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Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
Hello, and welcome to a health podocy. I'm your host, Rob Lott. Friends, as you may know, at health affairs, this September is all about our brand new theme issue dedicated to understanding the opioid crisis, a relatively nebulous but unquestionably dire policy challenge. Now, one of the particularly distinctive characteristics of this crisis is just how long it's been going on. We are definitely in the third decade of the struggle now, and although that's been just incredibly frustrating and sad, it also means that there have been a number of phases or waves of this crisis, an evolution that we can study.
Rob Lott:And it also means that the relatively slow gears of public policy reform have nevertheless had the opportunity to turn and turn and turn in ways that maybe, just maybe might be able to respond to the crisis by improving the tools at our disposal and removing the obstacles that have prevented their optimal use. Well, here we are some twenty five plus years since the crisis began, and the question remains, did our policy responses to the opioid crisis actually achieve their goals? That is, in a way, the subject of today's health odyssey. I'm here with Doctor. Steven Crystal, distinguished research professor and director of the Center for Health Services Research at Rutgers University.
Rob Lott:Together with coauthors, he has a new research article published in this month's issue of Health Affairs. The paper's title is also its main finding. States with substantial increases in buprenorphine uptake did so with increased Medicaid prescribing from 2018 to 2024. I cannot wait to learn more about this work and what it means for policymakers today. Doctor.
Rob Lott:Steven Crystal, welcome to A Health Odyssey.
Stephen Crystal:It's a pleasure.
Rob Lott:All right, let's start with some background. Buprenorphine is sort of the gold standard in terms of medication assisted treatment for people with opioid use disorder. Yet of the population that might benefit from buprenorphine, it's a pretty small proportion that actually use it. Can you take us back to 2017 before your study period begins and describe some of the barriers that were preventing people from getting treatment if they needed it?
Stephen Crystal:Yes. That was the year actually, that was the year that was, that was the year that when the opioid overdose crisis became sufficiently on the radar to justify a presidential declaration of public health emergency. This is a period when the overdose rates were increasing very rapidly. In fact, they increased about forty percent in the two years of 2016 and 2017. So everybody was feeling really very worried about that trend.
Stephen Crystal:As you mentioned in your intro, this crisis had been sort of a slow motion crisis for a long time, starting in the 2000s really at scale and even earlier. But the policy response was really, I've come to think of it as frozen in time, frozen in time from a very different era of the 1980s and 1990s when these medications for opioid use disorder were really pretty much considered experimental and we sort of have to control them very carefully and exercise a very high level of surveillance both on the patients and on the providers. So this was one of the great ironies of policy at that time is that you could write as a typical physician with a DEA license, you could write all the opioid analgesics prescriptions that you wanted, and that was assumed to be, you were assumed to be competent to manage that from your general training, but somehow if you wanted to prescribe a safer partial opioid blocker, buprenorphine, that had really much lower potential for problems like respiratory depression, you were somehow considered to be, you could only do this with a special license from the federal government, a special X waiver, special training requirements, and a lot of oversight by the DEA, which itself was a real concern to many prescribers, many primary care doctors who might consider doing this.
Stephen Crystal:Nobody in primary care wants to make themselves a target for DEA audit. That combined with the stigma towards people with opioid use disorder was really keeping treatment in that very limited framework. The same thing was happening in methadone where when it was in Methadone was initially introduced, we wanna make sure people have to come in person, they have to be supervised every single day, and for not very good reasons, that model has more or less persisted, the highly surveilled model, if you like. So that was the uptake prescribing was almost always from physicians and the uptake was very poor. So so a large part of the problem was simply unavailability of providers in in many areas of the country, in many neighborhoods, and those and and and minority neighborhoods were particularly underserved in a system where treatment pretty much had to be in person and from physicians.
Stephen Crystal:So that all changed quite a lot from 2017 to 2024, the period that we looked at.
Rob Lott:So tell us a little bit about that. Was that change a sort of realization in the sort of policy and treatment community that this isn't working, we've gotta change the rules. What sort of inspired these policy shifts and then what what exactly were the shifts that took place?
Stephen Crystal:This is sort of like somebody once said it takes seventeen years for a new evidence based practice to sort of become the standard. So in a way, it was reflective of the very inertia bound system that we have and the very slow pace of change. And you multiply that by the stigmatized nature of this population, the fact that many providers would prefer not to be for that not to be the population in their waiting room, and the sort of conservatism of policy. And so I think it represented a belated response to the evidence that we have, and the evidence has really been accumulating for a long time, since the 1990s of the effectiveness of buprenorphine. When you think about medical treatments that we have available, it's hard to think of a lot of other treatments that actually have as good a response, we have evidence that overdose deaths can be reduced anywhere from one third to two thirds for people when they have day supply of buprenorphine, and that evidence has been accumulating.
Stephen Crystal:And we were starting to accumulate health services research evidence about the inadequate uptake of MOUD. So one of the things that that led to, and this was actually sort of, a sense, a consumer driven initiative to get rid of the X waiver and some of the people who were influential in that movement were people who had lost family members.
Rob Lott:So just sorry to interrupt, to clarify, the X waiver was basically the limit on who was allowed to prescribe buprenorphine. Is that accurate?
Stephen Crystal:X waiver was a special endorsement to your DEA license with an X literally at the end of your DEA number that said that you had gone through the training, you had been certified and registered with the government as a buprenorphine provider. And but the sequence of events was that there were various liberalizations of that requirement. One of the earliest things that started happening in that period was opening up buprenorphine prescribing to nurse practitioners and physician assistants. And that was a very substantial change because now the advanced practitioners actually prescribed more buprenorphine than primary care physicians. They've become the largest group.
Stephen Crystal:So that represents an opening up of the provider shortage that was one of the big limiting factors in the earlier period. So that was sort of happening in 2017 through 2019. In 2020, the second big change that took place was the opening up to telehealth strategies for buprenorphine in with the onset of the pandemic, which has continued. And there was a lot of advocacy to continue those emergency that turned out to be an experiment, a pandemic era experiment that taught us a lot and taught us that you didn't need to be entirely in person. So that has also represented an opening up of provider supply.
Stephen Crystal:And then the third big change that happened in 2022, there were a couple of modifications of that ex waiver requirement earlier, but then in 2022, the MAT Act was passed eliminating that requirement. So the hope was among people concerned with opioid use disorder that those things in combination would really lead to a dramatic reduction in this gap and the gap between people with opioid use disorder and even people with severe problems like overdoses anywhere from twenty to thirty percent or so were being treated and the rest were not with MOUD. And the hope was, and the expectation was among many people was that it would lead to very considerable increases in buprenorphine uptake. And the bottom line from a national point of view was that that didn't happen, And that was when you look at the national figures. So that was very disappointing to many of us.
Stephen Crystal:So we decided to dig in a little bit more closely to how that played out on a state to state level.
Rob Lott:Got it. Okay. So going into the study, you had a sense that there was a disappointment there when you looked at national numbers. You wanted to see what was sort of driving those lackluster results, and so you looked at a a state by state basis. Can you tell us a little bit about sort of the outcomes you studied, how you measured them, and how you approach this question more generally?
Stephen Crystal:One of the things that is particularly concerning in this area is our lack of underlying data on need, and it turns out that the best data that we have on a population basis really don't tell us very much about the true underlying rates of opioid use disorder across states. That's for a variety of reasons that I'm not going to take too much time to get into, but the data that we have are not very good. So after looking, wanting to get some sense of variations in use relative to need, basically, you look at data, the data that we do have from sources like the National Study of Drug Use and Health, you see about a two to one ratio across states of identifiable opioid use disorder, as opposed to more like a 30 to one variation in treatment. But what we chose to do for this paper, because of the limitations of those data, is focus on variations in buprenorphine use per thousand state population and per fatal overdose as another measure of relative need. And by all of those measures, you see persisting enormous variation across states, both in the rate of treatment and in the trends in treatment.
Stephen Crystal:So when you look at a flat national trend, it's made up of improving states and retrogressing states. And each state has a very complex story of its own, but what it tells us is that in our system, when it comes to Medicaid, as they say, when you've seen one Medicaid program, you've seen one Medicaid program. So it's enormously variable, and it became increasingly clear how much Medicaid was the driver of overall prescribing rates across the country. And the changes in federal policy that we talked about, you could sort of see as enabling or necessary but not sufficient for broader uptake. And the the the the way those flexibilities played out depended enormously on state level factors.
Stephen Crystal:And and there's a whole range of state level factors ranging from from supply of providers to to prior authorization requirements and programs like Medicaid to limitations on despite this national increase in nurse practitioner prescribing, there's a lot of variation in states and what they're allowed to do. State rules about telehealth across state lines, many, many other barriers that are really the result of state policy. So we saw that in fact, proof of concept, there were states that responded very robustly during that period of time with improving treatment, but others that actually retrogressed.
Rob Lott:Well, I wanna hear a little more about those states and some of that variation, but first let's take a quick break. And we're back. I'm here with doctor Steven Crystal talking about, variation in, uptake of buprenorphine prescribing from state to state from between 2018 and 2024. Just a moment ago, said, you know, even while some states were sort of making the most of these policy changes, there were other states that didn't see the same success. What do you think was behind that variation?
Stephen Crystal:So one of the things that came out very strongly in this was the role of a Medicaid expansion status, which makes intuitive sense when we think about the fact that people with opioid use disorder are disproportionately single adults. They're in this expansion population, so the states that have expanded Medicaid to low income single adults have experienced, have brought a lot more people with opioid use disorder into the program, and that has had the effect of creating a greater focus on addressing opioid use disorder within the Medicaid program. We saw this very close-up in New Jersey, which made a lot of initiatives within its Medicaid program going beyond just the financial eligibility. They improved reimbursement for providers. They eliminated the prior authorization, and we saw from those changes that they improved uptake considerably.
Stephen Crystal:The original goal of that initiative was to make MOUD truly a primary care, make it part of primary care. When you have a patient, your patient may have diabetes and opioid use disorder and a couple of other medical problems, and the opioid use disorder can be managed in primary care along with those other conditions, and that gives us a broader range of providers available, and that was part of the thinking behind eliminating the X waiver. That turned out to be a little bit optimistic in that primary care providers are oftentimes, even with the X waiver eliminated, not that eager or ready to start embracing MRUD, but a lot of other providers emerged, particularly during the pandemic here, many hybrid providers and telehealth providers. So the combination of all those things worked very well in some states, but for example, in the states that never expanded, we actually saw over the entire twenty eighteen to twenty twenty four period, a slight reduction in population level and Medicaid, and the larger reduction in Medicaid paid prescribing. So one of the things that was most interesting was the rather robust overall improvement that you tended to see in the late expanding states because we had that wave of states that expanded in 2014 or soon thereafter.
Stephen Crystal:And then you had another wave of states, often sort of by popular demand through referenda or other means that expanded between 2018 and 2021. And those states on average saw quite a bit of improvement. And the interesting thing was that when states improved their Medicaid buprenorphine prescribing, they also improved their all payer prescribing. Now that might seem intuitive, but it was actually a controversial issue in health services research because some of the earlier literature found from the early expansions that Medicaid expansion didn't lead, it led to more Medicaid prescribing, but it didn't lead to much more all payer prescribing, so there was this idea of substitution, that prescriptions would be picked up from other sources. Well, there's a few problems with that.
Stephen Crystal:One of them is that when it shifted to other sources, one of those sources was self pay, and self pay is always going to be a barrier to people staying on medication, low income people. But the interesting thing, and we're pursuing this further with more elaborate statistical analysis, is that the later expansions occurred in a different environment where there were fewer barriers to providers entering the field, fewer barriers to, you had access to telehealth. So in that context, when expansion took place, you saw increases in the population level or payer prescribing that were not simply substituting for for other other other payers, but real population level level improvement. So that's kind of depressing story that you get from lack of national average improvement is actually a much more complicated story, and it tells you that that a lot of improvement is possible at the state level, but it requires state level action.
Rob Lott:Okay. Well, that that's a great sort of segue. I'm wondering if you can can I guess that what I I'm curious. Can you think of another policy or intervention where the rates and trends have varied so dramatically from state to state? And I guess in that context, what might those scenarios have in common?
Rob Lott:What can we learn?
Stephen Crystal:It's interesting because in general, most medical treatments, the standard of care becomes a little bit more consistent across states. So what's different about opioid use disorder is first and foremost, the amount of stigma that's associated at the patient level, at the provider level, and there's still this lingering feeling that extends to some patients and extends to many providers that a certain amount of discomfort with medications for opioid use disorder because of the perception that you're substituting one drug for another. And this has been very prevalent in the 12 Step movement, for example, and it's resulted in MOUD not being embraced as much, for example, in residential care where people go to a so called rehab and they come out, now they're at more risk than ever because they've now lost their physical tolerance, they're at greater risk for an overdose, and they have not been started on MOUD. So the fact that OUD is still seen oftentimes as much of a moral problem as a medical problem. It has really meant that the uptake has been highly varied across states.
Stephen Crystal:And if you were to think of other interventions that have been so varied, the other one that comes to mind is really another opioid use disorder related treatment, which is harm reduction. And harm reduction programs may actually have had more to do with the recent reductions in fatal overdoses than we've seen than treatment, since the treatment hasn't expanded that much.
Rob Lott:And when you say harm reduction, you're talking about like naloxone or syringe services. Syringe services,
Stephen Crystal:safe injection sites. Well, thought is that that's still another area where enormous amount of work needs to be done. And one of the things that I think we've left this study left us with is a tremendous amount of concern about whether we were going to be able to sustain this reduction in fatal overdoses. Some aspects of it are rather mysterious. Some of it has to do with depletion of susceptibles, if you wanna use a technical term, which means that some of the some of the people with opioid use disorder have already experienced their fatal overdoses.
Stephen Crystal:Some of it does have to do, we think a lot of it has to do with naloxone distribution, but all of this is very susceptible to retrogression, and we've seen retrogression already in some of the states during the unwinding. Because one of the other things that happened during the pandemic was the suspension of Medicaid disenrollments. And now that that's ended in 2023 and 2024, we saw retrogression at the population level and the Medicaid level in buprenorphine in a number of states. So when you think about the potential impact of the new Medicaid changes, the work requirements, which theoretically there's exemption for people with opioid use disorder, but how do they apply for and get that exemption? How do people deal with all of this reporting for work requirements?
Stephen Crystal:And those changes were intended to reduce Medicaid roles, and they will. And we think there's tremendous potential for retrogression on opioid use disorder treatment in in as as as states come under these these new financial pressures on their Medicaid programs.
Rob Lott:Okay. Wow. Well, that's probably a great place for us to wrap up. A stark picture of the future, but, I'm glad that we have a better sense of the variation taking place, and, perhaps that information can be used to inform policy decisions going forward. Doctor Steven Crystal, thanks so much for taking the time to chat with us.
Rob Lott:I had a great time.
Stephen Crystal:Thank you. It was a pleasure.
Rob Lott:To our listeners, thanks so much for tuning in. If you enjoyed this episode, please leave a review, recommend it to a friend, and, of course, tune in next week. Thanks, everyone. Thanks for listening. If you enjoyed today's episode, I hope you'll tell a friend about a health policy.