Treatment of Opioid Use Disorder Among Commercially Insured Patients in the Context of the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has complicated the US response to the opioid use disorder (OUD) epidemic. Multiple stressors, including social isolation and unemployment, may have contributed to increased opioid use and overdoses.¹ Meanwhile, outpatient visits have declined,² raising concerns that patients receiving OUD treatment before the pandemic are no longer receiving the same level of services and that fewer patients may be starting treatment.

There has also been a rapid increase in telemedicine use, facilitated by expanded reimbursement and regulatory waivers, including the requirement for an in-person visit before a clinician can prescribe certain OUD medications (eg, buprenorphine).³ The extent to which telemedicine has changed access to OUD care is unclear.

We examined OUD treatment during the early months of the pandemic, including medication fills, outpatient visits, and urine tests, among privately insured individuals compared with 2019.

We analyzed data from OptumLabs Data Warehouse,⁴ which includes claims for commercial and Medicare Advantage enrollees who are overrepresented in the South and Midwest (eTable in the Supplement), for individuals aged 18 to 64 years continuously enrolled with medical, behavioral health, and pharmacy benefits from January through May in 2020 and in 2019. We divided these cohorts into patients already receiving OUD medication (ie, had a fill in January/February) and patients not already receiving it (no fill in January/February).

Outcomes for March through May were the weekly and cumulative percentages with (1) at least 1 OUD medication prescription or facility/clinician administration, (2) at least 1 OUD visit, and (3) at least 1 urine OUD toxicology test (eAppendix in the Supplement). We calculated the differences (with 95% CIs) between 2019 and 2020 percentages (Microsoft Excel for Office 365). Significance was defined as a confidence interval excluding 0. We also examined the proportion of weekly OUD visits delivered via telemedicine among patients with at least 1 OUD visit.

This study was deemed exempt from review by Harvard Medical School’s institutional review board. Informed consent was not obtained for this secondary data analysis.

Enrollee demographics were similar for 2019 vs 2020 (eg, mean age, 42 years; 50% female). Among those continuously enrolled in January and February 2020, 92.94% remained enrolled through May (vs 93.44% in 2019); 7.53% were enrolled in Medicare Advantage.

Among individuals already receiving OUD medication (n = 21 005, with 79.47% using buprenorphine, in 2019; n = 24 450, with 80.03% using buprenorphine, in 2020), more filled at least 1 OUD prescription in March through May 2020 than in March through May 2019 (73.90% vs 71.25%; difference, –2.65% [95% CI, –3.48% to –1.83%]) (Figure and Table). The percentage receiving at least 1 OUD visit in March through May was not significantly different in 2020 and 2019 (28.66% vs 28.55%; difference, –0.11% [95% CI, –0.95% to 0.72%]); the percentage receiving at least 1 urine test was lower in 2020 than 2019 (11.70% vs 15.85%; difference, 4.15% [95% CI, 3.51%-4.79%]). In 2020, OUD visits delivered via telemedicine increased from 0.52% in week 1 (week of March 1) to 27.33% in week 13.

Among individuals not receiving medication in January/February (n = 6 122 636 in 2019; n = 5 963 857 in 2020), the percentage receiving at least 1 fill in March through May 2020 was lower than 2019 (0.14% vs 0.17%; difference, 0.03% [95% CI, 0.03%-0.04%]). The percentage receiving at least 1 OUD visit in March through May (0.09% vs 0.10%; difference, 0.01% [95% CI, 0.01%-0.02%]) and the percentage receiving at least 1 urine test (0.06% vs 0.09%; difference, 0.03% [95% CI, 0.02%-0.03%]) were lower in 2020 than 2019. OUD visits delivered via telemedicine increased from 0.62% in week 1 of 2020 to 34.80% in week 13.

During the first 3 months of the pandemic, among patients already receiving OUD medication, there was no decrease in medication fills or clinician visits. However, fewer individuals initiated OUD medications, and there was less urine testing across all patients. In recent research, OUD clinicians described that they could maintain care with existing patients via telemedicine during the pandemic but were uncomfortable initiating new patients with medication; they also reduced urine testing to protect patients from COVID-19 exposure.⁵ Also, fewer patients may be seeking care. Limitations include that the study population was 18 to 64 years old with private insurance or Medicare Advantage and the study period only extended through May 2020. Although individuals may have lost jobs and health insurance in 2020, the similar percentages continuing enrollment through May in 2019 and 2020 suggest no differential plan disenrollment.

Accepted for Publication: October 13, 2020.

Correction: This article was corrected online May 11, 2021, to fix data errors in the Results section, Table, Figure, and eTable in the Supplement caused by an error in the programming code used for the analyses.

Corresponding Author: Haiden A. Huskamp, PhD, Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115 (huskamp@hcp.med.harvard.edu).

Author Contributions: Drs Huskamp and Mehrotra had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Huskamp, Busch, Mehrotra.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Huskamp.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Mehrotra.

Obtained funding: Huskamp, Uscher-Pines, Mehrotra.

Administrative, technical, or material support: Riedel, Mehrotra.

Supervision: Uscher-Pines.

Conflict of Interest Disclosures: Dr Barnett reported being retained as an expert witness by government plaintiffs in lawsuits against opioid manufacturers. No other disclosures were reported.

Funding/Support: This study was funded by the National Institute on Drug Abuse (NIDA; grants R01 DA048533 and P30 DA035772).

Role of the Funder/Sponsor: The NIDA had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: Jeff Souza, MA, Harvard Medical School, provided expert statistical programming. His work was funded by a grant from the NIDA.