Trends in Use of Medication to Treat Opioid Use Disorder During the COVID-19 Pandemic in 10 State Medicaid Programs

Abstract

Importance: Federal and state agencies granted temporary regulatory waivers to prevent disruptions in access to medication for opioid use disorder (MOUD) during the COVID-19 pandemic, including expanding access to telehealth for MOUD. Little is known about changes in MOUD receipt and initiation among Medicaid enrollees during the pandemic.

Objectives: To examine changes in receipt of any MOUD, initiation of MOUD (in-person vs telehealth), and the proportion of days covered (PDC) with MOUD after initiation from before to after declaration of the COVID-19 public health emergency (PHE).

Design, setting, and participants: This serial cross-sectional study included Medicaid enrollees aged 18 to 64 years in 10 states from May 2019 through December 2020. Analyses were conducted from January through March 2022.

Exposures: Ten months before the COVID-19 PHE (May 2019 through February 2020) vs 10 months after the PHE was declared (March through December 2020).

Main outcomes and measures: Primary outcomes included receipt of any MOUD and outpatient initiation of MOUD via prescriptions and office- or facility-based administrations. Secondary outcomes included in-person vs telehealth MOUD initiation and PDC with MOUD after initiation.

Results: Among a total of 8 167 497 Medicaid enrollees before the PHE and 8 181 144 after the PHE, 58.6% were female in both periods and most enrollees were aged 21 to 34 years (40.1% before the PHE; 40.7% after the PHE). Monthly rates of MOUD initiation, representing 7% to 10% of all MOUD receipt, decreased immediately after the PHE primarily due to reductions in in-person initiations (from 231.3 per 100 000 enrollees in March 2020 to 171.8 per 100 000 enrollees in April 2020) that were partially offset by increases in telehealth initiations (from 5.6 per 100 000 enrollees in March 2020 to 21.1 per 100 000 enrollees in April 2020). Mean monthly PDC with MOUD in the 90 days after initiation decreased after the PHE (from 64.5% in March 2020 to 59.5% in September 2020). In adjusted analyses, there was no immediate change (odds ratio [OR], 1.01; 95% CI, 1.00-1.01) or change in the trend (OR, 1.00; 95% CI, 1.00-1.01) in the likelihood of receipt of any MOUD after the PHE compared with before the PHE. There was an immediate decrease in the likelihood of outpatient MOUD initiation (OR, 0.90; 95% CI, 0.85-0.96) and no change in the trend in the likelihood of outpatient MOUD initiation (OR, 0.99; 95% CI, 0.98-1.00) after the PHE compared with before the PHE.

Conclusions and relevance: In this cross-sectional study of Medicaid enrollees, the likelihood of receipt of any MOUD was stable from May 2019 through December 2020 despite concerns about potential COVID-19 pandemic-related disruptions in care. However, immediately after the PHE was declared, there was a reduction in overall MOUD initiations, including a reduction in in-person MOUD initiations that was only partially offset by increased use of telehealth.

Figure 1.. Monthly Rates of Any Receipt of Medication for Opioid Use Disorder (MOUD) Among Medicaid Enrollees in 10 States

Medicaid enrollees were adults aged 18 to 64 years with full benefits who were not dually eligible for Medicare in Kentucky, Maine, Maryland, Michigan, North Carolina, Ohio, Pennsylvania, Virginia, West Virginia, and Wisconsin. Vertical dashed line indicates the time of declaration of the COVID-19 public health emergency.

Figure 2.. Monthly Rates of Outpatient Initiation of Medication for Opioid Use Disorder (MOUD) Among Medicaid Enrollees in 10 States

Initiation was defined as a new MOUD treatment episode following 30 days with no MOUD. All office- and facility-based MOUD administrations were classified as in-person initiations. Telehealth vs outpatient initiation for prescription fills was determined by identifying outpatient visits within 7 days before to 3 days after the prescription fill with either a matching prescriber identification for the prescription and clinician identification for the visit or with an OUD diagnosis at the visit and then applying state-specific definitions for telehealth. MOUD prescription fills with no outpatient visits within 7 days before to 3 days after the prescription fill meeting these criteria were unclassified. Medicaid enrollees were adults aged 18 to 64 years with full benefits who were not dually eligible for Medicare in Kentucky, Maine, Maryland, Michigan, North Carolina, Ohio, Pennsylvania, Virginia, West Virginia, and Wisconsin. Vertical dashed line indicates the time of declaration of the COVID-19 public health emergency.

Figure 3.. Monthly Mean Proportion of Days Covered With Medication for Opioid Use Disorder (MOUD) in the 90 Days After Initiation Among Medicaid Enrollees in 10 States

Medicaid enrollees were adults aged 18 to 64 years with full benefits who were not dually eligible for Medicare in Kentucky, Maine, Maryland, Michigan, North Carolina, Ohio, Pennsylvania, Virginia, West Virginia, and Wisconsin. Mean proportion of days covered was calculated for initiations from May 2019 through September 2020 to ensure 90 days of follow-up in the data. Vertical dashed line indicates the time of declaration of the COVID-19 public health emergency.