(12) Insurance and Racial/Ethnic Disparities in Receipt of Medications for Alcohol Use Disorder

Background & Introduction: Complications from untreated alcohol use disorder (AUD) remain a leading cause of preventable death worldwide,1 highlighting the need for effective treatments. Medications for AUD (MAUD) are efficacious for persons with moderate and severe forms of AUD but are underutilized.2 Identifying predictors of MAUD receipt is critical for recognizing for whom treatment disparities are greatest so that implementation intervention efforts can be optimized. Although substance use disorders (SUDs) are over-represented among persons with Medicaid,3 persons with Medicaid have historically been less likely to receive medications used for SUD treatment relative to persons with private insurance.4 The Mental Health Parity and Addiction Equity Act enacted in 2008 and the Affordable Care Act enacted in 2010 were designed in part to mitigate insurance disparities in substance use disorder treatment. The primary purpose of this study was to examine the association between insurance type and likelihood of receiving MAUD treatment. Given known racial and ethnic disparities in AUD-related outcomes,5 a secondary purpose of the study was to examine associations between race and ethnicity and likelihood of MAUD receipt.

Methods: In this retrospective cohort study, we analyzed claims from Merative™ MarketScan® Commercial Claims and Encounters and Medicaid databases from 2015-2019. Individuals aged 18-64 with an International Classification of Diseases (ICD)-9 or -10 code corresponding to moderate or severe AUD and a treatment claim for AUD were included in analyses. AUD treatment claims included any of the three MAUDs with approval from the Food and Drug Administration for the treatment of AUD—naltrexone (in either oral or extended-release depot formulation), acamprosate, and disulfiram—as well as psychosocial counseling treatments. Treatment claims were identified with relevant treatment and diagnostic codes. Our unit of measurement was the treatment episode, defined as consecutive treatment claims until a 45-day gap in care was observed. For the primary analyses, we used logistic regression to measure likelihood of MAUD receipt as a function of Medicaid vs private insurance while adjusting for co-variates including age, gender, co-occurring SUDs and other co-occurring illness. Secondary analyses examined associations between race and ethnicity and MAUD receipt within the Medicaid insurance database; race and ethnicity data were not available in the Commercial database. Analyses were adjusted to account for individuals who underwent multiple treatment episodes.

Results: Among n=318,576 AUD treatment episodes analyzed, only 19% were associated with MAUD. After adjustment for co-variates, private insurance was associated with 5 times greater likelihood of receiving MAUD relative to Medicaid insurance (adjusted RR 5.0, 95% CI 4.8-5.1). Among persons with Medicaid, Black and Hispanic persons were less likely than White persons to receive MAUD (adjusted RR 0.5, 95% CI 0.4-0.6 for Black vs. White comparison; adjusted RR 0.7, 95% CI 0.5-0.9 for Hispanic vs. White comparison).

Conclusion & Discussion: There are stark insurance and racial and ethnic disparities in MAUD receipt among adults with moderate or severe forms of AUD. Further, the overall prevalence of MAUD receipt was less than 20%, indicating the majority of persons with the most severe forms of AUD do not receive evidence- and guideline-based treatment. Research is urgently needed to identify causes for observed inequities in MAUD provision, as are implementation efforts to improve the uptake of MAUD among persons with AUD.

References: (1) GBD 2016 Alcohol Collaborators (2018). Alcohol use and burden of 195 countries and territories, 1990-2016: a systemic analysis for the Global Burden of Disease Study 2016. Lancet, 392(10152):1015-1035.
(2) Han B, Jones CM, Einstein EB, Powel, PA, Compton WM (2021). Use of medications for alcohol use disorder in the US: Results from the 2019 National Survey on Drug Use and Health. JAMA Psychiatry, 78(8), 922-924.
(3) Saunders H, & Rudowitz R (2022). Demographics and health insurance coverage of nonelderly adults with mental illness and substance use disorders in 2020. Kaiser Family Foundation. https://www.kff.org/mental-health/issue-brief/demographics-and-health-insurance-coverage-of-nonelderly-adults-with-mental-illness-and-substance-use-disorders-in-2020/. Accessed October 17, 2023.
(4) Abraham AJ, Knudsen HK, Rieckmann T, Roman PM. (2023). Disparities in access to physicians and medications for the treatment of substance use disorders between publicly and privately funded treatment programs in the United States. J Stud Alcohol Drugs, 74(2):258-265.
(5) Chartier K, Caetano R (2010). Ethnicity and health disparities in alcohol research. Alcohol Research and Health, 33(1-2):152-160.