Opioid Addiction Drug Underutilized in Medicare Patients

Liam Davenport

July 20, 2016

Only a fraction of Medicare patients who have opioid use disorder receive opioid agonist therapy (OAT) with buprenorphine-naloxone (multiple brands), say US researchers, who found that nonspecialist physicians are the least likely to prescribe the drug.

The Medicare population of 55 million patients has one of the largest and fastest growing rates of opioid use disorder in the United States. More than 6 in 1000 Medicare patients are diagnosed with the disorder; this translates to more than 300,000 affected individuals. Moreover, 211,200 Medicare patients require hospitalization for opioid overuse every year.

Because Medicare Part D, which covers prescription drugs, does not pay for methadone maintenance, buprenorphine-naloxone is the only OAT that is covered for Medicare patients. It is the most effective pharmacotherapy for opioid addiction that is available for Medicare patients with opioid use disorder.

However, an analysis of claims data revealed that only about 81,000 Medicare patients are receiving buprenorphine-naloxone therapy and that the drug is prescribed by just 1 in 40 family physicians who prescribe an opioid painkiller. Moreover, it is rarely used by pain specialists.

"We believe this reflects a significant treatment gap, although we are limited in providing precise estimates; not all patients with an opioid use disorder warrant OAT, but on the other hand, opioid disorders are systematically underdiagnosed and increasing in prevalence," study investigators Anna Lembke, MD, and Jonathan H. Chen, MD, PhD, of Stanford University School of Medicine, in California, write.

"To combat the current prescription opioid epidemic, integration and promotion of OAT should be encouraged, and not just among addiction medicine specialists, who are far too few to meet the current and projected need," they add.

The research was published online July 20 in JAMA Psychiatry.

To determine whether rates of buprenorphine-naloxone prescribing meet the projected need, investigators examined individual prescriber data from the 2013 Medicare Part D claims dataset, which identifies each drug prescribed, the number of beneficiaries, the total number of claims, and the total costs.

Data were available for 808,020 prescribers and included the prescribers' location and speciality of practice. A total of 1,188,393,892 claims were filed, at a cost of $80,941,763,731.

The analysis identified 6707 prescribers with 486,099 claims for buprenorphine-naloxone. The prescriptions were written for approximately 81,000 patients. Prescribers of buprenorphine-naloxone represented fewer than 2% of the 381,575 prescribers, with 56,516,854 Schedule II opioid claims.

The investigators found that only 1 in 40 of every family-practice physician who prescribed an opioid painkiller prescribed buprenorphine-naloxone.

Furthermore, despite taking into account the thousands of prescriptions for opioid painkillers written each year, pain physicians wrote only a negligible number of buprenorphine-naloxone prescriptions, at an average of typically fewer than five per annum.

The physicians with the highest average of buprenorphine-naloxone prescriptions were prescribers whose primary specialty was addiction medicine, at 98.8 claims per year. Medicare has only 100 such prescribers for the whole of the United States.

The states with the highest number of claims were Vermont, Maine, Massachusetts, Rhode Island, the District of Columbia, and New Hampshire. Each had a claims ratio of more than 300 times the national average.

"Geographic differences in buprenorphine-naloxone prescribing should be explored to assess state-level variations in advocacy for and barriers to its use," the researchers write.

The research was supported in part by the Peter F. McManus Charitable Trust, the National Institutes of Health, and the US Department of Veterans Affairs Office of Academic Affiliations and with Health Services Research and Development Service Research funds.

JAMA Psychiatry. Published online July 20, 2016. Abstract

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