Publications

INTRODUCTION: A 2019 Medicare opioid safety policy limited initial opioid duration to 7 days and long-term daily dosage to 90 morphine milligram equivalence (MME). Because effective pain management may vary by rurality, this study examined whether the policy differentially affected opioid prescribing among rural versus urban beneficiaries with disabilities.

METHODS: Deidentified claims data was used to gather a rolling cohort of Medicare Advantage beneficiaries with disabilities ages 18 to 64 from 2016 to 2021. Comparative interrupted time series were used in 2025 to analyze rural-urban differences in the duration and dosages of opioid fills for new-to-opioid beneficiaries, the target of the 7-day limit (N = 526,019 person-months), and the number of high-dosage episodes for long-term opioid beneficiaries, the target of the 90-MME limit (N = 3,312,161 person-months).

RESULTS: Despite significant reductions in initial opioid duration for both groups, the 7-day limit effect on initial opioid duration weakened over time (trend change: 0.17 [98.75% CI 0.04 to 0.30]) in the rural relative to the urban group. By the end of the study period, the rural group experienced 3.8 percentage points more initial opioid fills exceeding the 7-day limit (95% CI 0.4 to 7.3) than the urban group. Furthermore, the total dosage prescribed in subsequent fills among rural beneficiaries was 27.97 MME (95% CI -52.19 to -3.75) less than urban beneficiaries by the end of the study period. The rural and urban groups responded similarly to the 90-MME limitation.

CONCLUSIONS: Rural relative to urban new-to-opioid beneficiaries with disabilities experienced a weakened effect on initial opioid duration after Medicare's 7-day limit, while receiving declining dosage in follow-up opioid fills, suggesting potential disparities in access to follow-up opioid prescriptions for rural versus urban beneficiaries with disabilities. Policymakers may consider more flexible opioid regulations and attention to alternative pain management for rural Medicare beneficiaries.

BACKGROUND: Despite limited evidence of efficacy and well-established risks, long-term benzodiazepine use remains common. In July 2016, the Oregon Medicaid program introduced a prior authorization policy limiting benzodiazepine prescriptions to 4 weeks.

OBJECTIVES: To evaluate the impact of Oregon's benzodiazepine policy on medication utilization and health outcomes.

RESEARCH DESIGN: Interrupted time series regressions from January 2015-December 2017 (18 mo pre vs. post-policy).

SUBJECTS: Rolling cohorts of adult benzodiazepine recipients with 6 months of continuous enrollment before and after each month of observation.

MEASURES: Benzodiazepine utilization included monthly measures of overall, prevalent long-term, and incident long-term medication use. Harms included a composite measure of emergency department or inpatient admissions for overdose, self-harm, acute withdrawal, or acute psychiatric events, and were compared with patients using similar medications that were not affected by the policy.

RESULTS: The study population included 69,143 benzodiazepine recipients; 68% were female, and the average age was 41 years or older. Following policy implementation, there was a significant segment decrease (-​​​29.82 recipients/1000 patients; 95% CI: -​​​33.75 to -​​​25.89) in incident long-term benzodiazepine use and a 1.17 recipients/1000 patients/month (95% CI: 0.82-1.52) increase in trend. Trends in prevalent long-term (-1.16 recipients/1000 patients/month: 95% CI: -1.32 to -0.99) benzodiazepine use also declined. Modest trend decreases in harm were observed among all cohorts.

CONCLUSIONS: A policy to limit benzodiazepine duration was associated with a substantial reduction in progression to longer-term use and modest declines in the trend for potential harms.

Medicaid is the largest insurer for patients with opioid use disorder (OUD) and finances a disproportionate share of medication treatment for OUD (MOUD). Within Medicaid, initiation and continuity of MOUD are associated with improved outcomes, but substantial inequities across populations and care settings remain. The Medicaid Outcomes Distributed Research Network (MODRN) has supported Medicaid agency efforts to improve MOUD receipt and continuity of care. In the context of MODRN-Examining Quality Improvement for Medicaid Programs, the Behavioral Health Treatment Engagement and Retention Learning Collaborative (BHTER) will implement and evaluate interventions focused on improving quality and reducing variation in process and clinical outcomes in Medicaid patients with OUD. BHTER's aims are to (1) estimate the effects of a quality improvement intervention on receipt and continuity of MOUD in intervention practices relative to comparison practices, (2) examine whether a quality improvement intervention narrows racial gaps in rates and continuity of MOUD in intervention relative to comparison practices, (3) examine provider perspectives on the quality improvement intervention, with a focus on practice and process changes that resulted in improvement, and factors that impede or facilitate delivery of high-quality MOUD care. In this protocol paper, we describe the rationale, methods, and impact of BHTER.

Public payers in the US cover more than half of individuals who receive treatment for opioid use disorder (OUD). Despite this, patient-reported measures that reflect treatment engagement and quality of life are largely missing from OUD quality improvement initiatives. This commentary describes the survey protocol for Project ELVIS (ELevating patient VoIceS to Improve OUD Treatment Quality), 1 of 3 projects of the Medicaid Outcomes Distributed Research Network's initiative Examining Quality Improvement in Medicaid Programs. Project ELVIS collects patient experiences with OUD treatment and tests the relationship between patient-reported and claims-based measures of treatment quality. As this commentary describes, Project ELVIS is innovative in its approach to grounding measure development in sustained, iterative engagement with individuals with lived experience and Medicaid policymakers and in employing a policy-driven regional survey sampling approach that prioritizes Medicaid decision-making relevance. Our project is also innovative in its planned linkages of self-reported patient experiences and outcomes with quality measures based on administrative data, positioning patient experience to explain-not just quantify-treatment quality in Medicaid programs. The goals of this project are to inform mechanisms underlying providers' high (and low) performance on claims-based measures, offering insight into why patients initiate, remain engaged in, or discontinue medication for OUD. In doing so, this work endeavors to support the development of patient-centered, process-based quality measures that complement existing and emerging utilization-based metrics.

BACKGROUND: Medicaid prescription cap policies persist in 12 states; however, it is unclear how they affect the quality of opioid use disorder (OUD) treatment.

OBJECTIVES: To examine the association between cap policies and the continuity in receipt of medication for OUD (MOUD) treatment in Medicaid.

METHODS: Using 2016-2021 T-MSIS Analytical Files data from 37 states, we identified nondual adult (18-64 y) Medicaid enrollees diagnosed with OUD who received MOUD. The exposure was the state's Medicaid prescription cap policy status. The main outcome was a binary variable for MOUD continuity, overall and by type, defined as no treatment gap exceeding 7 consecutive days during a 180-day observation period. We estimated risk ratios for MOUD continuity using modified Poisson regression models, adjusting for individual and state-level covariates to test associations.

RESULTS: Nearly half the sample was female, and the mean age was 37 years. MOUD continuity ranged from 40.7% to 44.3% in states without cap policies and 37.5%-39.6% in cap states. Compared with enrollees in noncap states, those in cap states had a 12% higher likelihood of experiencing at least 1 MOUD treatment gap [risk ratio (RR)=1.12; 95% CI: 1.12-1.13]. These findings were consistent for buprenorphine and methadone. Factors associated with overall MOUD discontinuity included younger age, male sex, living in nonmetropolitan areas, and having 3 or more comorbidities.

CONCLUSIONS: Prescription caps were associated with reduced continuity of MOUD, overall and for buprenorphine and methadone, suggesting that revising or removing these policies could improve OUD quality metrics in Medicaid.

IMPORTANCE: Efforts to improve heart failure (HF) outcomes have focused on prescribing guideline-directed medical therapy at hospital discharge. Whether new prescriptions translate to sustained medication use after HF hospitalization is largely unknown.

OBJECTIVE: To characterize medication-use patterns following HF hospitalizations.

DESIGN, SETTING, AND PARTICIPANTS: A cohort study of patients in a regional US health system discharged home after an HF hospitalization between July 1, 2017, and March 30, 2023. Data were analyzed from August 2024 to February 2026.

MAIN OUTCOMES AND MEASURES: Medications of interest included β-blockers, renin-angiotensin system inhibitors (RASis), mineralocorticoid receptor antagonists (MRAs), and sodium-glucose co-transporter 2 inhibitors (SGLT2is). New prescriptions were identified by in-hospital administration or discharge medication orders. Using electronic health records linked to pharmacy dispensation records, medication initiation (prescription dispensation) and primary nonadherence (discharge prescriptions that were not filled) were assessed at 7 and 90 days postdischarge. Adherence (proportion of days covered ≥80%) and persistence (continuous days' supply) were assessed over 6 months postdischarge.

RESULTS: This cohort study included 6111 patients with HF hospitalizations (mean [SD] age, 69.9 [13.6] years; 37.3% female [2277]) of whom 51% of were prescribed at least 1 new HF medication at discharge. At admission, 58.1% of patients were prescribed β-blockers (3549), 41.4% RASis (2530), 16.3% MRAs (997), and 4.9% SGLT2is (299); and at discharge, use increased to 73.3% (4481), 52.9% (3232), 28.5% (1740), and 9.0% (548), respectively. Primary nonadherence was observed in 51% (972 of 1904) of new prescriptions for β-blockers, 48% (659 of 1361) for RASis, 39% (482 of 1225) for MRAs, and 35% (134 of 383) for SGLT2is. Thus, of 4873 new discharge prescriptions, only 54% (2626) were initiated within 7 days of discharge and an additional 20% (954) had delayed initiation, between 7 and 90 days postdischarge. At 6 months, persistence to β-blockers was 70% (3127 of 4481), for RASis was 60% (1952 of 3232), for MRAs was 55% (961 of 1740), and for SGLT2is was 56% (306 of 548). As a result, at 6 months, only 42% (2188 of 5183) of patients were adherent and 51% (2620 of 5183) were persistent to all HF medications used at discharge.

CONCLUSIONS AND RELEVANCE: This cohort study found that following HF hospitalization, most new guideline-directed medical therapy prescriptions went unfilled. Moreover, most newly initiated prescriptions did not persist at 6 months, suggesting a need to develop interventions to support patients' medication use beyond the initial prescription at discharge.

IMPORTANCE: The 2026 American Heart Association/American College of Cardiology/multisociety guideline on the management of dyslipidemia issued new recommendations on estimating atherosclerotic cardiovascular disease (ASCVD) risk and on populations eligible for statins for primary prevention.

OBJECTIVE: To assess the population health impact of the 2026 guideline on primary prevention statin therapy.

DESIGN, SETTING, AND PARTICIPANTS: Nationally representative, cross-sectional sample of nonpregnant adults aged 30 to 79 years without known ASCVD, who participated in the National Health and Nutrition Examination Survey from 2017 to 2023. Data were analyzed from March to May 2026.

MAIN OUTCOMES AND MEASURES: Changes in eligibility for primary prevention statin therapy, comparing the 2026 and 2018 lipid guidelines.

RESULTS: The weighted sample included 4366 NHANES participants representative of 154.5 million US adults (weighted mean age, 51 years; 52.0% female). Of these, 5.5% (95% CI, 4.7%-6.6%) had untreated low-density lipoprotein cholesterol below 70 mg/dL, 17.8% (95% CI, 16.3%-19.5%) reported currently taking statins, and 8.6% (95% CI, 7.6%-9.8%) met criteria for statin eligibility independent of ASCVD risk estimation based on a low-density lipoprotein cholesterol of 190 mg/dL or greater, diabetes, or chronic kidney disease. The remaining 68.0% of patients (95% CI, 65.9%-70.0%) met guideline criteria for using ASCVD risk estimation to guide statin decisions. In total, an estimated 87.5 million (56.6% [95% CI, 54.2%-58.9%]) nonpregnant US adults aged 30 to 79 years were statin eligible based on the 2026 guideline, including 21.5 million (13.9% [95% CI, 12.5%-15.5%]) who were newly statin eligible. More than 93% of adults aged 70 to 79 years and 85% of adults aged 60 to 69 years are eligible for primary prevention statin therapy compared with 11% of adults aged 30 to 39 years. Newly statin-eligible populations were largely younger and lower risk than populations previously recommended statin therapy (mean estimated 10-year ASCVD risk, 3.1% [95% CI, 2.7%-3.5%] for newly statin-eligible individuals vs 6.1% [95% CI, 5.8%-6.4%] for individuals previously eligible for statin therapy).

CONCLUSIONS AND RELEVANCE: The 2026 dyslipidemia guideline substantially expands the US population recommended for primary prevention statin therapy, predominantly in lower-risk individuals.

Substance use disorder (SUD) is a complex chronic condition requiring a multi-disciplinary approach to both research and treatment. Randomized controlled trials (RCTs) are gold standard methodologies for inferring causal relationships between an intervention and treatment outcomes but often face challenges in generalizability, scalability and real-world implementation. Target trial emulation (TTE) is a powerful methodological framework that uses observational or real-world data sources to emulate the methodology of these gold standard target trials to complement the learning from RCTs and enhance translation to real world evidence. An additional methodological innovation is the translational testing of clinical- and community-based digital health systems to provide new insights into SUD in the real world and provide scalable access to therapeutic resources. To explore these methodological innovations in SUD research, the National Institute on Drug Abuse Center for the Clinical Trials Network convened a variety of experts for a virtual workshop titled "Target Trial Emulation in Observational Research and Translational Testing of Advanced Digital Health Tools for Substance Use Disorder Prevention and Treatment." This article summarizes the discourse of the workshop, focused on three thematic areas: TTE using real-world healthcare data, SUD evidence from nationwide data sources that may be useful in TTE analyses, and translational testing of clinical- and community-based digital health systems. The workshop also highlighted various exemplars of digital health systems that demonstrate success in translational research addressing SUDs, key methodological and translational challenges, importance of rigorous study design, robust data linkages and expanding use of common data elements, and the integration of digital health tools to enhance causal inference and clinical impact. Future research directions are outlined to refine these approaches, address barriers, and maximize the utility of real-world data in shaping effective SUD prevention and treatment strategies.