Methadone Tx Rates Tumble After Medicaid Funding Is Pulled

Nancy A. Melville

March 10, 2016

Utilization of opioid agonist therapy ― mainly methadone maintenance treatment ― for the management of opioid addiction substantially drops when Medicaid coverage is pulled, new research shows.

"We found that opioid agonist therapy utilization was overall nearly 30 percentage points higher among Medicaid enrollees in states with Medicaid reimbursement for methadone compared with states with no public funding for methadone maintenance, after adjustment for individual characteristics," the authors, led by Brendan Saloner, PhD, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, write.

The study was published online March 9 in Psychiatric Services.

Significant Copayments

Although methadone represents a lower-cost alternative to newer opioid agonist treatments, such as buprenorphine (multiple brands), the latter have improved safety profiles and are currently covered by Medicaid to some extent in every state. By contrast, methadone maintenance therapy is not covered by Medicaid in 17 states, and its coverage is under threat in other states.

To investigate the role of Medicaid or block grant funding in the overall utilization of opioid agonist therapy among Medicaid patients, the researchers analyzed Medicaid data from all 50 states. They linked the information with data from the 2012 Treatment Episode Data Set (TEDS), which includes information on 1.7 million public-sector substance abuse treatment admissions.

Importantly, the TEDS data mainly reflected methadone maintenance utilization, Dr Saloner told Medscape Medical News.

"Our data did not allow us to separate out people who received methadone vs buprenorphine, but we know from other data that most of the medication-assisted treatment we observed at these facilities would have been methadone (>90%)," he said.

The results showed that overall, utilization of opioid agonist therapy among Medicaid enrollees in states that did not provide coverage for methadone through Medicaid was just 7%, compared with 46.6% in states that did provide coverage for methadone maintenance. In states that provided coverage for methadone only through a substance abuse prevention and treatment (SAPT) block grant, utilization was lower, at 26.3%.

After adjustment for individual measures of substance abuse and for factors such as age, sex, and education, corresponding rates of utilization were 17% in states with no methadone coverage through Medicaid, 45.0% in states with coverage, and 30.1% in states that provided coverage for methadone only through an SAPT block grant (for all, P < .01).

The decline in utilization in states offering only block grant coverage likely reflects the increased restriction of such funds, which results in patients being required to pay significant copayments, the authors note.

"These results support the notion that although block grants may facilitate some methadone treatment, they are more constrained than Medicaid financing," they write.

Political Resistance

Limitations of the study include the fact that the study focused on admissions to specialty treatment providers, whereas some Medicaid enrollees may have entered treatment or switched to buprenorphine treatment through office-based physician practices, the authors note.

Dr Saloner speculated that the findings suggest that when patients no longer have methadone coverage through Medicaid, they may not get alternative addiction treatment with buprenorphine.

"We don't know for sure, and this is an important possibility. We do know that availability of methadone through opioid treatment programs increases the number of people receiving treatment overall, so my best guess is that fewer people may receive any kind of opioid agonist treatment when their state Medicaid program does not cover methadone maintenance, but we would want to study this issue further," he said.

Methadone maintenance therapy, which has been shown to be effective for managing cravings and withdrawal symptoms and in reducing illicit opioid use, is typically administered in opioid treatment programs under clinic staff supervision.

Although many in need of treatment for opioid addiction may rely on Medicaid coverage for access, the reasons why states drop methadone maintenance programs from Medicaid coverage often have more to do with politics and a lack of understanding of the benefits of the treatment than more sound factors, Dr Saloner added.

"Anecdotally, there is political resistance to methadone maintenance ― and a not-in-my-backyard mentality ― that leads states to prevent opioid treatment programs from operating or restricts their funding," Dr Saloner said.

"There is also some misunderstanding about what kinds of patients might uniquely benefit from methadone maintenance, and concerns about misuse of methadone.

"These concerns are largely misplaced, because when appropriately dosed and prescribed, methadone is safe and effective."

The bottom line in terms of tackling the nation's opioid addiction problem, as treatment guidelines indicate, is to provide access to methadone as well as buprenorphine, said Dr Saloner.

"Some patients are better candidates for methadone maintenance, and for these individuals, the treatment is likely to lead to best outcomes and to be cost-effective for states, as methadone is less expensive per patient than buprenorphine," he noted.

"Buprenorphine is a good option to keep, however, because, for the right patients, it is convenient and likely to lead to better adherence with less clinical supervision."

The authors have disclosed no relevant financial relationships.

Psychiatr Serv. Published online March 9, 2016. Abstract


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.