Use of Medications for Opioid Use Disorder Grew from 2018 to 2022, but Remained Low

Key Takeaways:

• Use of medications for opioid use disorder (MOUD) grew from 2018 to 2022, but fewer than half of people with opioid use disorder and employer-sponsored insurance received MOUD.
• Primary care providers prescribed more than 70% of MOUD among people with employer-sponsored insurance.
• Fewer than half of patients with employer-sponsored insurance filled enough prescriptions to regularly take MOUD for one year.

Nearly one-third of Americans report having a family member who is, or has been, addicted to opioids. While opioid overdose deaths have fallen from their peak in 2022, they are still the most common type of drug overdose death, claiming more than 54,000 lives in 2024.

Medications for opioid use disorder (MOUD) are the gold-standard approach for treating OUD and its associated risks (e.g., overdose, hepatitis, HIV). MOUD are medications that treat opioid dependence by reducing cravings and treating withdrawal symptoms to help people safely stop using opioids. The three main classes of MOUD are methadone, buprenorphine, and naltrexone. These drugs, alone or in combination with other therapies (e.g., counseling), have proven effective at reducing overdose deaths, decreasing opioid use, and reducing acute health care episodes like emergency department visits.

Because more than one-third of adults under age 65 with OUD have private insurance, this analysis explores the prevalence of OUD and use of MOUD among adults with employer-sponsored insurance (ESI). We used data from HCCI’s ESI claims database to examine rates of OUD diagnoses, prescriptions for MOUD, and the types of providers who are prescribing MOUD.

We focused our MOUD analysis on buprenorphine and naltrexone because claims for methadone were uncommon in the claims data we used. Buprenorphine and naltrexone can be prescribed by a physician and taken either orally at home or injected in a physician’s office. We examined both long-acting, injectable MOUD administered in a physician’s office and prescriptions for oral buprenorphine and naltrexone. We restricted the analysis to people between 18 and 64 years old who were enrolled in ESI as their primary coverage and had pharmacy benefits for at least 10 months during the year.

Rates of MOUD use Grew from 2018 to 2022, but with room for improvement

The number of ESI enrollees with an OUD diagnosis declined from 690 per 100,000 in 2018 to 550 per 100,000 in 2022 (Figure 1).

The share of ESI enrollees with OUD who received either buprenorphine or naltrexone rose between 2018 and 2022, driven by increased use of buprenorphine (Figure 1). The share of enrollees with OUD who received buprenorphine rose 29% during the five-year period, growing from 28.7% to 37.3%. Use of naltrexone fell from 5.7% of enrollees with OUD in 2018 to 4.9% in 2022.

Despite the increase in the share of enrollees receiving MOUD from 2018 to 2022, fewer than half of enrollees with OUD used MOUD in 2022. Other research has shown higher treatment rates in Medicaid (71% in 2022) and lower in traditional Medicare (21%).

Use of MOUD may be lower in ESI than in Medicaid because ESI enrollees face higher out-of-pocket costs for MOUD than they would within the Medicaid program. Figure 2 shows the average annual out-of-pocket spending per patient on buprenorphine and naltrexone from 2018 to 2022. Out-of-pocket spending includes only costs paid by the enrollee. Out-of-pocket spending on buprenorphine averaged $89 per patient in 2018 and grew to $110 in 2022. Out-of-pocket spending for naltrexone was consistently higher, increasing from $141 in 2018 to $172 in 2022.

Primary Care Providers Are the Most Common MOUD Prescribers in ESI

More than half of the prescriptions for oral MOUD that we analyzed were written by primary care providers (PCPs). This was true for both buprenorphine and naltrexone, but the share of PCP prescribers was higher in all years for buprenorphine compared to naltrexone. In 2022, 71.6% of buprenorphine prescriptions were written by a PCP compared to 62.7% of naltrexone prescriptions. The shift toward treating OUD and prescribing MOUD in the primary care setting has accelerated since 2022.

Adherence to MOUD Remains a Challenge

Clinical guidelines say that patients should be on MOUD for at least six months, but experts believe that a year or more of treatment is needed to achieve sustainable recovery from OUD.

To determine whether people with ESI were receiving medication consistent with medical guidelines, we evaluated whether people received enough medication to regularly take their MOUD for 12 months following their first prescription. For this piece of the analysis, we looked at new prescriptions for oral MOUD between 2018 and 2022. We chose to focus on oral MOUD because they accounted for 96.6% of the prescriptions in the data and measuring how many days’ supply that physician-administered, injectable MOUD contained is difficult in claims data.

Claims-based measures of days’ supply are commonly used to study drug adherence, but this approach does have limitations. We cannot determine whether patients took the medicine they filled prescriptions for or whether they took the full dose or rationed their supply to last longer. Additionally, patients who transitioned to paying for MOUD outside of their insurance plan may appear has non-adherent in our data.

We wanted to understand whether adherence differed between the PCP and specialist prescribers. We assigned each patient’s follow-up period to either a PCP or specialist based on the provider type who prescribed the majority of the MOUD supply the patient filled.

Only 54% of PCP-initiated episodes and 49% of specialist-initiated episodes had enough medication over the first three months to remain adherent to MOUD treatment. Adherence rates were lower when looking at longer periods. Adherence over six months was 53% for PCP patients and 45% for specialist patients. Fewer than half of patients remained adherent for a full year across both PCPs (49%) and specialists (41%).

Adherence was consistently higher for people who saw PCPs than specialists, but the gap is not necessarily indicative of better care by PCPs. Specialists may see more complex patients who face greater challenges to MOUD adherence and are also represent a higher share of naltrexone prescriptions (see Figure 3). Naltrexone may be more difficult for patients to adhere to because it does not address withdrawal symptoms.

Continued research and policy action are needed to improve OUD treatment rates

Our analysis showed that while the share of ESI enrollees with OUD who received MOUD increased from 2018 to 2022, there is still a great deal of progress to be made. Our finding that adherence was low in the ESI population is supported by other studies, one of which found that adherence might be as low as 20%.

MOUD treatment rates and adherence may be low because of stigma associated with the disease and treatment. Public health campaigns targeted at employed adults may also increase demand for MOUD.

To make treatment gains among people with ESI, state and federal policies should be designed to effectively promote MOUD for this population.

Addressing the health impacts of the opioid crisis will take coordination across all parts of the health care system, including plan sponsors like employers, health plans, providers, and state governments. Increasing the take-up of MOUD is one of the most promising approaches to reducing the burden of OUD and overdoses in the United States.