients, Medicaid patients are much more likely to receive methadone, but not more likely to be treated with buprenorphine. • Patients in older age groups—especially those 65 and older—exhibit significantly lower rates of receiving MAT compared with younger patients.
- A 2016 federal rule change that raised the limit on the number of buprenorphine patients per provider (from 100 to 275) may have succeeded in enabling some prescribers to reach more patients.
- A separate federal policy from 2016 that allowed mid-level practitioners (such as physician assistants) to obtain permission to prescribe buprenorphine resulted in newly eligible practitioners prescribing the drug, particularly to patients in high-poverty Zip codes who previously were not receiving MAT.
- The data suggest that many more patients in Rhode Island could be treated with buprenorphine under current policies if existing prescribers took full advantage of their prescribing limits.
Implications
The evidence from this study and others argues strongly for policies focused on improving medication-assisted treatment (MAT) retention as well as initiation—that is, helping opioid use disorder (OUD) patients to continue with MAT after they have begun this treatment. Policies that have been proposed to facilitate retention in methadone treatment in particular include relaxing restrictions on take-home doses, deploying mobile methadone vans, and establishing what are known as medication-only sites. The analysis of changes in buprenorphine prescribing practices following federal policy changes enacted in 2016 supports the view that raising patient limits can enable select prescribers to serve more patients and as a result expand the total patient pool.
The analysis also finds that the policy changes allowing nurse practitioners and physician assistants to prescribe buprenorphine may have helped more Rhode Island patients in high-poverty Zip codes gain access to the drug. This finding lends support to proposed policies that would further expand the pool of buprenorphine prescribers to include, for example, pharmacists.
Abstract
This paper uses the all-payer claims database (APCD) for Rhode Island to study three questions about the use of medication-assisted treatment (MAT) for opioid use disorder (OUD): (1) Does MAT reduce the risk of opioid overdose; (2) are there systematic differences in the uptake of MAT by observable patient-level characteristics; and (3) how successful were federal policy changes implemented in 2016 that sought to promote increased use of buprenorphine, one of three medication options within MAT? Regarding the first question, we find that MAT as practiced in Rhode Island is associated with a reduced risk of repeated opioid overdose among patients who had an initial nonfatal opioid overdose, consistent with the strong endorsement of MAT by public health officials. Concerning the second, we find that factors such as age, gender, health insurance payer, and the poverty rate in one’s residential Zip code are associated with significant differences in the chance of receiving methadone and/or buprenorphine, suggesting that certain groups may face unwarranted disparities in access to MAT. About the third question, we find that a 2016 federal rule change enabled at least some experienced Rhode Island buprenorphine prescribers to reach more patients, and a separate 2016 policy aimed at recruiting new buprenorphine prescribers was also found to be effective. However, the data also suggest that many more patients in the state could be treated with buprenorphine if prescribers took full advantage of their prescribing limits.