The lock-in loophole: Using mixed methods to explain patient circumvention of a Medicaid opioid restriction program

Details

• Alternative Title:
  Subst Abus
• Personal Author:
  Roberts, Andrew W. ; Skinner, Asheley C. ; Lauffenburger, Julie C. ; Galt, Kimberly A.
• Description:
  Background:
  
  Lock-in programs are proliferating among private and public payers to restrict access to controlled substance prescriptions and enhance care coordination for patients exhibiting high-risk use of, primarily, opioids. Patients enrolled in lock-in programs are required to seek opioids from a designated provider and pharmacy for insurance coverage of their opioid and benzodiazepine prescriptions. Lock-in program restrictions are often circumvented by patients through out-of-pocket cash purchases of opioid prescriptions, undermining the program’s intended function. This study sought to construct and explain trajectories of Medicaid-covered and cash pay opioid prescription fills among adults enrolled in an opioid lock-in program.
  
  Methods:
  
  We used sequential explanatory mixed methods, which involved a quantitative retrospective cohort analysis of opioid fill trajectories using North Carolina Medicaid administrative claims data linked with state prescription drug monitoring program data, followed by qualitative semi-structured interviews with North Carolina pharmacists. The quantitative component included adults enrolled in the North Carolina Medicaid lock-in program between 10/½010–3/3½012. The qualitative component included a maximum variation sample of community pharmacists in North Carolina delivering care to lock-in patients. Quantitative outcomes included group-based trajectories of monthly Medicaid-covered and cash pay opioid prescription fills six months before and after LIP enrollment, and qualitative analyses generated themes explaining observed trajectories.
  
  Results:
  
  Two-thirds of subjects exhibited reduced Medicaid-covered opioid prescription fills and no increase in cash pay fills after lock-in enrollment, with one-third exhibiting increased cash pay fills after lock-in. Pharmacists attributed increases in cash pay fills primarily to illicit behaviors, while some cash pay behavior likely reflected new unintended barriers to care.
  
  Conclusions:
  
  Lock-in programs appear to reduce prescription opioid use for most enrolled patients. However, lock-in programs may have limited capacity to deter illicit behaviors among patients intent on abusing, misusing, or diverting these medications and may introduce new access barriers to necessary care for some.
  
  
• Subjects:
  Adult Analgesics, Opioid Controlled Substances Humans Medicaid Opioid-Related Disorders Retrospective Studies United States
• Keywords:
  Buprenorphine Health Services Research Lock-in Program Managed Care Methadone Mixed Methods Mortality Naltrexone Opioid Policy Opioids Patient Review And Restriction Program Trajectory Modeling Treatment

  More +
• Source:
  Subst Abus. 41(4):510-518
• Pubmed ID:
  31644398
• Pubmed Central ID:
  PMC7176522
• Document Type:
  Journal Article
• Funding:
  KL2 TR000119/TR/NCATS NIH HHSUnited States/ ; KL2 TR002367/TR/NCATS NIH HHSUnited States/ ; U01 CE002160/CE/NCIPC CDC HHSUnited States/ ; UL1 TR000083/TR/NCATS NIH HHSUnited States/
• Volume:
  41
• Issue:
  4
• Collection(s):
  CDC Public Access
• Main Document Checksum:
  urn:sha-512:25636692335d2d87ae3f9fc1155eecff3da10719dabbfac34f2679cd483aa7377a34bd4825cec3fe3a7df781f55dc2cd54695046714a80b0e999ebd528f0a777
• Download URL:
  https://stacks.cdc.gov/view/cdc/87162/cdc_87162_DS1.pdf
• File Type:
  [PDF - 617.97 KB ]