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For young people with opioid use disorder (OUD), buprenorphine costs have declined overall but with drastic variation by payer type, researchers found.

Examining buprenorphine prescriptions dispensed for U.S. youth ages 12 to 19, mean daily out-of-pocket costs declined 57.6% from 2015 through 2020 (from $4.03 to $1.71), with an increasing percentage of prescriptions paid by Medicaid, Andrew Terranella, MD, MPH, of the CDC, and colleagues .

However, those costs were approximately 24 times higher with commercial payers and 119 times higher for self-pay than with Medicaid in 2020, they noted.

"Ensuring that eligible youth with OUD can access buprenorphine without cost barriers could improve treatment access," the researchers wrote, noting that such medications for OUD are recommended but underused by the estimated 366,000 individuals ages 12 to 25 affected by OUD in the U.S.

A separate study simultaneously by Ashley Leech, PhD, MS, of Vanderbilt University School of Medicine in Nashville, Tennessee, and colleagues showed the impact of higher out-of-pocket costs on risk of discontinuation of buprenorphine among commercially insured U.S. adults.

A in JAMA Network Open using the National Survey on Drug Use and Health showed that, of the estimated 2.5 million U.S. adults with OUD in the past year, only 22% received medications to treat it in 2021.

"More than 80,000 people are dying of a drug overdose involving an opioid every year, while safe and effective medicines to treat opioid use disorder are sitting on the shelf unused," said study author Wilson Compton, MD, MPE, deputy director of the National Institute on Drug Abuse, in a .

"This is preventable, as treatment is highly effective, yet most individuals with an opioid use disorder don't access or continue recommended treatment," Leech told MedPage Today in an email. "While reasons for not accessing or sustaining treatment over time could be many, few studies have assessed patient behavior and responsiveness to out-of-pocket costs associated with treatment."

Barriers for Youth

Terranella and colleagues examined IQVIA Longitudinal Prescription Data, which spans prescriptions dispensed from 48,900 retail pharmacies, representing 93% of prescriptions in the U.S. Daily out-of-pocket costs were calculated across prescriptions of differing durations and adjusted to 2020 dollars using the Consumer Price Index.

Of 221,342 buprenorphine prescriptions dispensed for youths from 2015 to 2020, Medicaid had the lowest mean daily out-of-pocket cost for buprenorphine prescriptions, consistently at less than $0.10 per day, the researchers noted. Those costs for prescriptions paid by commercial insurance decreased from $3.80 in 2015 to $1.68 in 2020. Costs remained highest for self-pay prescriptions across the study period ($9.80 in 2015 to $8.33 in 2020), followed by those paid by discount card, coupon, voucher, or other assistance ($7.88 and $5.81, respectively).

From 2015 to 2020, Medicaid covered the largest proportion of buprenorphine prescriptions among youth, and that share climbed 63.6%, from 27.1% to 44.3%.

"The biggest implication is that of a policy one," Terranella told MedPage Today. "Improving access to insurance coverage that includes medications for opioid use disorder could decrease cost burden for adolescents and their families, thus reducing or eliminating cost as a barrier to treatment."

"For clinicians, this study highlights the fact that while cost remains a barrier for many patients, out-of-pocket costs for most patients are low," he continued. "Clinicians, including general pediatricians, should consider prescribing buprenorphine for adolescents with opioid use disorder and should work with their benefits coordinators to ensure all eligible youth are enrolled in state Medicaid programs to minimize out-of-pocket costs."

Additional findings included that, geographically, in the southern part of the U.S., prescriptions had higher out-of-pocket costs. In 2020, a higher proportion were paid by self-pay and assistance in the region, while fewer were paid by Medicaid.

Buprenorphine prescriptions in rural counties had higher out-of-pocket costs, and a higher proportion were self-pay.

And prescriptions for youth ages 12 to 15 were less likely to be paid by Medicaid and had higher out-of-pocket costs than those for older adolescents.

Limitations of the study included the use of unweighted data as well as a lack of data on race and ethnicity or diagnoses, Terranella and colleagues noted. Also, buprenorphine prescriptions dispensed outside retail pharmacies were not included. And all prescriptions were assumed to be for OUD, even though some prescriptions might have been for pain management.

Adults With OUD Face Cost Challenges Too

In a separate study of commercially insured U.S. adults, researchers found that higher costs were associated with an increased risk of buprenorphine discontinuation.

Among 40,035 patients initiated on the medication from 2013 through 2020, compared with the first (lowest) quartile of out-of-pocket costs ($0-$0.71), each quartile of higher costs was associated with increasingly higher likelihood of discontinuation:

• Second quartile ($0.72-$1.84): adjusted HR 1.09 (95% CI 1.06-1.13)
• Third quartile ($1.85-$4.27): adjusted HR 1.18 (95% CI 1.13-1.22)
• Fourth quartile ($4.28-$97.50): adjusted HR 1.34 (95% CI 1.29-1.39)

A mere 22% of patients continuously used buprenorphine during follow-up, Leech and colleagues reported.

For their research, researchers utilized information on adults ages 18-64 from the MarketScan Commercial Claims Database.

Compared with sublingual buprenorphine/naloxone film (Suboxone), risk of discontinuation was higher with the generic buprenorphine/naloxone film, generic buprenorphine/naloxone tablet, generic buprenorphine tablet, and Suboxone tablet.

Additional risk factors for discontinuation included being of a younger age, residing in the Western region of the U.S. versus the North Central region, initiating medication in any month other than January, having other substance use diagnoses, and having physical comorbidities, according to the study.

Limitations included that the study findings might not be generalizable to other insured or uninsured populations and that it did not capture methadone use.

Leech and colleagues further noted that they did not account for hospitalizations during follow-up, and that they were unable to assess equity concerns because they did not have access to patient data on race or ethnicity.

"Even though there has been a 300% increase in the number of clinicians trained to prescribe buprenorphine over the last decade," Leech told MedPage Today, "most individuals with opioid use disorders are still not on recommended medications, and we now have more evidence to show that out-of-pocket cost is likely a barrier."