In North Carolina, more than 10,000 people have died from an opioid-related overdose since 2008. Researchers from the University of North Carolina at Chapel Hill and Duke University have published a white paper analyzing prescription opioid use and medications to treat opioid use disorder (OUD) in Medicaid from 2013 to 2018.
One key finding is that although more Medicaid enrollees are accessing medications for treatment of OUD, there is an ongoing gap between the number of people who have OUD and the number of people who receive treatment for it. “Given the rising prevalence of OUD in the population, the rate of treatment is not keeping up with the increasing number of people who need it. From 2014 to 2017, the treatment rate declined from 45 percent to 41 percent,” the report noted.
This report, supported by Arnold Ventures, builds on the state’s Opioid Action Plan by profiling opioid-related medication utilization and describing populations at risk of opioid-related harms in the North Carolina Medicaid program. NC Medicaid serves over 2 million low-income adults, children, pregnant women, elderly adults, and people with disabilities throughout the state.
To identify criteria that characterize people at risk of opioid-related harms, researchers reviewed the scientific literature and consulted medical experts and designed this study to apply those criteria to NC Medicaid claims data and investigate trends over time. They also characterized the degree to which Medicaid enrollees diagnosed with opioid use disorder (OUD) receive medications to treat OUD. The North Carolina Department of Health and Human Services approved the use of NC Medicaid data for this study.
The researchers noted several positive trends. For instance, even as more people have been served by NC Medicaid since 2013, fewer NC Medicaid enrollees overall are filling Medicaid-paid opioid prescriptions:
• In 2013-2014, nearly 1 in 5 of all NC Medicaid enrollees (19 percent) filled at least one opioid prescription. By 2017-2018, that figure dropped to 13 percent. In addition to fewer people filling opioid prescriptions, fewer people meet various criteria for opioid-related risk.
• For example, in 2017-2018, the number of NC Medicaid enrollees under age 65 exposed to particularly high doses of prescription opioids was roughly half of what it was in 2013-2014 (from 53,000 to 28,000). Absolute declines in reported opioid-related overdoses in the NC Medicaid population have been modest.
• In 2013-2014, 1,788 NC Medicaid enrollees under age 65 had a diagnosed, claims-documented overdose, compared to 1,656 in 2017-2018.
But the researchers noted that while there are some encouraging trends to report, there is ongoing cause for concern and need for action.
• In 2017-2018, over 45,000 people in the study population had a documented diagnosis of OUD. This represents an increase of 66 percent since 2013-2014. This increase is likely due to a combination of an increase in the development of OUD in the population, and increased recognition and diagnosis by the clinical community.
The researchers see a need to manage and support high-risk populations even if the numbers of persons remaining in certain at-risk cohorts have declined. For example, while the number of Medicaid enrollees with a documented opioid overdose has declined by 7 percent since 2013-2014, 40 percent of NC Medicaid enrollees with opioid overdoses go on to fill more opioid prescriptions in the year following their overdose.
In some cases, researchers say, there are potential unintended consequences of the trends they report. A sharp reduction in the number of Medicaid enrollees receiving Medicaid-paid prescription opioids from multiple providers coincides with a period in which the opioid epidemic overall (not specific to NC Medicaid) has shifted to illicit opioids like heroin and non-medical fentanyl. “While policies enacted by governments at all levels and greater vigilance and coordination on the part of clinicians can reduce the supply of opioids in the formal health system, it is less clear what effect this may have on persons accessing such medications outside the formal health system or illicit opioids,” the white paper says.
The report highlights gaps in the provision of medications for treatment of OUD for the growing number of NC Medicaid enrollees with a diagnosis of OUD. While more Medicaid enrollees are accessing medications for treatment of OUD, there is an ongoing gap between the number of people who have OUD and the number of people who receive treatment for it.
In 2017, among persons with a diagnosis of OUD, 41 percent received at least one instance of a medication to treat OUD. Among adults diagnosed with OUD who started treatment in early 2017 with medication, 48 percent received medication for at least six consecutive months, the period that the scientific literature suggests could be the minimum time necessary for patients to derive substantial benefit from them.
Overall, the report notes important progress to report along with ongoing cause for concern and need for action. “As the opioid epidemic evolves, it is increasingly important to devote attention to harms associated with use of heroin and other illicit substances. As awareness of OUD (stemming from prescription or illicit opioids) grows, there is a concomitant need to focus on efficient and effective methods to help people get and stay on evidence-based, long-term treatment.”
