STATE TARGETED FUNDING AND TECHNICAL ASSISTANCE TO INCREASE ACCESS TO MEDICATION TREATMENT FOR OPIOID USE DISORDER

Abstract

Objective:

As the United States grapples with an opioid epidemic, expanding access to effective opioid use disorder treatment is a major public health priority. Identifying effective policy tools that can be used to expand access to care is critically important. This paper examines the relationship between state targeted funding and technical assistance and adoption of three opioid use disorder treatment medications: oral naltrexone, injectable naltrexone, and buprenorphine.

Methods:

This study draws from the 2013-2014 wave of the National Drug Abuse Treatment System Survey, a nationally-representative, longitudinal study of substance use disorder treatment programs. The sample includes data from 695 treatment programs (85.5% response rate) and representatives from Single State Agencies in 49 states and DC (98% response). Logistic regression was used to examine the relationship of Single State Agency targeted funding and technical assistance for opioid use disorder treatment medications to their availability among programs.

Results:

State targeted funding was associated with increased program-level adoption of oral naltrexone (Adjusted Odds Ratio [AOR], 3.14; 95% CI=1.49-6.60, p=.004) and buprenorphine (AOR= 2.47, 95% CI=.31-4.67; p=.006). Buprenorphine adoption was also correlated with state technical assistance to support medication provision (AOR= 1.18, 95% CI=1.00-1.39; p=.049).

Conclusions:

State targeted funding for medications may be a viable policy lever for increasing access to opioid use disorder medications. Given the historically low rates of opioid use disorder medication adoption in treatment programs, Single State Agency targeted funding is a potentially important tool to reduce mortality and morbidity associated with opioid disorders and misuse.

INTRODUCTION

In 2014, an estimated 4.7 million Americans were dependent on opioids, including both prescription opioids and heroin (1). Prescription opioid overdose, abuse and misuse cost an estimated at $78.5 billion in 2013 (2). Opioid use disorder is associated with a range of health issues including cardiovascular disease, diabetes, HIV/AIDS, and Hepatitis C (3–10). Of particular concern is the dramatic rise in opioid overdose deaths related to prescription opioids and heroin (11, 12). The rate of opioid-related overdose deaths has increased over 200% since 2000. In 2015, opioids were involved in a record 33,091 deaths (13).

Increasing access to medications for opioid use disorder treatment is widely acknowledged to be a key strategy for addressing the opioid epidemic (11, 14, 15). Methadone maintenance therapy has been shown effective in many trials (16). Buprenorphine, a partial opioid agonist, and naltrexone, an opioid antagonist, the main focus of this paper, can be readily prescribed in outpatient treatment settings and have also demonstrated efficacy (17–21). Poor compliance associated with oral naltrexone suggests it may be more effective for patients who are highly motivated and/or patients who are closely monitored. Patients must also be free from opioids for 7 to 10 days prior to initiating treatment with naltrexone.

Buprenorphine is a schedule II narcotic and can only be prescribed by a physician holding a DATA 2000 waiver. Physicians are limited to prescribing buprenorphine to a maximum of 30 patients at one time in the first year of holding a wavier, a maximum of 100 patients in the second year, and a maximum of 275 patients in the third year of holding a waiver. There are no such prescribing regulations on naltrexone.

Use of opioid use disorder medications is associated with reductions in opioid use, withdrawal and craving, infectious disease transmission and treatment dropout (18, 19, 22–25). Research also shows that buprenorphine and both formulations of naltrexone are cost-effective, and their use is associated with reductions in other types of health care utilization (26–28). For many Americans with opioid use disorder, these medications, used in conjunction with psychosocial therapy, are the most effective treatment option (17–20).

Despite the efficacy of buprenorphine and naltrexone only a limited number of treatment programs in the United States prescribe them (29). Data indicate that less than half of non-Opioid Treatment Programs (i.e., specialty treatment programs that are not licensed to dispense methadone) prescribe a single medication and less than 40% have a physician on staff. Buprenorphine is the most commonly prescribed medication in non-OTPs, followed by oral naltrexone and injectable naltrexone (29).

The reasons for low rates of adoption of these medications in treatment programs are complex. Financial barriers have been a longstanding challenge for patients and treatment programs. Because many patients are unable to afford these medications, treatment programs that serve clients who are predominantly low-income and uninsured are less likely to offer them. Prior research demonstrates that treatment programs that are large, for-profit, accredited, and serve a higher percentage of patients with private health insurance are significantly more likely to offer opioid use disorder treatment medications such as buprenorphine and naltrexone (30–37).

Additionally, access to prescribers of medications has been a challenge for many treatment programs due to a lack of resources and federal restrictions limiting the number of physicians who can prescribe buprenorphine and the number of patients they can serve. As a result, it has been difficult for specialty treatment programs to attract and retain physicians with opioid use disorder prescribing capacity. Hospital-based programs and programs with a physician on staff have historically been more likely to adopt medications (29, 31, 36, 38).

The Role of States in Medication Adoption

Substance use disorder treatment in the United States is delivered by the more than 14,000 programs that compose the specialty substance use disorder treatment system. Approximately two-thirds of specialty treatment programs rely on Substance Abuse Prevention and Treatment block grant funding, provided by the Substance Abuse and Mental Health Services Administration and administered through each state’s Single State Authority (39–42). SSAs are state governmental organizations responsible for overseeing and licensing substance use disorder treatment programs. Each state’s SSA organizes and administers the distribution and oversight of the block grant, including determining treatment provider qualifications, payment methods and rates, and reporting requirements (39, 43, 44).

State policies influence adoption of medications by treatment programs (43, 45). Reickmann and colleagues reported that a majority of SSAs used contract language (i.e., contracts with treatment programs that either required or encouraged evidence-based practices) as a tool to promote implementation of evidence-based practices including medications (45). Other studies examining the influence of state policy on medication adoption have focused exclusively on the adoption of buprenorphine. Using data from 2006, Ducharme and Abraham found a positive association between state Medicaid coverage of buprenorphine and adoption of buprenorphine (31). A more recent study by Andrews and colleagues examined the adoption of buprenorphine in a national sample of OTPs and found that the odds of offering buprenorphine were greater in OTPs located in states that provided subsidies to support buprenorphine adoption (30).

Taken together, these studies suggest that state targeted funding, i.e., funding specifically allocated to support medications, and incentives may have a significant influence on programs’ decisions to offer medications. However, these studies report on data collected nearly a decade ago—a particularly problematic lag in light of significant changes in structure and financing of the specialty treatment system spurred by the Affordable Care Act (30, 31). Moreover, these studies do not include oral and injectable naltrexone, important medications for treatment of opioid use disorder (30, 31). To address this gap in the literature, this current study examines the influence of state targeted funding and technical assistance on the adoption of three medications used to treat opioid use disorder: oral naltrexone, injectable naltrexone, and buprenorphine. The study focuses on non-OTPs which represent 90% of the substance use disorder treatment system and historically have low rates of medication adoption.

METHODS

This study draws data from the sixth wave of the National Drug Abuse Treatment System Survey (NDATSS), a nationally-representative, longitudinal study of treatment programs in the United States. NDATSS uses a split panel design with replacement sampling to replace programs that exit the sample over time and refresh the sample to ensure a nationally representative sample at each wave of data collection. Survey weights account for possible nonresponse bias and ensure the sample was representative of the study population. Data from program directors and clinical services supervisors of treatment programs were collected from November 2013 to June 2014. Interviews were 90 minutes long and were conducted via Internet-based survey. Interviews were completed with 695 treatment programs (response rate= 85.5%). See D’Aunno and colleagues for a complete description of the study methods (46). This study reports data from 456 non-OTP programs in the study. To measure state targeted funding and incentives for treatment medications, we conducted a 15 minute Internet-based survey with representatives from Single State Agencies which included a population of all states and the District of Columbia (response rate=98%). These data were collected from October 2013 to July 2014. The Institutional Review Boards at The Miriam Hospital, University of Chicago, University of South Carolina, and the University of Georgia approved this study.

Measures

Dependent Variables

The study included three dependent variables measuring whether treatment programs provided each of the following medications for the treatment of opioid use disorder: oral naltrexone, injectable naltrexone, and buprenorphine.

Independent Variables

Our primary independent variables of interest were designed to gauge the extent to which SSAs provided targeted funding and technical assistance to encourage the availability of medications. We assessed whether states specifically allocated block grant funding for each of three medications (oral naltrexone, injectable naltrexone and buprenorphine), and whether any state funds, other than those available through Medicaid, were used to subsidize the availability of buprenorphine. The study also measured the extent of technical assistance provided by states to treatment programs to address potential barriers to adoption of medications using seven items: creating information technology and/or electronic health records infrastructure, obtaining Medicaid certification, becoming in-network providers within private insurance plans, collaborating with FQHCs, collaborating with other medical providers, collaborating with mental health providers, and providing education and/or training to increase the number of substance abuse treatment counselors (See Appendix A). The response to each item was coded ‘1’ if the state responded affirmatively and ‘0’ otherwise. Items were then summed to create a scale ranging from 0 to 7. In addition, we conducted a factor analysis and retained the first factor. The results did not chance; thus we used the summed score for ease of interpretation.

Control Variables

We included measures of treatment programs that have been significantly related to medication adoption in prior research (29–31, 33–37, 47–59). These included program ownership (private for-profit, private non-profit, and public); program type (outpatient, inpatient/residential); accreditation by the Joint Commission or Commission on Accreditation of Rehabilitation Facilities; the number of clients served by each program in the past year (log transformed to adjust for skewness); the percentage of staff with a Master’s degree; and the percentage of program revenues in the past year from private insurance. We also measured each program’s percentage of Black, Hispanic and female clients in the past year.

To control for patient demand for treatment services and perceptions of market competition that might also influence adoption of medications, we measure the percentage of treatment program clients experiencing heroin and prescription opioid disorders in the past year. These measures also indicate the extent to which treatment programs specialize in these patient populations. To capture perceptions of competition we include a survey measure which assessed whether the program director perceived an increase in competition in the local labor market in the past year.

Analytic Technique

Descriptive statistics were calculated for all study variables. Using logistic regression, we examined the relationship of state targeted funding and technical assistance to adoption of opioid use disorder medications among treatment programs. Our models accounted for the nesting of treatment programs in states and included sample weights using STATA’s svy command suite to account for sampling strata. Imputation was conducted using STATA’s mi impute command suite to account for missing data on treatment program-level independent variables. The total number of treatment programs included in multivariate analyses varied based on the amount of missing data on each dependent variable. All analyses were conducted in STATA 14.1 (60).

RESULTS

Descriptive Statistics

Among the fifty Single State Agencies (SSAs), six (13%) allocated block grant funding to treatment programs for provision of oral naltrexone, seven (15%) allocated block grant funding for injectable naltrexone, and eight (17%) allocated block grant funding for buprenorphine in 2014 (See Table 1). Fifteen SSAs (31%) reported subsidizing the use of buprenorphine with state funds other than Medicaid. Most SSAs reported providing at least some technical assistance to assist treatment programs with adoption of opioid use disorder treatment medications; on average, SSAs offered about five assistance services to treatment providers. Among treatment programs, approximately 11% offered oral naltrexone and injectable naltrexone, and 26% offered buprenorphine in 2014.

Table 1:

Descriptive Statistics (n=456 Treatment Programs; n=50 States)

	N	%
State Policy (n=50)
SSA block grant funding for oral naltrexone	6	13
SSA block grant funding for injectable naltrexone	7	15
SSA block grant funding for buprenorphine	8	17
SSA subsidizes buprenorphine with state funds	15	31
SSA level of technical assistance (M±SD)	4.62±1.68
Treatment Programs (n=456)
Dependent Variables
Oral naltrexone	45	11
Injectable naltrexone	45	11
Buprenorphine	112	26
Control Variables
Organizational Characteristics
Program ownership
Private for-profit	99	23
Private non-profit	280	66
Public	45	11
Program type
Outpatient	323	71
Inpatient/Residential	133	29
Accredited by JC/CARF	193	49
Program size (number of clients served, log) (M±SD)	5.29± 1.18
Staff professionalism (M±SD)	40.01±30.16
% private insurance revenues (M±SD)	14.39±22.93
Client socio-demographic characteristics
% Black (M±SD)	19.02±23.74
% Hispanic (M±SD)	13.57±19.43
% women (M±SD)	37.23±26.91
Market Factors
Perceived increase in competition	140	32
% heroin clients (M±SD)	23.61±27.06
% prescription opioid clients (M±SD)	26.74±23.65

Note: Descriptive statistics are presented for all programs in the study. The number of programs and states included in multivariate analyses varies by medication, based on the amount of missing data.

Logistic Regression Models

The adjusted odds of adopting oral naltrexone were greater in treatment programs located in states that provided block grant funding specifically for opioid use disorder medications (AOR=3.14; see Table 2). The adjusted odds of adopting buprenorphine (AOR=2.47) were positively associated with provision of state funding for buprenorphine, as well as the extent of state-based technical assistance provided to treatment programs (AOR=1.18). Although the odds ratios for technical assistance in the naltrexone models were similar to the buprenorphine model, they were not statistically significant.

Table 2:

Results of Logistic Regression Models Predicting Adoption of Opioid Use Disorder Medications

	Oral Naltrexone (n=383)			Injectable Naltrexone (n=383)			Buprenorphine (n=397)
	AOR	95% CI	p-value	AOR	95% CI	p-value	AOR	95% CI	p-value
State Policy
SSA block grant funding for medication	3.14	1.49-6.60	.004	1.44	.66-3.16	.350	.54	.27-1.11	.093
SSA subsidizes buprenorphine with state funds	--		--	--		--	2.47	1.31-4.67	.006
SSA level of technical support	1.13	.88-1.46	.332	1.25	.94-1.65	.115	1.18	1.00-1.39	.049
Control Variables
Organizational Characteristics
Program ownership
Private non-profit (reference: private for-profit)	3.59	1.40-9.20	.009	1.17	.34-4.06	.789	2.56	1.09-6.02	.032
Public ownership (reference: private for-profit)	3.07	.74-12.69	.117	.60	.10-.71	.573	2.87	.88-9.36	.078
Program type
Inpatient/Residential (reference: outpatient)	3.14	1.07-9.22	.038	2.22	1.01-4.91	.049	1.51	.87-2.63	.138
Accredited by JC/CARF	1.41	.60-3.32	.424	1.58	.51-4.93	.420	1.16	.49-2.76	.732
Program size (number of clients served, log)	1.24	.91-1.69	.176	1.06	.74-1.50	.759	1.53	1.21-1.94	.001
Staff professionalism	.53	.11-2.65	.428	3.74	.65-21.52	.135	1.18	.27-5.09	.817
% private insurance revenues	1.02	.99-1.04	.167	1.01	.99-1.04	.274	1.01	.99-1.03	.171
Client socio-demographic characteristics
% Black	.98	.96-1.01	.135	.99	.97-1.01	.343	.99	.98-.00	.183
% Hispanic	.99	.96-1.01	.394	1.00	.97-1.03	.854	1.00	.97-1.03	.893
% women	1.01	.99-1.02	.259	1.00	.98-1.03	.692	1.00	.99-1.01	.903
Market Factors
Perceived increase in competition	2.33	1.34-4.03	.004	.54	.28-1.04	.064	1.08	.51-2.31	.829
% heroin clients	1.00	.98-1.02	.661	1.02	1.01-1.04	.013	1.01	.99-1.02	.057
% prescription opioid clients	1.00	.98-1.03	.689	1.00	.97-1.02	.784	1.01	1.00-1.02	.146

Note: The number of programs and states included in multivariate analyses varies by medication, based on the amount of missing data.

Organizational factors were also positively associated with adoption of opioid use disorder medications. The adjusted odds of adopting oral naltrexone and buprenorphine were greater in private non-profit programs (AOR=3.59; AOR=2.56) compared with private for-profit programs. The adjusted odds of adopting buprenorphine were greater in larger programs (AOR=1.53). The adjusted odds of oral and injectable naltrexone adoption were higher in inpatient and residential programs than in outpatient programs (AOR=3.14; AOR=2.22)

Market factors were also associated with the adoption of oral and injectable naltrexone. The adjusted odds of adopting injectable naltrexone were greater in programs that reported an increase in competition in the past year (AOR=2.33), and the adjusted odds of adopting injectable naltrexone were greater in programs with a higher percentage of patients with heroin use disorders (AOR=1.02).

DISCUSSION

This national survey found that state targeted funding was linked to adoption of two medications for opioid use disorder—oral naltrexone and buprenorphine. However, adoption of medications among substance use disorder treatment programs remains low, with less than 27% of treatment programs offering buprenorphine and less than 12% of programs offering either oral or injectable naltrexone.

Given the increase in demand for opioid use disorder treatment and the rise in opioid overdose deaths over the past 15 years, it is critically important to increase access to these medications (11). Our findings suggest that state targeted funding for medications may be one viable policy lever to increase their availability in treatment programs. Through the 21^st Century CURES Act states are receiving additional funding administered through SAMHSA to directly address the opioid crisis. One goal of this funding is to expand access to opioid use disorder medications. Thus, it will be particularly important to monitor how states are using these funds and if these additional funds result in increased access to opioid use disorder medications.

Although states act relatively autonomously to make decisions about the allocation of Substance Abuse Prevention and Treatment block grant dollars to prevention, treatment, outreach and administrative costs, SAMHSA might consider offering additional incentives to states to increase availability of opioid use disorder medications. The federal government could also encourage the Centers for Medicare and Medicaid Services to offer incentives to providers to encourage comprehensive coverage of opioid use disorder medications. This approach may be particularly important for states hardest hit by the opioid crisis. At present, only three states with the highest rates of opioid overdose deaths or opioid use disorder rates allocate any block grant funding for opioid use disorder medications (61).

In addition to allocating a portion of treatment dollars from the federal block grant to medications, our findings suggest that subsidizing the use of medications using other streams of state funding may also be a viable strategy. Both the current study and prior research demonstrate the utility of this strategy to facilitate adoption of buprenorphine (30). However, the states utilizing this strategy are not always those states with the greatest need. Among the 15 states subsidizing buprenorphine with state funding (other than Medicaid and the block grant), only seven are among those with the highest rates of opioid overdose deaths and only four states are among those with the highest rates of opioid use disorder (61, 62).

We also found that programs located in states with SSAs that provide a greater level of technical assistance were more likely to adopt buprenorphine. This finding suggests that the availability of technical assistance indicates a more supportive state policy environment which places an emphasis on the use of evidence-based practices, collaboration with primary care and mental health providers, adoption of electronic health records and obtaining Medicaid certification, all of which might contribute to increased accessibility and quality of treatment. Indeed, treatment providers who begin collaborating with primary care and mental health providers may gain access to prescribing staff for the first time. Taken together, these findings suggest that when states help programs overcome financial and technological barriers to offering these medications, treatment programs respond as hoped—by adopting medications.

Although SSA policy influenced adoption of oral naltrexone and buprenorphine, it did not impact adoption of injectable naltrexone. This may be related to the cost of injectable naltrexone which can be as much as $1000 per injection. Even when the medication is covered by insurance, it still may not be an affordable option for patients. The administration of the injection also requires a higher degree of technical expertise than the other medications which are administered orally (63). Staff may need additional training, or new staff may need to be hired. Our findings suggest that the adoption and implementation of injectable naltrexone may require a greater commitment of resources on the part of SSAs and treatment programs.

In contrast to some prior research, we found that private non-profit treatment programs were more likely to offer oral naltrexone and buprenorphine compared to private for-profit programs. There may be several explanations for this finding. First, data from the National Survey of Substance Abuse Treatment Services (NSSATS) and prior studies that utilize NSSATS data indicate that private for-profits were more likely to be early adopters of buprenorphine compared to private non-profits (31, 33). However, by 2015 the percentage of private non-profit, private for-profit and publicly owned programs offering buprenorphine was very similar (64). Second, studies which found that private for-profit programs were more likely to adopt oral naltrexone compared to private non-profit programs (34) restricted their sample to privately funded programs. Our study does not use eligibility criteria based on sources of funding, thus direct comparisons with these studies cannot be drawn. Third, other studies which include both samples of privately and publicly funded programs (36) utilize separate variables to measure funding and profit status. Therefore, our results are not directly comparable to these prior studies. Fourth, most of these studies do not control for state policy or market characteristics which may account for these differences.

Limitations

The current study has several limitations. First, its data are cross-sectional; hence, we are unable to draw any causal inferences. Second, the study did not examine the relationship between Medicaid coverage and adoption of medications due to a lack of variation in coverage. In 2014, all state Medicaid plans covered buprenorphine and 48 states covered injectable naltrexone. Third, the survey did not ask if states used non-Medicaid state funds to support oral or injectable naltrexone. Fourth, our study relied on self-report data, which are subject to response bias. Fifth, there may be other factors not included in these analyses that account for variation in availability of medications.

CONCLUSIONS

Given historically low rates of medication adoption in treatment programs and the rise in opioid overdose deaths and treatment admissions for opioid use disorder, increasing access to these potentially life saving medications is imperative. SSA targeted funding and technical assistance may be viable policy levers to increase access to effective medications in the great majority of treatment programs that do not offer medications. SSAs in many states with the highest rates of opioid use disorder and opioid-related overdose deaths are not currently utilizing these funding and assistance strategies, and thus additional federal incentives may be necessary.