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The opioid epidemic in the United States has accelerated during the COVID-19 pandemic. As of 2021, roughly a third of Americans now live in a state with a recreational cannabis law (RCL). Recent evidence indicates RCLs could be a harm reduction tool to address the opioid epidemic. Individuals may use cannabis to manage pain, as well as to relieve opioid withdrawal symptoms, though it does not directly treat opioid use disorder. It is thus unclear whether RCLs are an effective policy tool to reduce adverse opioid-related health outcomes. In this study, we examine the impact of RCLs on a key opioid-related adverse health outcome: opioid-related emergency department visit rates. We estimate event study models using nearly comprehensive emergency department data from 29 states from 2011 through 2017. We find that RCLs reduce opioid-related emergency department visit rates by roughly 7.6% for two quarters after implementation. These effects are driven by men and adults aged 25–44. These effects dissipate after six months. Our estimates indicate RCLs did not increase opioid-related emergency department visits. We conclude that, while cannabis liberalization may offer some help in curbing the opioid epidemic, it is likely not a panacea.

Establishing care with primary care and specialist clinicians is critical for Medicare beneficiaries with complex care needs. However, beneficiaries with disabilities may struggle to access ambulat...

BACKGROUND Substance use can exacerbate cancer-related morbidity and mortality in adolescent/young adult (AYA) cancer survivors and place them at increased risk for adverse health outcomes. The objective of this study was to assess substance use, misuse, and substance use disorders [SUDs], as well as receipt of treatment for SUDs, among AYA cancer survivors. METHODS The authors used data from the National Survey of Drug Use and Health (2015-2018) to identify a nationally representative sample of AYAs aged 12 to 34 years. Outcomes assessed past-year tobacco, alcohol, marijuana, and illicit drug use; misuse of prescription opioids; SUDs; and SUD treatment. Multiple logistic regression was estimated to compare outcomes between 832 AYAs who reported a cancer history (survivors) and 140,826 AYAs who did not, adjusting sequentially for sociodemographic characteristics and health status. RESULTS In regressions adjusting for sociodemographic characteristics, survivors were more likely than a noncancer comparison group of peers to use alcohol (6% relative increase; P = .048) and illicit drugs (34% relative increase; P = .012), to misuse prescription opioids (59% relative increase; P < .001), and to have a marijuana (67% relative increase; P = .011), illicit drug (77% relative increase; P < .001), or prescription opioid (67% relative increase; P = .048) SUD. When further adjusting for health status, survivors were still 41% more likely (P < .001) to misuse prescription opioids than noncancer peers. Among those with SUDs, survivors were more likely than peers to receive treatment (unadjusted, 21.5% vs 8.0%; adjusted, P < .05). CONCLUSIONS AYA survivors were as likely as or more likely than noncancer peers to report substance use problems. These findings underscore the importance of interventions to reduce substance use and improve SUD treatment among AYA cancer survivors. LAY SUMMARY The authors assessed substance use, misuse, and substance use disorders, as well as the receipt of treatment for substance use disorders, among adolescent and young adult (AYA) cancer survivors. In a nationally representative AYA sample, cancer survivors, despite their increased risk for morbidity and early mortality, were as likely as or more likely than peers without cancer to experience substance use problems. In particular, survivors had a significantly higher rate of prescription opioid misuse than peers. However, only 1 in 5 AYA survivors who experienced substance use disorders received treatment. These findings underscore the importance of interventions toward reducing substance use and improving access to treatment among AYA survivors.

The Institutions for Mental Diseases (IMD) exclusion prohibits use of federal Medicaid funds to treat enrollees ages 21–64 in psychiatric residential treatment facilities that have more than sixtee...

BACKGROUND: Rural Americans have less access to care than urban Americans. Preventable acute care use is a marker of unmet ambulatory healthcare needs, but little is known about how such utilization has differed between rural and urban areas over time. OBJECTIVE: Compare preventable emergency department (ED) visit and hospitalization rates among rural versus urban residents over the past decade. DESIGN: Observational study using a validated algorithm to compute age-sex-adjusted rates per 100,000 individuals of preventable ED visits and hospitalizations. Differences in overall, annual, and condition-specific rates for rural versus urban residents were assessed and linear regression was used to assess 10-year trends. SETTING: Nationwide Emergency Department Sample, National Inpatient Sample, and US Census, 2008–2017. PARTICIPANTS: US adults, an annual average of 241.3 million individuals. MEASUREMENTS: Preventable ED visits and hospitalizations. RESULTS: Compared to urban residents, rural residents had 45% higher rates of preventable ED visits in 2008 (3003 vs. 2070 per 100,000, adjusted difference [AD]: 933; 95% CI: 928–938) and 44% higher rates of preventable ED visits in 2017 (3911 vs. 2708 per 100,000, AD: 1202; 95% CI: 1196–1208). Rural residents had 26% higher rates of preventable hospitalizations in 2008 (2104 vs. 1666 per 100,000, AD: 439; 95% CI: 434–443) and 13% higher rates in 2017 (1634 vs. 1440 per 100,000, AD: 194; 95% CI: 190–199). Preventable ED visits increased more in absolute terms in rural versus urban residents, but the percentage increase was similar (30% vs. 31%) because rural residents started at a higher baseline. Preventable hospitalizations decreased at a faster rate (22% vs. 14%) among rural versus urban residents. LIMITATIONS: Observational study; unable to infer causality. CONCLUSIONS: Rural disparities in acute care use are narrowing for preventable hospitalizations but have persisted for all preventable acute care use, suggesting unmet demand for high-quality ambulatory care in rural areas. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s11606-020-06532-4.

BACKGROUND Since early 2016, an increasing number of states passed legislations that limit the duration and/or dosage of initial opioid prescriptions or opioids for acute pain. OBJECTIVE The objective of this study was to assess changes in the number of opioid prescriptions covered by Medicaid and received by Medicaid patients associated with state implementation of legislative limits on initial opioid prescriptions. RESEARCH DESIGN We explored the natural experiment resulting from the staggered implementation of state legislative limits. The analysis adopted a Difference-in-Differences framework and controlled for other major state policies bearing implications for prescription opioid use. The main analysis included 26 states that implemented limits from early 2016 to late 2018. A secondary analysis included all 50 states and the District of Columbia. MEASURES Population-adjusted state-quarter level counts of Schedule II and III opioid prescriptions received by Medicaid patients, based on data from the Medicaid State Drug Utilization Data and state Medicaid enrollment reports for 2013-2018. RESULTS Implementation of legislative limits on initial opioid prescriptions was associated with a 7% reduction in the number of opioid prescriptions per 100 Medicaid enrollees. Such reduction was largely attributable to a reduction in Schedule II opioid prescriptions. Secondary analysis by including all jurisdictions and sensitivity checks supported the robustness of results. CONCLUSION The recent implementation of state legislative limits on initial opioid prescriptions was associated with meaningful reductions in the volume of Schedule II opioid prescriptions received by Medicaid patients.

Self-help groups and medications (buprenorphine, methadone, and naltrexone) both play important roles in opioid addiction treatment. The relative use of these two treatment modalities has not been ...

Hospitalizations for ambulatory care–sensitive conditions indicate barriers to care outside of inpatient settings. We found that Medicaid expansions under the Affordable Care Act were associated wi...

BACKGROUND: Ambulatory care-sensitive condition (ACSC) hospitalizations are used to evaluate physicians’ performance in Medicare value-based payment programs. However, these measures may disadvantage physicians caring for vulnerable populations because they omit social, cognitive, and functional factors that may be important determinants of hospitalization. OBJECTIVE: To determine whether social, cognitive, and functional risk factors are associated with ACSC hospitalization rates and whether adjusting for them changes outpatient safety-net providers’ performance. DESIGN: Using data from the Medicare Current Beneficiary Survey, we conducted patient-level multivariable regression to estimate the association (as incidence rate ratios (IRRs)) between patient-reported social, cognitive, and functional risk factors and ACSC hospitalizations. We compared outpatient safety-net and non-safety-net providers’ performance after adjusting for clinical comorbidities alone and after additional adjustment for social, cognitive, and functional factors captured in survey data. SETTING: Safety-net and non-safety-net clinics. PARTICIPANTS: Community-dwelling Medicare beneficiaries contributing 38,616 person-years from 2006 to 2013. MEASUREMENTS: Acute and chronic ACSC hospitalizations. RESULTS: After adjusting for clinical comorbidities, Alzheimer’s/dementia (IRR 1.30, 95% CI 1.02–1.65), difficulty with 3–6 activities of daily living (ADLs) (IRR 1.43, 95% CI 1.05–1.94), difficulty with 1–2 instrumental ADLs (IADLs, IRR 1.54, 95% CI 1.26–1.90), and 3–6 IADLs (IRR 1.90, 95% CI 1.49–2.43) were associated with acute ACSC hospitalization. Low income (IRR 1.28, 95% CI 1.03–1.58), lack of educational attainment (IRR 1.33, 95% CI 1.04–1.69), being unmarried (IRR 1.18, 95% CI 1.01–1.36), difficulty with 1–2 IADLs (IRR 1.30, 95% CI 1.05–1.60), and 3–6 IADLs (IRR 1.44, 95% CI 1.16–1.80) were associated with chronic ACSC hospitalization. Adding these factors to standard Medicare risk adjustment eliminated outpatient safety-net providers’ performance gap (p

This paper uses the all-payer claims database (APCD) for Rhode Island to study three questions about the use of medication-assisted treatment (MAT) for opioid use disorder (OUD): (1) Does MAT reduce the risk of opioid overdose; (2) are there systematic differences in the uptake of MAT by observable patient-level characteristics; and (3) how successful were federal policy changes implemented in 2016 that sought to promote increased use of buprenorphine, one of three medication options within MAT? Regarding the first question, we find that MAT as practiced in Rhode Island is associated with a reduced risk of repeated opioid overdose among patients who had an initial nonfatal opioid overdose, consistent with the strong endorsement of MAT by public health officials. Concerning the second, we find that factors such as age, gender, health insurance payer, and the poverty rate in one’s residential Zip code are associated with significant differences in the chance of receiving methadone and/or buprenorphine, suggesting that certain groups may face unwarranted disparities in access to MAT. About the third question, we find that a 2016 federal rule change enabled at least some experienced Rhode Island buprenorphine prescribers to reach more patients, and a separate 2016 policy aimed at recruiting new buprenorphine prescribers was also found to be effective. However, the data also suggest that many more patients in the state could be treated with buprenorphine if prescribers took full advantage of their prescribing limits.

Using data from Truven Health MarketScan Commercial Claims and Encounters Database between 2009 and 2015, we studied the effects of medical and recreational marijuana laws on opioid prescribing in employer-sponsored health insurance. We used a differences-in-differences (DD) approach and found that the implementation of medical marijuana laws (MMLs) and recreational marijuana laws (RMLs) reduced morphine milligram equivalents per enrollee by 7% and 13%, respectively. The reduction associated with MMLs was predominately in people aged 55-64, whereas the reduction associated with RMLs was largely in people aged 35-44 and aged 45-54. Our findings suggest that both MMLs and RMLs have the potential to reduce opioid prescribing in the privately insured population, especially for the middle-aged population.

Background Medicare uses the Centers for Medicare & Medicaid Services Hierarchical Condition Category (CMS-HCC) model to predict patients' annualized Medicare costs in value-based payment programs. The CMS-HCC model does not include measures of frailty, and prior research shows that it systematically underpredicts costs for frail Medicare beneficiaries. Objective To determine whether a claims-based frailty index can improve Medicare cost prediction. Design Retrospective cohort study. Setting Medicare Current Beneficiary Survey linked to Medicare claims, 2006 to 2013. Participants 16 535 community-dwelling, fee-for-service beneficiaries representing 26 705 patient-years. Measurements Patient frailty status was classified using a validated claims-based frailty index. The association between the frailty index and annualized Medicare costs was examined, and regression methods were used to compare observed Medicare costs versus predictions based on the standard CMS-HCC model with and without the frailty index. Results Mean costs were $5724 for the 8910 patients classified as robust (46.4% of patient-years), $12 462 for the 8405 prefrail patients (41.6%), $26 239 for the 2215 mildly frail patients (9.6%), and $44 586 for the 593 patients classified as moderately to severely frail (2.5%). The frailty index addition to the CMS-HCC model predicted on average an additional $2712, $7915, and $16 449 in costs for prefrail, mildly frail, and moderately to severely frail patients, respectively, beyond the CMS-HCC model alone. On average, the model with the frailty index addition resulted in more accurate predictions of costs for patients at all 4 levels of frailty. However, observed costs remained more widely distributed than predictions from the enhanced model at all levels of frailty. Limitation The claims-based index is a proxy for frailty and is likely less accurate than an in-person examination. Conclusion The CMS-HCC model with the frailty index addition is an improvement over current Medicare cost prediction. Primary funding source None.

People living in rural areas have worse health outcomes than their urban counterparts do. Understanding what factors account for this could inform policy interventions for reducing rural-urban disparities in health. We examined a nationally representative survey of Medicare beneficiaries with one or more complex chronic conditions, which represented 61 percent of rural and 57 percent of urban Medicare beneficiaries. We found that rural residence was associated with a 40 percent higher preventable hospitalization rate and a 23 percent higher mortality rate, compared to urban residence. Having one or more specialist visits during the previous year was associated with a 15.9 percent lower preventable hospitalization rate and a 16.6 percent lower mortality rate for people with chronic conditions, after we controlled for having one or more primary care provider visits. Access to specialists accounted for 55 percent and 40 percent of the rural-urban difference in preventable hospitalizations and mortality, respectively. Medicare should consider interventions for rural beneficiaries who lack access to specialist care to reduce rural-urban disparities in health outcomes.

Comprehensive mandates for prescription drug monitoring programs (PDMPs) require state-licensed prescribers and dispensers both to register with and to use the programs in most clinical circumstances. Such mandates have the potential to improve providers' participation and reduce opioid-related adverse events. Using Medicaid prescription data and hospital utilization data across the US in the period 2011-16, we found that state implementation of comprehensive PDMP mandates was associated with a reduction in the opioid prescription rate from 161.47 to 147.07 per 1,000 enrollees per quarter, a reduction in the opioid-related inpatient stay rate from 97.50 to 93.34 per 100,000 enrollees per quarter, and a reduction in the opioid-related emergency department (ED) visit rate from 74.60 to 61.36 per 100,000 enrollees per quarter. Our estimated annual reductions of approximately 12,000 inpatient stays and 39,000 ED visits could save over $155 million in Medicaid spending, a fact that deserves policy attention when states attempt to strengthen and refine PDMPs to better tackle the opioid crisis.

OBJECTIVES Medicare value-based payment programs evaluate physicians' performance on their patients' annual Medicare costs and clinical outcomes. However, little is known about how geriatricians, who disproportionately provide care for medically complex older adults, perform on these measures. DESIGN A retrospective study using multivariable regression methods to estimate the association of geriatric risk factors with annualized Medicare costs and preventable hospitalization rates and to compare geriatricians' performance on these outcomes to other primary care physicians (PCPs) under standard Medicare risk adjustment and after adding additional adjustment for geriatric risk factors. SETTING Eight years (2006-2013) of cohort data from the Medicare Current Beneficiary Survey. PARTICIPANTS Medicare beneficiaries, aged 65 years and older, with primary care services contributing 27 027 person-years of data. MEASUREMENTS Outcomes were costs and preventable hospitalization rates; geriatric risk factors were patient frailty, long-term institutionalization, dementia, and depression. RESULTS Geriatricians were more likely to care for patients with frailty (22.8% vs 14.1%), long-term institutionalization (12.0% vs 4.7%), dementia (21.6% vs 10.2%), and depression (23.6% vs 17.4%) than other PCPs (P

Office-based visits involving a buprenorphine prescription increased significantly among primary care and specialist physicians from 2006 to 2014. The growing involvement of nonpsychiatry physicians in buprenorphine prescribing has the potential to provide better access to care for people with opioid use disorders.

Expansions of eligibility for Medicaid under the Affordable Care Act may have increased the number of Medicaid drug prescriptions. However, the expansions did not drive Medicaid spending on prescription drugs overall in 2014.

Previous research has associated declines in health care resources such as hospitals and trauma centers with communities' racial composition. However, little is known about changes in the substance use disorder treatment infrastructure in recent years and the implications for black communities. We used data for the period 2002-10 from the National Survey of Substance Abuse Treatment Services to describe changes in the supply of public and private outpatient facilities for substance use disorder treatment, and to determine whether these trends had implications for the geographical availability of these facilities in counties with high percentages of black residents. During the study period the number of publicly owned facilities declined 17.2percent, whereas the number of private for-profit facilities grew 19.1percent. At baseline, counties with very high percentages of black residents (that is, more than one standard deviation above the mean) were more likely than counties with less than the mean percentage of black residents to be served by public facilities and were thus disproportionately affected by the overall decline in public facilities. Future research should examine the effect of expanding eligibility for Medicaid on the supply of substance use disorder treatment facilities across diverse communities.

7042 Background: Adolescent and young adult (AYA) survivors of cancer are at an elevated risk of early-life morbidity and mortality due to the disease trajectory and treatment. Engagement in risk behaviors, including substance use, can exacerbate survivors’ vulnerabilities and place them at further risk for adverse health outcomes. This study provides national estimates of the prevalence of substance use and misuse, substance abuse or dependence (i.e., substance use disorders [SUD]), and receipt of treatment for SUD among AYA cancer survivors. Methods: We used 2015-2018 National Survey of Drug Use and Health data to identify a nationally-representative AYA sample (aged 12-34 years). Outcomes included past-year alcohol use, marijuana use, other illicit drug use, misuse of any prescription psychotherapeutic drugs (including opioid analgesics, stimulants, sedatives, or tranquilizers), and misuse of prescription opioid analgesics. Outcomes also assessed past-year SUD in aforementioned drug classes. Among those with SUD, we evaluated past-year receipt of SUD treatment. Multiple logistic regressions were estimated to compare outcomes between 846 AYAs who reported a cancer history and 142,870 AYAs who did not, adjusting for sociodemographic and need-related characteristics. Results: In bivariate analyses, AYAs with a cancer history were more likely than noncancer peers to use alcohol (78.6% vs. 63.4%; p< 0.001) and illicit drugs other than marijuana (11.2% vs. 7.8%; p= 0.02), misuse any prescription psychotherapeutic drugs (16.9% vs. 10.6%; p< 0.001) and prescription opioid analgesics (12.0% vs. 5.9%; p< 0.001), and have an illicit drug (other than marijuana) SUD (3.7% vs. 1.3%; p< 0.01) in the past year. In regression analyses, differences in past-year misuse of any prescription psychotherapeutic drug and prescription opioid analgesics persisted ( p= 0.02, p< 0.01, respectively). Among AYAs with SUD, those with a cancer history were more likely than noncancer peers to receive SUD treatment (21.0% vs. 8.1%; p= 0.01) in the past year; this difference persisted in regression analyses ( p= 0.03). Conclusions: AYAs with a cancer history had an elevated risk for misusing prescription psychotherapeutic medications, which was driven by misuse of prescription opioids; yet, only one in five AYAs with a cancer history and SUD received treatment. Our findings underscore the need for future interventions designed to reduce substance use and misuse and improve access to SUD treatment in AYA cancer survivors.

Importance The rate of opioid-related emergency department (ED) visits and inpatient hospitalizations has increased rapidly in recent years. Medicaid expansions have the potential to reduce overall opioid-related hospital events by improving access to outpatient treatment for opioid use disorder. Objective To examine the association between Medicaid expansions and rates of opioid-related ED visits and inpatient hospitalizations. Design, Setting, and Participants A difference-in-differences observational design was used to compare changes in opioid-related hospital events in US nonfederal, nonrehabilitation hospitals in states that implemented Medicaid expansions between the first quarter of 2005 and the last quarter of 2017 with changes in nonexpansion states. All-payer ED and hospital discharges from 45 states in the Healthcare Cost and Utilization Project FastStats were included. Exposures State implementation of Medicaid expansions between 2005 and 2017. Main Outcomes and Measures Rates of all opioid-related ED visits and inpatient hospitalizations, measured as the quarterly numbers of treat-and-release ED discharges and hospital discharges related to opioid abuse, dependence, and overdose, per 100 000 state population. Results In the 46 states and District of Columbia included in the study, 1524 observations of emergency department data and 2219 observations of opioid-related inpatient hospitalizations were analyzed. The post-2014 Medicaid expansions were associated with a 9.74% (95% CI, −18.83% to −0.65%) reduction in the rate of opioid-related inpatient hospitalizations. There appeared to be no association between the pre-2014 or post-2014 Medicaid expansions and the rate of opioid-related ED visits (post-2014 Medicaid expansions, −3.98%; 95% CI, −14.69% to 6.72%; and pre-2014 Medicaid expansions, 1.02%; 95% CI, −5.25% to 7.28%). Conclusions and Relevance Medicaid expansion appears to be associated with meaningful reductions in opioid-related hospital use, possibly attributable to improved care for opioid use disorder in other settings.

Importance Medicare is moving toward value-based payment. The Merit-Based Incentive Payment System (MIPS) program judges outpatient clinicians’ performance on a measure of annual Medicare spending. However, this measure may disadvantage outpatient clinicians who care for vulnerable populations because the algorithm omits meaningful determinants of cost. Objectives To determine whether factors not included in Medicare risk adjustment, including patient neuropsychological and functional status, as well as local area health resources and economic conditions, are associated with Medicare total annual cost of care (TACC), and evaluate whether accounting for these factors is associated with improved TACC performance by outpatient safety-net clinicians. Design, Setting, and Participants In this retrospective observational study, we used the Medicare Current Beneficiary Survey (MCBS) to examine patient-reported neuropsychological and functional status and the Area Health Resources File to obtain information on local area characteristics. Included were Medicare beneficiaries with annual physician or clinic visits to outpatient safety-net (federally qualified health centers and rural health clinics) and non–safety-net clinics, contributing 76 927 person-years of data to the MCBS from 2006 through 2013. We used patient-level multivariable regression models to estimate the association between each factor and annual Medicare spending, and compared outpatient safety-net performance under current risk adjustment and after adding additional adjustment for these factors. Main Outcomes and Measures Medicare TACC, measured as the total annual reimbursed amount per patient for Medicare Part A and Part B services, in all categories. Results Our study included 111 414 unique identifiable physicians, and the final weighted sample included 213 904 324 patient-years (unweighted, 76 927 patient-years) from 30 058 unique patients, of whom 17 478 (58.1%) were women. The mean (SD) patient age was 71.84 (12.48) years. The mean TACC was $9117. Those with higher than mean TACC included beneficiaries with depression ($14 436), dementia ($18 311), and difficulty with 3 or more activities of daily living (ADLs, $19 113) or instrumental ADLs ($17 443). After adjusting for comorbidities, depression and dementia were still associated with $2740 (95% CI, $2200-$2739) and $2922 (95% CI, $2399-$3445) higher TACC, respectively. Difficulty with 3 or more ADLs ($3121 higher; 95% CI, $2633-$3609) or instrumental ADLs ($895 higher; 95% CI, $452-$1337) was also associated with higher TACC. Adding these neuropsychological and functional factors, as well as local residence area factors, to risk adjustment calculations reduced outpatient safety-net clinicians’ underperformance on Medicare TACC relative to non-safety–net clinicians by 52% (from 0.098 to 0.047 difference in the observed to expected ratio). Conclusions and Relevance Neuropsychological and functional impairment are common in Medicare beneficiaries and are associated with increased annual Medicare spending. Failure to account for these factors may inappropriately penalize outpatient clinicians who care for these vulnerable groups, such as safety-net clinicians, for factors that are arguably beyond their control.

We estimate the effect of medical marijuana laws (MMLs) in ten states between 2004 and 2012 on adolescent and adult use of marijuana, alcohol, and other psychoactive substances. We find increases in the probability of current marijuana use, regular marijuana use and marijuana abuse/dependence among those aged 21 or above. We also find an increase in marijuana use initiation among those aged 12-20. For those aged 21 or above, MMLs further increase the frequency of binge drinking. MMLs have no discernible impact on drinking behavior for those aged 12-20, or the use of other psychoactive substances in either age group.

Prescription drug monitoring programs are promising tools to use in addressing the prescription opioid epidemic, yet prescribers' participation in these state-run programs remained low as of 2014. Statutory mandates for prescribers to register with their state's program, use it, or both are believed to be effective tools to realize the programs' full potential. Our analysis of aggregate Medicaid drug utilization data indicates that state mandates for prescriber registration or use adopted in 2011-14 were associated with a reduction of 9-10 percent in population-adjusted numbers of Schedule II opioid prescriptions received by Medicaid enrollees and amounts of Medicaid spending on these prescriptions. This effect was largely associated with mandates of registration, which were comprehensive in all adopting states, and not with mandates of use, which were largely limited in scope or strength before 2015. Our findings support the use of mandates of registration in prescription drug monitoring programs as an effective and relatively low-cost policy. Future research should further assess the value of strong mandates of use to ensure safer and more appropriate prescribing of opioids.

Buprenorphine has been proven effective in treating opioid use disorder. However, the high cost of buprenorphine and the limited prescribing capacity may restrict access to this effective medication-assisted treatment for opioid use disorder.To examine whether Medicaid expansion and physician prescribing capacity may have impacted buprenorphine utilization covered by Medicaid.We used a quasi experimental difference-in-differences design to compare the pre-post changes in Medicaid-covered buprenorphine prescriptions and buprenorphine spending between the 26 states that implemented Medicaid expansions under the Affordable Care Act in 2014 and those that did not.All Medicaid enrollees in the expansion states and the nonexpansion and late-expansion states.Quarterly Medicaid prescriptions for buprenorphine and spending on buprenorphine from the Centers for Medicare and Medicaid Services Medicaid Drug Utilization files 2011 to 2014.State implementation of Medicaid expansions in 2014 was associated with a 70% increase (P0.05) in Medicaid-covered buprenorphine prescriptions and a 50% increase (P0.05) in buprenorphine spending. Physician prescribing capacity was also associated with increased buprenorphine utilization.Medicaid expansion has the potential to reduce the financial barriers to buprenorphine utilization and improve access to medication-assisted treatment of opioid use disorder. Active physician participation in the provision of buprenorphine is needed for ensuring that Medicaid expansion achieves its full potential in improving treatment access.

The study examined the association between private health insurance and the receipt of specialty substance use disorder treatment.Weighted logistic regressions were estimated to examine the association between health insurance and the receipt of any specialty substance use disorder treatment in national samples of nonelderly adults with alcohol abuse or dependence (N=22,778), alcohol dependence (N=10,104), drug abuse or dependence (N=9,427), and drug dependence (N=6,736). Receipt of any specialty substance abuse treatment was compared among the uninsured and privately insured persons who reported known coverage, no coverage, or unknown coverage for alcohol and drug abuse treatment. Regressions adjusted for sociodemographic characteristics, treatment need, criminal justice involvement, and year of survey.Compared with being uninsured, private insurance was associated with greater use of any specialty substance use disorder treatment only among those with alcohol dependence with known coverage for alcohol treatment (p.05).Private insurance was associated with increased use of specialty treatment among persons with severe alcohol use disorders who knew they had coverage for alcohol abuse treatment.

This study uses National Ambulatory Medical Care Survey data to assess the percentage of psychiatrists who have accepted Medicaid-insured patients before and after Medicaid expansion.

Background and Objectives Daily smoking rates are decreasing while intermittent or nondaily smoking rates are increasing. Little is known about the association of depression, alcohol abuse and dependence, and illicit drug abuse and dependence with different patterns of smoking, particularly nondaily smoking. Thus, we examined these relationships among current smokers versus nonsmokers and among those who smoke daily versus less frequently. Methods We conducted a secondary analysis of 37,897 adults who participated in the 2008 National Survey on Drug Use and Health. We developed logistic regression models examining predictors of (i) current smoking and (ii) number of days smoking per month (1–10 days, 11–29 days, and ≥30 days) among current smokers, focusing on past-year major depression, alcohol abuse and dependence, and illicit drug abuse and dependence. Results Compared to nonsmokers, current smokers more frequently reported a major depressive episode (p

Key Points Question Is the availability of buprenorphine-waivered physicians associated with buprenorphine treatment use and prescription opioid use among Medicaid enrollees? Findings In this economic evaluation study using the all-capture Medicaid prescription data between 2011 and 2016, a 10% increase in the number of buprenorphine-waivered physicians was associated with an approximately 10% increase in the Medicaid-covered buprenorphine prescribing rate and a 1.2% reduction in the opioid prescribing rate. Meaning Expanding capacity for buprenorphine treatment holds the potential to improve access to opioid addiction treatment, which may further reduce prescription opioid use and slow the ongoing opioid epidemic in the United States., This economic evaluation study uses Medicaid prescription data from 2011 to 2016 to analyze the association of number of physicians permitted to prescribe buprenorphine for opioid addiction treatment with use of buprenorphine treatment and prescription opioid use among Medicaid enrollees., Importance Expanding treatment for opioid addiction has been recognized as an essential component of a comprehensive national response to the opioid epidemic. The Drug Addiction Treatment Act and its amendments attempted to improve access to treatment by involving office-based physicians in the provision of buprenorphine treatment. Objectives To estimate the association of availability of buprenorphine-waivered physicians with buprenorphine treatment use and, secondarily, with prescription opioid use among Medicaid enrollees. Design, Setting, and Participants This economic evaluation study used state-level panel data analysis to estimate the association between the number of buprenorphine-waivered physicians and the Medicaid-covered buprenorphine prescribing rate and opioid prescribing rate among Medicaid fee-for-service and managed care enrollees throughout the United States between January 1, 2011, and December 31, 2016. Main Outcomes and Measures Buprenorphine prescribing rate and opioid prescribing rate, measured as the number of buprenorphine prescriptions and opioid prescriptions covered by Medicaid on a quarterly basis per 1000 enrollees. Results The sample included 1059 quarterly observations. Two additional 100-patient-waivered physicians per 1 000 000 residents (approximately a 10% increase) were associated with an increase in the quarterly number of Medicaid-covered buprenorphine prescriptions of 0.46 (95% CI, 0.24-0.67) per 1000 enrollees and a reduction in the quarterly number of opioid prescriptions of 1.01 (95% CI, −1.87 to −0.15) per 1000 enrollees. Furthermore, 5 additional 30-patient-waivered physicians per 1 000 000 residents (approximately a 10% increase) were associated with an increase in the quarterly number of Medicaid-covered buprenorphine prescriptions of 0.37 (95% CI, 0.22-0.52) per 1000 enrollees and a reduction in the quarterly number of opioid prescriptions of 0.96 (95% CI, −1.85 to −0.07) per 1000 enrollees. A 10% increase in the number of buprenorphine-waivered physicians was associated with an approximately 10% increase in the Medicaid-covered buprenorphine prescribing rate and a 1.2% reduction in the opioid prescribing rate. Conclusions and Relevance Expanding capacity for buprenorphine treatment holds the potential to improve access to opioid addiction treatment, which may further reduce prescription opioid use and slow the ongoing opioid epidemic in the United States.

Importance Overprescribing of opioids is considered a major driving force behind the opioid epidemic in the United States. Marijuana is one of the potential nonopioid alternatives that can relieve pain at a relatively lower risk of addiction and virtually no risk of overdose. Marijuana liberalization, including medical and adult-use marijuana laws, has made marijuana available to more Americans. Objective To examine the association of state implementation of medical and adult-use marijuana laws with opioid prescribing rates and spending among Medicaid enrollees. Design, Setting, and Participants This cross-sectional study used a quasi-experimental difference-in-differences design comparing opioid prescribing trends between states that started to implement medical and adult-use marijuana laws between 2011 and 2016 and the remaining states. This population-based study across the United States included all Medicaid fee-for-service and managed care enrollees, a high-risk population for chronic pain, opioid use disorder, and opioid overdose. Exposures State implementation of medical and adult-use marijuana laws from 2011 to 2016. Main Outcomes and Measures Opioid prescribing rate, measured as the number of opioid prescriptions covered by Medicaid on a quarterly, per-1000-Medicaid-enrollee basis. Results State implementation of medical marijuana laws was associated with a 5.88% lower rate of opioid prescribing (95% CI, −11.55% to approximately −0.21%). Moreover, the implementation of adult-use marijuana laws, which all occurred in states with existing medical marijuana laws, was associated with a 6.38% lower rate of opioid prescribing (95% CI, −12.20% to approximately −0.56%). Conclusions and Relevance The potential of marijuana liberalization to reduce the use and consequences of prescription opioids among Medicaid enrollees deserves consideration during the policy discussions about marijuana reform and the opioid epidemic.

Objective To examine the effect of Medicaid expansions on health insurance coverage and access to care among low-income adults with behavioral health conditions. Data Sources/Study Setting Nine years (2004–2012) of individual-level cross-sectional data from a restricted-access version of National Survey on Drug Use and Health. Study Design A quasi-experimental difference-in-differences design comparing outcomes among residents in 14 states that implemented Medicaid expansions for low-income adults under the Section §1115 waiver with those residing in the rest of the country. Data Collection/Extraction Methods The analytic sample includes low-income adult respondents with household incomes below 200 percent of the federal poverty level who have a behavioral health condition: approximately 28,400 low-income adults have past-year serious psychological distress and 24,900 low-income adults have a past-year substance use disorder (SUD). Principal Findings Among low-income adults with behavioral health conditions, Medicaid expansions were associated with a reduction in the rate of uninsurance (p

21 states and the District of Columbia currently have laws that permit marijuana use for medical purposes, often termed medical marijuana laws (MMLs). We tested the effects of MMLs adopted in seven states between 2004 and 2011 on adolescent and adult marijuana, alcohol, and hard drug use. We employed a restricted-access version of the National Survey on Drug Use and Health (NSDUH) micro-level data with geographic identifiers. For those 21 and older, we found that MMLs led to a relative increase in the probability of marijuana use of 16 percent, an increase in marijuana use frequency of 12-17 percent, and an increase in the probability of marijuana abuse/dependence of 15-27 percent. For those 12-20 years old, we found a relative increase in marijuana use initiation of 5-6 percent. Among those aged 21 or above, MMLs increased the frequency of binge drinking by 6-9 percent, but MMLs did not affect drinking behavior among those 12-20 years old. MMLs had no discernible impact on hard drug use in either age group. Taken together, MML implementation increases marijuana use mainly among those over 21, where there is also a spillover effect of increased binge drinking, but there is no evidence of spillovers to other substance use.Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.

Importance Although substance use disorders (SUDs) are prevalent and associated with adverse consequences, treatment rates remain low. Unlike physical and mental health problems, treatment for SUDs is predominantly provided in a separate specialty sector and more heavily financed by public sources. Medicaid expansion under the Patient Protection and Affordable Care Act has the potential to increase access to treatment for SUDs but only if an infrastructure exists to serve new enrollees. Objective To examine the availability of outpatient SUD treatment facilities that accept Medicaid across US counties and whether counties with a higher percentage of racial/ethnic minorities are more likely to have gaps in this infrastructure. Design, Setting, and Participants We used data from the 2009 National Survey of Substance Abuse Treatment Services public use file and the 2011-2012 Area Resource file to examine sociodemographic factors associated with county-level access to SUD treatment facilities that serve Medicaid enrollees. Counties in all 50 states were included. We estimated a probit model with state indicators to adjust for state-level heterogeneity in demographics, politics, and policies. Independent variables assessed county racial/ethnic composition (ie, percentage black and percentage Hispanic), percentage living in poverty, percentage living in a rural area, percentage insured with Medicaid, percentage uninsured, and total population. Main Outcomes and Measures Dichotomous indicator for counties with at least 1 outpatient SUD treatment facility that accepts Medicaid. Results Approximately 60% of US counties have at least 1 outpatient SUD facility that accepts Medicaid, although this rate is lower in many Southern and Midwestern states than in other areas of the country. Counties with a higher percentage of black (marginal effect [ME], −3.1; 95% CI, −5.2% to −0.9%), rural (−9.2%; −11.1% to −7.4%), and/or uninsured (−9.5%; −13.0% to −5.9%) residents are less likely to have one of these facilities. Conclusions and Relevance The potential for increasing access to SUD treatment via Medicaid expansion may be tempered by the local availability of facilities to provide care, particularly for counties with a high percentage of black and/or uninsured residents and for rural counties. Although states that opt in to the expansion will secure additional federal funds for the SUD treatment system, additional policies may need to be implemented to ensure that adequate geographic access exists across local communities to serve new enrollees.

In the wake of the Connecticut school shooting, a public dialogue emerged about the accessibility of mental health (MH) care in the United States. Policy makers have called for a more critical examination of the MH treatment system, and advocates are rallying around federal legislation that would strengthen community-based MH services -- especially for children and adolescents.1 Although the implementation of recent federal policies (i.e., Mental Health Parity and Addiction Equity Act and the Affordable Care Act) will expand insurance coverage for MH disorders among many U.S. children, these expansions will not improve access if communities lack a sufficient infrastructure to serve those in need of care. Mental health facilities that provide outpatient specialty services for youth comprise a critical element of the treatment infrastructure for those with MH problems, especially for youth who are living in poverty, uninsured, and/or publicly insured. To inform the current dialogue, we present data from the 2008 National Survey of Mental Health Treatment Facilities (NSMHTF) and examine the extent to which gaps exist in this infrastructure. The NSMHTF is a national facility-level survey of entities that provide specialty MH services such as psychiatric hospitals, residential treatment centers, freestanding outpatient clinics/partial care facilities, and multiservice MH facilities.2 A response rate of 74% was achieved from the 13,068 facilities that were surveyed. Results from supplemental analyses restricting the sample of counties to those with complete facility-level data were similar to those presented below. Using these data, we examine the percentage of U.S. counties that have at least one outpatient MH facility offering: (1) services for children and adolescents; and (2) any specially designed programs to treat youth with the most severe MH problems (i.e., severe emotional disturbance). Only 63% of U.S. counties have a MH facility that provides outpatient treatment for children/adolescents, and fewer than half of U.S. counties have a MH facility with any special programs for youth with severe emotional disturbance. [Figure] These gaps in infrastructure are especially pronounced in rural communities; fewer than half of rural counties have a MH facility that provides outpatient treatment for children/adolescents and only one-third have an outpatient facility with special programs for youth with severe emotional disturbance. Figure 1 Percentage of U.S. Counties with Outpatient Facilities Providing MH Specialty Services to Youth These data likely represent conservative estimates of the extent of the problem because state funding for MH services has been reduced since 2008. Between 2009 and 2012, states eliminated more than $1.6 billion in general funds from their state MH agency budgets.3 These budgetary reductions have resulted in decreased services for children and adults with serious mental illness and closures of community MH programs, especially in states that have consistently reduced their budgets since 2009.3 These gaps in the MH facility infrastructure are part of a larger problem of geographic access to MH services for those with limited financial resources. Although some youth may seek treatment from MH clinicians in solo or small group practices, the accessibility of these services is limited for youth who are either uninsured or publically insured. For example, only 3% to 8% of patient caseloads for psychiatrists in solo or group practice, respectively, are covered by Medicaid.4 While services delivered through school-based MH programs could help address geographic and financial barriers to the MH care system, many school systems have also faced substantial budgetary reductions since the economic downturn;5 these budgetary reductions have affected the availability of school-based MH programs. Even if schools can offer MH services, they may lack the resources and personnel necessary to provide comprehensive services for youth with severe emotional disturbance for whom medication, intensive psychotherapy services, or both may be indicated. One option for addressing these gaps in geographic accessibility for low-income youth is to expand the capacity of primary care safety-net facilities such as federally qualified health centers (FQHCs) or rural health clinics (RHC) to provide youth MH services. Nearly three-fourths of counties have at least one of these clinics,6 most of which offer some type of MH services.7 Rural communities, in particular, may have the capacity to support these primary care facilities even if they do not have the capacity to support a specialty MH treatment facility. However, these primary care safety-net facilities typically care for patients with less severe MH disorders,7 suggesting that they may require additional resources to be able to provide comprehensive services to youth with the most severe MH problems. Telepsychiatry programs are one promising approach for providing specialty expertise for the treatment of complex patients in these primary care facilities. In addition to expanding the number of facilities that can provide MH services for children, efforts to improve access will also need to address the national shortage of MH providers – especially those who specialize in providing services to youth. The Health Resources and Services Administration has designated four-fifths of U.S. counties as partial or whole Mental Health Professional Shortage Areas.6 Policy makers should work to ensure there is an adequate workforce to serve this population through mechanisms such as supplementary training grants and loan forgiveness programs. The delivery system reforms considered above are necessary but not sufficient to ensure access to needed MH services for youth. Research has shown that knowledge, attitudes, beliefs, and stigma about MH problems and treatment greatly affect whether, when, and how youth access the treatment system.8 Many youth do not receive treatment for MH problems because they and/or their parents do not perceive a need for services, do not believe treatment will be helpful, or they are worried about what others will think if they receive treatment. Educational outreach efforts about MH problems and available treatment options are key tools for overcoming these gaps in knowledge and attitudes. School health curricula should be expanded to better address mental health problems and treatments. Although the implementation of recent federal policies expands insurance coverage for MH problems among many youth, the data presented above highlight large gaps in geographic access to a critical element of the MH infrastructure for youth with severe MH problems. These structural problems in access are compounded by ongoing shortages of MH providers, lack of knowledge about MH problems and available treatments, and stigma. The national dialogue that emerged from the Connecticut school shooting has provided an opportunity to address these challenges and achieve meaningful improvements in our children’s MH system. Improving access to MH services for this vulnerable population will require an ongoing national dialogue, sustained commitment from policy makers, and a comprehensive approach that addresses the complex array of barriers to treatment that exist in the current system.

Objective This study examined differences in treatment rates for substance use disorders (SUD) among adolescents of white, black, Hispanic, Asian, Native American/Alaska Native, and Native Hawaiian/Pacific Islander race/ethnicity. Method Eight years of cross-sectional data (2001–2008) were pooled from the National Survey on Drug Use and Health to derive a nationally representative sample of 144,197 adolescents (aged 12–17 years); 12,634 adolescents were identified with SUD in the previous year. Weighted probit regressions were estimated with year fixed effects to examine whether racial/ethnic minorities had lower rates of treatment in any setting, in medical settings (i.e., hospital, rehabilitation facility, mental health clinic, and/or doctor's office), and in self-help programs. Initial models controlled for demographics and health status. Additional models further adjusted for family income and health insurance status. Results Among adolescents with SUD, unadjusted treatment rates ranged from 8.4% among blacks to 23.5% among Native Hawaiian/Pacific Islanders. After adjusting for demographics and health status, blacks (RD = −3.9%, 95% CI=−6.4%, −1.3%) and Hispanics (RD = −2.3%, 95% CI=−4.1%, −0.4%) were significantly less likely to receive SUD treatment than whites (adjusted treatment rate 10.7%). These differences were exacerbated after adjusting for family income and insurance status. Lower treatment rates for black and Hispanic adolescents persisted when examining SUD treatment rates in medical settings and self-help programs. Treatment rates for other racial/ethnic groups did not generally differ from whites. Conclusion Results highlight exceptionally low treatment rates for SUD among all adolescents, with blacks and Hispanics experiencing the lowest treatment rates across all racial/ethnic groups.

Importance The passage of the 2008 Mental Health Parity and Addiction Equity Act and the 2010 Affordable Care Act incorporated parity for substance use disorder (SUD) treatment into federal legislation. However, prior research provides us with scant evidence as to whether federal parity legislation will hold the potential for improving access to SUD treatment. Objective To examine the effect of state-level SUD parity laws on state-aggregate SUD treatment rates and to shed light on the impact of the recent federal SUD parity legislation. Design, Setting, and Participants We conducted a quasi-experimental study using a 2-way (state and year) fixed-effect method. We included all known specialty SUD treatment facilities in the United States and examined treatment rates from October 1, 2000, through March 31, 2008. Our main source of data was the National Survey of Substance Abuse Treatment Services, which provides facility-level information on specialty SUD treatment. Interventions State-level SUD parity laws during the study period. Main Outcomes and Measures State-aggregate SUD treatment rates in (1) all specialty SUD treatment facilities and (2) specialty SUD treatment facilities accepting private insurance. Results The implementation of any SUD parity law increased the treatment rate by 9% ( P P = .02) in facilities accepting private insurance. Full parity and parity only if SUD coverage is offered increased the SUD treatment rate by 13% ( P = .02) and 8% ( P = .04), respectively, in all facilities and by 21% ( P = .03) and 10% ( P = .04), respectively, in facilities accepting private insurance. Conclusions and Relevance We found a positive effect of the implementation of state SUD parity legislation on access to specialty SUD treatment. Furthermore, the positive association is more pronounced in states with more comprehensive parity laws. Our findings suggest that federal parity legislation holds the potential to improve access to SUD treatment.

Importance Medicaid is the largest payer of mental health (MH) care in the United States, and this role will increase among states that opt into the Medicaid expansion. However, owing to the dearth of MH care providers who accept Medicaid, expanded coverage may not increase access to services. Facilities that provide specialty outpatient MH services and accept Medicaid compose the backbone of the community-based treatment infrastructure for Medicaid enrollees. For states that opt into the expansion, it is important to understand which local communities may face the greatest barriers to access these facilities. Objective To examine the availability of outpatient MH facilities that accept Medicaid across US counties and whether specific types of communities are more likely to lack this infrastructure. Design, Setting, and Participants Data from the 2008 National Survey of Mental Health Treatment Facilities and Area Resource File were merged. A generalized ordered logistic regression with state fixed effects was estimated to examine determinants of accessibility of these facilities. Covariates included the percentages of residents who are black, Hispanic, living in poverty, and living in a rural area. Main Outcomes and Measures An ordered variable assessed whether a county had no access to outpatient MH facilities that accept Medicaid, intermediate access to these facilities (ie, ≥1 facility, but not top quintile of facility to Medicaid enrollee per capita ratio), or high access (ie, top quintile of facility to Medicaid enrollee per capita ratio). Results More than one-third of counties do not have any outpatient MH facilities that accept Medicaid. Communities with a larger percentage of residents who are black (marginal effect [ME] = 3.9%; 95% CI, 1.2%-6.6%), Hispanic (ME = 4.8%; 95% CI, 2.3%-7.4%), or living in a rural area (ME = 27.9%; 95% CI, 25.3%-30.4%) are more likely to lack these facilities. Conclusions and Relevance Many communities may face constraints on the MH safety-net system as Medicaid is expanded, especially rural communities and communities with a large percentage of black or Hispanic residents.