West Virginia is ground zero for the nation’s opioid crisis. That also makes it fertile ground to study the impacts of Medicaid expansion on treatment.
A new study published in the April edition of Health Affairs looked at changes in opioid treatment trends in West Virginia following the state’s adoption of Medicaid expansion under the Affordable Care Act in 2014. Researchers found significant increases in the number of opioid use disorder (OUD) diagnoses between 2014 and 2016. Buprenorphine prescriptions filled, in turn, spiked from roughly 33% of individuals diagnosed with OUD in 2014 to over 75% in 2016.
These results add to a growing body of research suggesting Medicaid expansion plays a role in improving care among opioid patients.
They also raise questions about whether public health policy could be modified further to yield more gains. The study found that while many patients saw improvements in care, some demographic groups and areas of the state benefited more than others.
“We were surprised to find that in West Virginia, among diagnosed people treatment with buprenorphine was higher in rural areas than in urban areas,” says study author Brendan Saloner, Ph.D., of the Johns Hopkins Bloomberg School of Public Health.
The study found that patients in urban areas, as well as Hispanic and non-Hispanic black patients, were more likely to receive prescriptions for naltrexone, which Saloner says tends to be less well-tolerated than buprenorphine. Researchers are still working to understand whether that discrepancy represents a success story in rural areas or something else.
Saloner also notes that methadone was not covered by Medicaid in West Virginia during the study period, but has been added since then as a benefit. From a health policy standpoint, he says methadone and buprenorphine offer patients comparable clinical benefits, especially for those earlier in recovery.
The duration of treatment rose for patients taking buprenorphine during the study period as well, from 161 days in 2014 to 185 in 2016. That indicates patients stick with the treatment longer than they do naltrexone. But Saloner says there’s still plenty of room for improvement.
“A lot of patients need more time than that, so issues like prior authorization and other real or perceived barriers to keeping patients retained on medication still need to be addressed,” he explains.
The study also suggests a well-intentioned policy that requires patients taking buprenorphine to obtain counseling may prove counterproductive in the long run. “From a public health perspective, it would be much better if patients were encouraged to get medication and the medication was available,” says Saloner.
Getting more people into treatment represents a net positive for public health, but the study suggests we still have a long way to go. Rising diagnosis rates could be a good sign that increased access and improved screening processes are moving more people into treatment—or they could simply be a sign that the number of people falling prey to opioid abuse continues to rise.
Saloner believes it’s likely a little of both. Still, he says, the trends in terms of improved prevention look more promising after Medicaid expansion than before. Even without hard data to prove expansion caused all of the benefits the study perceived, the program seems well-suited to the particular challenges faced by a rural, underinsured population.
“I think about a continuum of things that can happen for people, and Medicaid can play a role in most of them,” Saloner says. The key is to ensure that Medicaid expansion is tailored to provide the particular mix of services needed in each individual state.
“I think other similarly rural, socio-economically disadvantaged states might want to consider ways to really push treatment out to those rural areas,” he says. “I think really trying to understand how a program like Medicaid expansion can work in areas where there’s low provider capacity or limited resources is key.”