Telemedicine Buprenorphine Initiation and Retention in Opioid Use Disorder Treatment for Medicaid Enrollees

Abstract

Importance: Early COVID-19 mitigation strategies placed an additional burden on individuals seeking care for opioid use disorder (OUD). Telemedicine provided a way to initiate and maintain transmucosal buprenorphine treatment of OUD.

Objective: To examine associations between transmucosal buprenorphine OUD treatment modality (telemedicine vs traditional) during the COVID-19 public health emergency and the health outcomes of treatment retention and opioid-related nonfatal overdose.

Design, setting, and participants: This retrospective cohort study was conducted using Medicaid claims and enrollment data from November 1, 2019, to December 31, 2020, for individuals aged 18 to 64 years from Kentucky and Ohio. Data were collected and analyzed in June 2022, with data updated during revision in August 2023.

Exposures: The primary exposure of interest was the modality of the transmucosal buprenorphine OUD treatment initiation. Relevant patient demographic and comorbidity characteristics were included in regression models.

Main outcomes and measures: There were 2 main outcomes of interest: retention in treatment after initiation and opioid-related nonfatal overdose after initiation. For outcomes measured after initiation, a 90-day follow-up period was used. The main analysis used a new-user study design; transmucosal buprenorphine OUD treatment initiation was defined as initiation after more than a 60-day gap in buprenorphine treatment. In addition, uptake of telemedicine for buprenorphine was examined, overall and within patients initiating treatment, across quarters in 2020.

Results: This study included 41 266 individuals in Kentucky (21 269 women [51.5%]; mean [SD] age, 37.9 [9.0] years) and 50 648 individuals in Ohio (26 425 women [52.2%]; mean [SD] age, 37.1 [9.3] years) who received buprenorphine in 2020, with 18 250 and 24 741 people initiating buprenorphine in Kentucky and Ohio, respectively. Telemedicine buprenorphine initiations increased sharply at the beginning of 2020. Compared with nontelemedicine initiation, telemedicine initiation was associated with better odds of 90-day retention with buprenorphine in both states (Kentucky: adjusted odds ratio, 1.13 [95% CI, 1.01-1.27]; Ohio: adjusted odds ratio, 1.19 [95% CI, 1.06-1.32]) in a regression analysis adjusting for patient demographic and comorbidity characteristics. Telemedicine initiation was not associated with opioid-related nonfatal overdose (Kentucky: adjusted odds ratio, 0.89 [95% CI, 0.56-1.40]; Ohio: adjusted odds ratio, 1.08 [95% CI, 0.83-1.41]).

Conclusions and relevance: In this cohort study of Medicaid enrollees receiving buprenorphine for OUD, telemedicine buprenorphine initiation was associated with retention in treatment early during the COVID-19 pandemic. These findings add to the literature demonstrating positive outcomes associated with the use of telemedicine for treatment of OUD.

Trial registration: ClinicalTrials.gov NCT04111939.

Figure 1.. Sankey Diagram Depicting Flow of Kentucky and Ohio Patients Across Consecutive Quarters

Individuals were assigned to a node (vertical bar) based on their treatment during each quarter (Q1-Q4): exclusively nontelemedicine buprenorphine (blue) or at least 1 telemedicine buprenorphine (tan). Patients who received buprenorphine in one quarter were followed up into the next quarter (connecting ribbons), with blue or tan ribbons for individuals who went on to receive buprenorphine in the next quarter and gray ribbons for individuals who did not receive buprenorphine in the next quarter. Individuals who stopped meeting inclusion criteria in the next quarter are included in the node for that quarter but not in any connecting ribbon (n = 684).

Figure 2.. Weekly Proportion of Telemedicine Initiations, Relative to All Buprenorphine Initiations

Figure 3.. Adjusted Odds of Telemedicine Buprenorphine Initiation in Kentucky or Ohio

Analysis limited to patients with buprenorphine initiations in 2020. The “other” race category includes those with a race other than Black or White as well as those with unknown race and ethnicity. MH indicates mental health; NA, not applicable; OR, odds ratio; and Q, quarter.

Figure 4.. Telemedicine Initiation and the Adjusted Odds of Retention in Kentucky or Ohio

Analysis limited to patients with buprenorphine initiations in quarter 2 (Q2) or Q3 of 2020. The “other” race category includes those with a race other than Black or White as well as those with unknown race and ethnicity. MH indicates mental health; NA, not applicable; OR, odds ratio; and Telemedicine, telemedicine initiation.

Figure 5.. Telemedicine Initiation and the Adjusted Odds of Opioid-Related Nonfatal Overdose in Kentucky or Ohio

Analysis limited to patients with buprenorphine initiations in quarter 2 (Q2) or Q3 of 2020. The “other” race category includes those with a race other than Black or White as well as those with unknown race and ethnicity. MH indicates mental health; NA, not applicable; OR, odds ratio; and Telemedicine, telemedicine initiation.