Medicaid expansion, which took effect as the opioid epidemic ballooned, provided insurance coverage to people at highest risk of opioid use disorder (OUD) – lower-income, younger adults. Because Medicaid covers the overdose-reversal drug naloxone, the expansion gave Harvard Medical School professor Richard Frank an opportunity to compare how Medicaid expansion impacted naloxone prescribing in expansion and non-expansion states.

In a recent study published in the journal Addiction, Frank found that expansion states dramatically increased their Medicaid-covered naloxone prescriptions. In 2016, states that did not expand Medicaid averaged 83.1 Medicaid-covered prescriptions per 100,000 enrollees, while expansion states averaged nearly four-times that amount – 215.6 per 100,000 enrollees. On average, naloxone (Narcan) saves one life for every 14 prescriptions written, which means expansion states saved an additional 22.7 lives per year per state.

Frank’s study suggests Medicaid expansion has been highly effective because it made naloxone available and affordable to the consumers, family members, and friends who are most likely to be on-site when an overdose occurs.

Frank, who specializes in the economics of health, took time recently to answer questions about how his findings could enhance states’ policy responses to the opioid epidemic.

Why is naloxone and harm reduction critical for states working to improve OUD treatment? 

Given that addiction is an illness, your goal should be to prevent death and disability and get people into treatment. If a person with diabetes doesn’t eat properly, you don’t stop giving them insulin, you keep treating them.

Why was providing insurance coverage and free access to naloxone so successful?

Previously, when if you didn’t have insurance coverage, the way most people who overdosed (OD’d) got naloxone was through first responders who carried it and administered it – if they got there in time. But two things happened, recently, user-friendly versions of naloxone became available, and that opened up the opportunity for lay people to be able to administer it to family and friends. Suddenly, a new opportunity to have naloxone johnny-on-the spot when someone OD’d became available. Second, what Medicaid did was to make naloxone available by giving purchasing power and access to consumers, families, and friends who were most likely to be on-site when there was an overdose. This is especially important as the epidemic morphed from one mostly that involved prescription medications to one where deaths were driven by heroin cut with fentanyl, and fentanyl alone, because fentanyl takes effect much more quickly, so having naloxone accessible is much more important today than it was six or seven years ago. [Fentanyl’s reach has recently spread from New England to the Midwest and Appalachia and is now appearing in California and Oregon.]

Does this study suggest that funding naloxone through Medicaid expansion is more effective than through federal funding vehicles? [The federal government has allocated $1 billion under the 21st Century Cures Act and $11 million from the Substance Abuse and Mental Health Services Administration to 12 states.]

The federal government has set up grant programs that are generous and important, but grant program funding goes away as soon as public attention to an issue disappears. The nice thing about Medicaid is that it’s a mandatory program with long-term insurance coverage. As a result, Medicaid continuously puts purchasing power into the hands of people who are most at risk from opioids. It’s not impacted by the ebb and flow of political salience, it just ebbs and flows with the demand of people caught up in the opioid epidemic.

How does naloxone deployment improve access to treatment? 

Having an overdose reversed by naloxone is extraordinarily unpleasant, so many people who are treated with naloxone are taken to a hospital emergency department (ED). What’s interesting about naloxone is it detoxes you, it blocks the opioid receptors in your system and creates an opportunity to start treatment with evidence-based, medication-assisted treatment (MAT) like buprenorphine [which can be prescribed or dispensed in physician offices, significantly increasing treatment access.] There is an increasing number of EDs starting to do that warm hand-offs to treatment facilities and provide MAT when they get overdoses. If you can get someone who ODs to go to the ED, the chance of getting them started on treatment goes up. These are important opportunities to link harm reduction to treatment.

There’s another consideration, we need to remember that there are people who are not addicted who experiment with heroin who will unknowingly use heroin cut with fentanyl. They’re going to suddenly OD, so they need to be revived and how you treat them is different when they’re not addicted. You have to take the opportunity to address the problem in an appropriate matter, in some cases MAT is needed and in other cases you need to educate people about this dangerous recreational drug use.

What other steps can states can take to improve OUD treatment?

It’s hugely important that states do more to ensure that people have the opportunity to get evidence-based, MAT treatment for addiction. Right now, there are many states where providers can get accredited to treat addiction, and yet refuse to offer MAT to individuals or refuse to take people who are currently being treated with MAT, (e.g., following release from a hospital.) There are also providers/facilities who won’t do a warm hand-off to community-based treatment centers that support MAT. You are less likely to get people better if you don’t do those things. This is a failure of state regulatory and national accreditation agencies that oversee residential treatment centers. The fact that states license them and pay huge amounts of money to these programs is troubling. I think states and accreditation agencies can do more to hold these programs accountable than they have traditionally done in order to promote the use of evidence-based treatments.

Given the results of this study, what would you tell state legislators today who were considering expanding Medicaid in their states?

I would quote former Ohio Gov. John Kasich, who said Medicaid expansion was one of the most important tools to fight the opioid epidemic in his state. He argued that among other things that Ohio hospitals’ budgets were overwhelmed by overdoses among people who had no insurance. After Medicaid expansion increased access to naloxone, Ohio hospitals saw uncompensated care among people with opioid use disorder decline from 20 percent to 5 percent overnight, which put millions of dollars back into hospitals’ bottom line.