Overcoming Barriers to Opioid Treatment: A Study of Medicaid Prescription Caps

With over $3.5M in support from the National Institute on Drug Abuse, Brown investigators hope to identify best practices for navigating Medicaid policies and ultimately improve patient and population health.

Medications for opioid use disorder can be life-saving for the more than two million Americans struggling with opioid addiction. However, cost can be a major barrier to accessing these medications, especially for those relying on Medicaid coverage.

As of November 2021, ten states have implemented Medicaid cap policies that limit the number of covered prescriptions in an effort to control spending: Alabama, Arkansas, Illinois, Kansas, Louisiana, Mississippi, Oklahoma, South Carolina, Tennessee and Texas. These policies can restrict access to essential care and increase hospitalizations and mortality. Texas Medicaid, for instance, limits its beneficiaries to three prescription fills per month, which can be problematic for those who need more, forcing them to choose between paying out of pocket or forgoing some treatments altogether. 

Jaclyn White Hughto, assistant professor of behavioral and social sciences and of epidemiology, has been awarded over $3.5M from the NIH’s National Institute on Drug Abuse to study the impact of these spending caps. The grant spans five years and is aimed at investigating the impact of Medicaid cap policies on access to and utilization of Medication for Opioid Use Disorder (MOUD) and associated outcomes, such as overdose among Medicaid beneficiaries with opioid use disorder and other chronic health conditions.

By analyzing Medicaid claims data and conducting interviews with patients and providers, Hughto and Patience Moyo, co-principal investigator of the study and assistant professor of health services, policy and practice, hope to identify best practices for navigating these policies and ultimately improve patient and population health. Their findings will be especially important for vulnerable populations who rely on public assistance to access medications for chronic conditions.

We spoke with Professor Hughto about her team’s project, “Impact of Medicaid Prescription Cap Policies on Treatment Outcomes for Opioid Use Disorder: A National Mixed-Methods Study.”

Tell us the significance of this study and how it might inform policy decisions related to opioid treatment?

We aim to study how “cap policies” affect people with Opioid Use Disorder (OUD) who rely on Medicaid. By analyzing Medicaid claims data and talking to patients and providers, we hope to identify the best ways to navigate these policies and improve access to treatment.

If successful, the research could lead to policy changes that improve health outcomes and save lives among individuals with OUD who are subject to Medicaid cap policies. By demonstrating the impact of cap policies on the opioid and overdose crisis, our work could inform efforts to  reduce structural barriers to life-saving medications and treatment, in turn helping people with OUD to access MOUD, reduce their use of illicit opioids, and ultimately, decrease the number of overdose deaths.

Your research often centers around the impact of stigma on the health of marginalized populations. Will your team integrate this perspective into the current project? And what are some of the potential implications for addressing stigma within opioid treatment?

We are using a mixed-methods approach that includes analyzing Medicaid claims data and conducting interviews with prescribers, pharmacists, and people with OUD. We want to identify the different forms of stigma that may impact access to treatment, both at the interpersonal and individual levels.

By understanding the role of stigma in medication access, we can make recommendations to reduce stigma and improve access to treatment for all people with OUD, regardless of whether they are subject to Medicaid cap policies.

How do you envision your study contributing to the broader efforts to address the overdose crisis?

Much of the current opioid and overdose crisis is driven by the widespread availability of illicitly-manufactured fentanyl in the drug supply. Research shows that people who are on MOUD and are exposed to fentanyl are at reduced risk of fatal fentanyl–involved overdoses. Thus, increasing access to medication is essential to help reduce the harms of fentanyl exposure and help people meet their recovery goals.

One way to do this is to understand how existing policies shape access to care. If these policies result in adverse health outcomes, we can use this information to educate policymakers on the importance of modifying these policies to improve access.

Together, these studies have the potential to document and address  the multi-level barriers to MOUD uptake and continuity, improve treatment outcomes and ultimately save lives.

Jaclyn White Hughto assistant professor of behavioral and social sciences and of epidemiology
Jaclyn White Hughto

Medicaid is an extremely rich but complex data source to work with given that each state has its own Medicaid program. Thus, working with the data takes a good deal of time and requires knowledge of the idiosyncrasies of each state’s program. Fortunately, my co-principal investigator, Patience Moyo, is an expert at analyzing Medicaid data. We have also assembled a team of researchers and consultants with knowledge of each state’s Medicaid program to help us navigate analytical issues and interpret the data in the context of each state’s program.

Additionally, although recruiting providers and people with OUD who work and live in Medicaid cap states, respectively, may present some challenges, we have formed a National Advisory Panel comprised of prescribers, pharmacists and people with OUD who can support our recruitment efforts as well as help us to interpret findings and develop recommendations.

Your research has also focused on developing and testing bio-behavioral interventions for substance use disorder, HIV, and mental health. How do you see your current project informing future research in this area? Are there any specific interventions you are currently working on, or planning to develop, in the future?

Although I have experience using my research to inform organizational or state policy change, much of my intervention development research has worked at the individual or interpersonal levels to improve the health of marginalized populations.

The data collected as part of this study holds promise for improving the lives of individuals struggling with OUD by documenting the impact of Medicaid policies on treatment access and advocating for structural changes. Through my anticipated collaborative advocacy efforts, I hope to expand my program of intervention research to include national opioid policy initiatives and interventions.

With regard to my other opioid-related intervention development research, my collaborators and I recently completed a pilot intervention study called CoMBAT OUD. This study innovatively tested the use of behavioral activation to reduce depression and improve engagement in MOUD care among individuals with depression and OUD. The results were incredibly promising as the pilot intervention was found to be feasible, acceptable, and showed early signs of efficacy.

I am in the process of writing up the study findings and plan to submit a grant proposal to conduct a larger randomized controlled trial to test the efficacy of the intervention in reducing depression and improving MOUD treatment outcomes. 

Together, these studies have the potential to document and address  the multi-level barriers to MOUD uptake and continuity, improve treatment outcomes and ultimately save lives.