The Role of Primary Care in Improving Access to Medication-Assisted Treatment for Rural Medicaid Enrollees with Opioid Use Disorder.

Cole ES, DiDomenico E, Cochran G, Gordon AJ, Gellad WF, Pringle J, Warwick J, Chang CH, Kim JY, Kmiec J, Kelley D, Donohue JM. The Role of Primary Care in Improving Access to Medication-Assisted Treatment for Rural Medicaid Enrollees with Opioid Use Disorder. Journal of general internal medicine. 2019 Jun 1; 34(6):936-943.

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Abstract:

BACKGROUND: The opioid epidemic has disproportionately affected rural areas, where a limited number of health care providers offer medication-assisted treatment (MAT), the mainstay of treatment for opioid use disorder (OUD). Rural residents with OUD may face multiple barriers to engagement in MAT including long travel distances. OBJECTIVE: To examine the degree to which rural residents with OUD are engaged with primary care providers (PCPs), describe the role of rural PCPs in MAT delivery, and estimate the association between enrollee distance to MAT prescribers and MAT utilization. DESIGN: Retrospective cohort study. PARTICIPANTS: Medicaid-enrolled adults diagnosed with OUD in 23 rural Pennsylvania counties. MAIN MEASURES: Primary care utilization, MAT utilization, distance to nearest possible MAT prescriber, mean distance traveled to actual MAT prescribers, and continuity of pharmacotherapy. KEY RESULTS: Of the 7930 Medicaid enrollees with a diagnosis of OUD, a minority (18.6%) received their diagnosis during a PCP visit even though enrollees with OUD had 4.1 visits to PCPs per person-year in 2015. Among enrollees with an OUD diagnosis recorded during a PCP visit, about half (751, 50.8%) received MAT, most of whom (508, 67.6%) received MAT from a PCP. Enrollees with OUD with at least one PCP visit were more likely than those without a PCP visit to receive MAT (32.7% vs. 25%; p? < 0.001), and filled more buprenorphine and naltrexone prescriptions (mean? = 11.1 vs. 9.3; p? < 0.001). The median of the distances traveled to actual MAT prescribers was 48.8 miles, compared to a median of 4.2 miles to the nearest available MAT prescriber. Enrollees traveling a mean distance greater than 45 miles to MAT prescribers were less likely to receive continuity of pharmacotherapy (OR? = 0.71, 95% CI? = 0.56-0.91, p? = 0.007). CONCLUSIONS: PCP utilization among rural Medicaid enrollees diagnosed with OUD is high, presenting a potential intervention point to treat OUD, particularly if the enrollee's PCP is located nearer than their MAT prescriber.