Urine drug testing among Medicaid enrollees initiating buprenorphine treatment for opioid use disorder within 9 MODRN states

Abstract

Background: Treatment guidelines recommend regular urine drug testing (UDT) for persons initiating buprenorphine for opioid use disorder (OUD). However, little is known about UDT utilization. We describe state variation in UDT utilization and examine demographic, health, and health care utilization factors associated with UDT in Medicaid.

Methods: We used Medicaid claims and enrollment data from persons initiating buprenorphine treatment for OUD during 2016-2019 in 9 states (DE, KY, MD, ME, MI, NC, PA, WI, WV). The main outcome was at least 1 UDT within 180 days of buprenorphine initiation, the secondary outcome was at least 3. Logistic regression models included demographics, pre-initiation comorbidities, and health service use. State estimates were pooled using meta-analysis.

Results: The study cohort included 162,437 Medicaid enrollees initiating buprenorphine. The percent receiving ≥1 UDT varied from 62.1% to 89.8% by state. In the pooled analysis, enrollees with pre-initiation UDT had much higher odds of ≥1 UDT after initiation (aOR=3.83, 3.09-4.73); odds were also higher for enrollees with HIV, HCV, and/or HBV infection (aOR=1.25, 1.05-1.48) or who initiated in later years (2018 v 2016: aOR=1.39, 1.03-1.89; 2019 v 2016: aOR=1.67, 1.24-2.25). The odds of having ≥3 UDT were lower with pre-initiation opioid overdose (aOR=0.79, 0.64-0.96) and higher with pre-initiation UDT (aOR=2.63, 2.13-3.25) or OUD care (aOR=1.35, 1.04-1.74). The direction of associations with demographics varied by state.

Conclusions: Rates of UDT increased over time and there was variability among states in UDT rates and demographic predictors of UDT. Pre-initiation conditions, UDT, and OUD care were associated with UDT.

Keywords: Buprenorphine; Drug testing; Medicaid; Opioid use disorder; Overdose; Urinalysis.

Figure 1.

Percent of study population with at least 1 urine drug test (light grey + dark grey) or at least 3 urine drug tests (dark grey alone), by state. Coded results are presented for the 9 states (DE, KY, MD, ME, MI, NC, PA, WI, WV) and data was obtained from enrollees initiating treatment with buprenorphine between 2016 and 2019. Abbreviations: UDT = Urine Drug Testing

Figure 2.

Adjusted odds of having at least 1 urine drug test during the 180 days after buprenorphine initiation. Results are presented for random effects meta-analysis from the 9 states (DE, KY, MD, ME, MI, NC, PA, WI, WV). Data points and darker error bars represent the global odds ratios and 95% CIs. The lightly shaded bars represent 90% prediction intervals, which is the interval that would be expected to contain the true estimate if a different set of states were sampled. Data was obtained from enrollees initiating treatment with buprenorphine between 2016 and 2019. Diagnoses and HSU assessed in 30 days prior to initiation. Abbreviations: CI = Confidence Interval, OP = Outpatient, OR = Odds Ratio, OUD = Opioid Use Disorder, PI = Prediction Interval, SUD = Substance Use Disorder, HBV = Hepatitis B Virus, HCV = Hepatitis C Virus, HIV = Human Immunodeficiency Virus, HSU = Health Services Use, UDT = Urine Drug Testing *Only 5/9 states were able to generate estimates for “Unknown/Missing” race/ethnicity and only 8/9 states generated estimates for the “Other Race/Ethnicity” category.

Figure 3.

State-level adjusted odds ratios for the associations between having at least 1 urine drug test and (A) being Non-Hispanic Black, (B) being male, or (C) living in a rural area. Odds of UDT assessed during the 180 days after buprenorphine initiation. Separate models were run in each of the 9 states (DE, KY, MD, ME, MI, NC, PA, WI, WV) and coded results are presented here. Data points and error bars represent the odds ratios and 95% CIs. Data was obtained from enrollees initiating treatment with buprenorphine between 2016 and 2019. Abbreviations: CI = Confidence Interval, OR = Odds Ratio, UDT = Urine Drug Testing

Figure 4.

Adjusted odds of having at least 3 urine drug tests during the 180 days after buprenorphine initiation. Results are presented for random effects meta-analysis from the 9 states (DE, KY, MD, ME, MI, NC, PA, WI, WV). Data points and darker error bars represent the global odds ratios and 95% CIs. The lightly shaded bars represent 90% prediction intervals, which is the interval that would be expected to contain the true estimate if a different set of states were sampled. Data was obtained from enrollees initiating treatment with buprenorphine between 2016 and 2019. Diagnoses and HSU assessed in 30 days prior to initiation. Abbreviations: CI = Confidence Interval, OP = Outpatient, OR = Odds Ratio, OUD = Opioid Use Disorder, PI = Prediction Interval, SUD = Substance Use Disorder, HBV = Hepatitis B Virus, HCV = Hepatitis C Virus, HIV = Human Immunodeficiency Virus, HSU = Health Services Use, UDT = Urine Drug Testing *Only 6/9 states were able to generate estimates for “Unknown/Missing” race/ethnicity category.