To adequately address the opioid epidemic, we need policies supported by evidence

By | January 18, 2018

One hundred and sixty-one Americans died of an opioid overdose each day in 2016, and early 2017 data suggest this trend is continuing. The medical and public health community knows from decades of research that providing individuals suffering from opioid use disorder with specific medications can save lives. Our public policies governing opioid use disorder, however, often are not based on evidence. Thus, people continue to die needlessly.

Bachhuber and colleagues examine the consequences of a critical policy deficit in the care of pregnant women with opioid use disorder in this month’s Medical Care, in an article entitled “Medicaid Coverage of Methadone Maintenance and the Use of Opioid Agonist Therapy Among Pregnant Women in Specialty Treatment.” Methadone is a commonly used medication for individuals with opioid use disorder. It stimulates the opioid receptors in the brain, but, instead of producing euphoria, the medication allows individuals to function normally, without cravings for opioids or debilitating symptoms of withdrawal. There are hundreds of studies demonstrating that this medication helps individuals with opioid use disorder live longer, healthier, more productive lives. Methadone is considered standard of care for adults and pregnant women suffering from opioid addiction. Due to the stigma against opioid use disorder, however, many states do not cover methadone as part of their Medicaid plans. Medicaid is publicly funded insurance that covers low-income individuals, and crucially for the context of this study, provides insurance coverage for 50% of all births in the United States.  

The question Bachhuber and his colleagues hoped to answer is whether pregnant women with opioid use disorder insured by Medicaid were more likely to be offered methadone, a mainstay treatment for opioid use disorder, in states that cover methadone in their Medicaid plans. The researchers did a retrospective cross-sectional analysis of treatment admissions in 30 states during 2013 and 2014; 18 of the states offered methadone, and 12 of them did not. Approximately 3,354 pregnant women were included in the study.

Not surprisingly, the vast majority of the women offered methadone (74%) lived in states that covered methadone as part of the Medicaid formulary. Overall, only about 53% of women admitted to treatment programs for opioid use disorder were offered methadone. Care plans for women living in states that covered methadone in their Medicaid formulary were significantly more likely to involve methadone treatment (adjusted difference: 32.9 percentage points, 95% CI [19.2, 46.7]).

It is confounding to me why Medicaid plans would fail to cover methadone, particularly for pregnant women considering, as Bachhuber and colleagues point out, pregnant women with untreated opioid use disorder are at high risk for infection, overdose, fetal growth restriction, intra-uterine fetal demise, placental abruption, and preterm delivery. It is worth noting that there are other options – notably, buprenorphine, which all 50 states cover in their Medicaid plans and functions similarly to methadone. This might help mitigate the striking finding that only 53% of women in all 30 states studied were offered methadone – potentially the majority of the women were offered buprenorphine. However, methadone may be preferable for some patients, and given the scale of the opioid crisis, we must be able to use every tool in our toolbox to treat opioid use disorder for every patient. Ideally, 100% of affected individuals on Medicaid should be offered every available option to treat opioid use disorder. Is there any other medication considered the standard of care, recommended by clinical guidelines and known to reduce the morbidity and mortality of a chronic disease that is not covered by Medicaid in every state? Could we imagine insulin or cholesterol-lowering medications covered by Medicaid in some states and not others?

Medicaid policy has particularly profound consequences for the care of pregnant women with opioid use disorder and the public health effects of the opioid epidemic, given its level of coverage and the knowledge that adverse consequences of women going without treatment are shared by the fetus. According to the map on page 23 of this report [pdf] compiled by The American Society of Addiction Medicine in 2013, Medicaid plans in Idaho, Montana, Wyoming, North and South Dakota, Colorado, Kansas, Iowa, Indiana, West Virginia, Kentucky, Tennessee, Arkansas, Mississippi, Louisiana, and South Carolina do not fund methadone maintenance.

Policymakers of all stripes recognize that the opioid crisis is an emergency. Input from health professionals is likely to be welcomed in most lawmakers’ offices across the U.S. If you live in any of the states listed above and would like to do some advocacy to improve outcomes in the opioid use disorder, it is certainly worthwhile to share this study with your representative and encourage them to add methadone to their states’ Medicaid formulary. To address the opioid epidemic and save lives, Medicaid policy must be guided by evidence. Bachhuber and colleagues provide an excellent service by highlighting this gap in Medicaid policy in the literature.

Editor’s note: For more about opioids and pregnancy, check out this earlier post.

Audrey Provenzano

Audrey Provenzano

Audrey M. Provenzano, MD, MPH is a General Internist in the Boston area. She cares for patients in a community health center and works in quality improvement. She is interested in primary care practice reform and quality improvement and healthcare policy. She is the host and producer of the primary care and health policy podcast Review of Systems, which can be found at www.rospod.org.
Audrey Provenzano

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