State Medicaid Policies Governing Access to Medications for Opioid Use Disorder (MOUD) and MOUD Treatment Use in a Large Sample of People Who Inject Drugs in 20 U.S. States

Background: People who inject drugs (PWID) are especially vulnerable to harms from opioid use disorder (OUD). Medications for OUD (MOUD) effectively reduce overdose and infectious disease transmission risks. Objective: We investigate whether state Medicaid coverage for methadone and buprenorphine is related to past-year MOUD use among PWID using cross-sectional, multilevel analyses with individual-level data on PWID from the Centers for Disease Control and Prevention’s 2018 National HIV Behavioral Surveillance. The sample included 8,142 PWID aged 18-64 who reported daily opioid use from 22 U.S. metropolitan areas. Our outcome was any self-reported MOUD use in the past 12 months. Exposures were state Medicaid coverage and prior authorization requirements for methadone and buprenorphine. We interacted these exposures with PWID race/ethnicity, insurance status, and spatial access to treatment and harm reduction resources. Results: Compared with PWID in states without Medicaid methadone coverage, odds of past-year MOUD use were 73% (<i>p</i>&lt;0.05) higher among PWID in states with methadone coverage requiring prior authorization and 80% (<i>p</i>&lt;0.05) higher among PWID in states with coverage without prior authorization. Insured PWID were twice as likely to report MOUD use than uninsured PWID, with no statistically significant differences between Medicaid versus other insurance. Medicaid prior authorization requirements for buprenorphine were not significantly associated with MOUD use. Non-Hispanic Black PWID were significantly less likely to use MOUD than non-Hispanic White and Hispanic PWID. Conclusions: State Medicaid methadone coverage was strongly associated with higher odds that PWID utilized MOUD, suggesting that expanding methadone insurance coverage could improve MOUD treatment in a vulnerable population.

背景：注射毒品者（People who inject drugs, PWID）尤其容易受到阿片类药物使用障碍（Opioid Use Disorder, OUD）带来的健康损害。阿片类药物使用障碍治疗药物（Medications for OUD, MOUD）可有效降低过量用药及传染病传播风险。
目的：本研究借助美国疾病控制与预防中心（Centers for Disease Control and Prevention, CDC）2018年全国艾滋病行为监测项目中注射毒品者的个体层面数据，采用横断面多水平分析方法，探究各州美沙酮与丁丙诺啡的医疗补助计划（Medicaid）覆盖情况是否与注射毒品者过去一年的阿片类药物使用障碍治疗药物使用情况相关。本研究样本涵盖来自美国22个大都市区的8142名18至64岁、报告每日使用阿片类药物的注射毒品者。本研究的结局指标为过去12个月内自我报告使用过阿片类药物使用障碍治疗药物的情况。暴露因素为各州美沙酮与丁丙诺啡的医疗补助计划覆盖情况，以及相关的事前审批要求。我们将上述暴露因素与注射毒品者的种族/族裔、保险状态，以及治疗与减害资源的空间可及性进行交互分析。
结果：与未将美沙酮纳入医疗补助计划覆盖范围的州的注射毒品者相比，在要求事前审批的美沙酮医疗补助计划覆盖州中，注射毒品者过去一年使用阿片类药物使用障碍治疗药物的优势比高出73%（<i>p</i>&lt;0.05）；在无需事前审批的美沙酮医疗补助计划覆盖州中，该优势比则高出80%（<i>p</i>&lt;0.05）。有保险的注射毒品者报告使用阿片类药物使用障碍治疗药物的概率是无保险者的两倍，且拥有医疗补助计划与其他保险类型之间未观察到统计学显著差异。针对丁丙诺啡的医疗补助计划事前审批要求与阿片类药物使用障碍治疗药物使用情况无显著关联。非西班牙裔黑人注射毒品者使用阿片类药物使用障碍治疗药物的概率显著低于非西班牙裔白人及西班牙裔注射毒品者。
结论：各州医疗补助计划对美沙酮的覆盖情况与注射毒品者使用阿片类药物使用障碍治疗药物的更高优势比显著相关，这表明扩大美沙酮的保险覆盖范围可改善这一脆弱人群的阿片类药物使用障碍治疗服务。