Duration of medication treatment for opioid-use disorder and risk of overdose among Medicaid enrollees in 11 states: a retrospective cohort study

Marguerite Burns, Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA.
Lu Tang, Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.
Chung-Chou H. Chang, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
Joo Yeon Kim, Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.
Katherine Ahrens, Public Health Program, Muskie School of Public Service, University of Southern Maine, Portland, ME, USA.
Lindsay Allen, Health Policy, Management and Leadership Department, School of Public Health, West Virginia University, Morgantown, WV, USA.
Peter Cunningham, Health Behavior and Policy Department, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA.
Adam J. Gordon, Department of Medicine and Department of Psychiatry, School of Medicine, University of Utah, Salt Lake City, UT, USA.
Marian P. Jarlenski, Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.
Paul Lanier, Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.
Rachel Mauk, School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
Mary Joan McDuffie, Government Resource Center, Ohio Colleges of Medicine, The Ohio State University, Columbus, OH, USA.
Shamis Mohamoud, Center for Community Research and Service, Biden School of Public Policy and Administration, University of Delaware, Newark, DE, USA.
Jeffery Talbert, Hilltop Institute, University of Maryland Baltimore County, Baltimore, MD, USA.
Kara Zivin, Division of Biomedical Informatics, College of Medicine, University of Kentucky, Lexington, KY, USA.
Julie Donohue, Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.

Abstract

BACKGROUND AND AIMS: Medication for opioid use disorder (MOUD) reduces harms associated with opioid use disorder (OUD), including risk of overdose. Understanding how variation in MOUD duration influences overdose risk is important as health-care payers increasingly remove barriers to treatment continuation (e.g. prior authorization). This study measured the association between MOUD continuation, relative to discontinuation, and opioid-related overdose among Medicaid beneficiaries. DESIGN: Retrospective cohort study using landmark survival analysis. We estimated the association between treatment continuation and overdose risk at 5 points after the index, or first, MOUD claim. Censoring events included death and disenrollment. SETTING AND PARTICIPANTS: Medicaid programs in 11 US states: Delaware, Kentucky, Maryland, Maine, Michigan, North Carolina, Ohio, Pennsylvania, Virginia, West Virginia and Wisconsin. A total of 293 180 Medicaid beneficiaries aged 18-64 years with a diagnosis of OUD and had a first MOUD claim between 2016 and 2017. MEASUREMENTS: MOUD formulations included methadone, buprenorphine and naltrexone. We measured medically treated opioid-related overdose within claims within 12 months of the index MOUD claim. FINDINGS: Results were consistent across states. In pooled results, 5.1% of beneficiaries had an overdose, and 67% discontinued MOUD before an overdose or censoring event within 12 months. Beneficiaries who continued MOUD beyond 60 days had a lower relative overdose hazard ratio (HR) compared with those who discontinued by day 60 [HR = 0.39; 95% confidence interval (CI) = 0.36-0.42; P < 0.0001]. MOUD continuation was associated with lower overdose risk at 120 days (HR = 0.34; 95% CI = 0.31-0.37; P < 0.0001), 180 days (HR = 0.31; 95% CI = 0.29-0.34; P < 0.0001), 240 days (HR = 0.29; 95% CI = 0.26-0.31; P < 0.0001) and 300 days (HR = 0.28; 95% CI = 0.24-0.32; P < 0.0001). The hazard of overdose was 10% lower with each additional 60 days of MOUD (95% CI = 0.88-0.92; P < 0.0001). CONCLUSIONS: Continuation of medication for opioid use disorder (MOUD) in US Medicaid beneficiaries was associated with a substantial reduction in overdose risk up to 12 months after the first claim for MOUD.