Buprenorphine dosing patterns and treatment outcomes for patients with opioid use disorder insured by Medicaid in Philadelphia

INTRODUCTION: Opioid use disorder (OUD) remains a significant public health challenge, exacerbated by the rise of potent, synthetic opioids like fentanyl in the illicit drug supply. Buprenorphine, a partial opioid agonist, is an evidence-based treatment for OUD. While evidence suggests that higher buprenorphine doses (>16 mg/day) improve treatment retention and reduce overdose, many providers hesitate to prescribe these doses. METHODS: This study analyzed buprenorphine dosing patterns and treatment outcomes among Medicaid-insured individuals with OUD in Philadelphia from 2017 to 2023. Data were obtained from Community Behavioral Health (CBH), Philadelphia's Medicaid behavioral health managed care organization. The study included individuals with OUD who received buprenorphine through a prescription filled by a pharmacy, and are grouped into 3 dosage groups: ≤8 mg, 9-16 mg, and 17-24 mg. We examined demographic characteristics, co-occurring conditions, and outcomes such as emergency department visits and detoxification and rehabilitation stays across these dosage groups. RESULTS: We identified 5760 individuals with OUD who were prescribed buprenorphine in 2023. The proportion of prescriptions for 17-24 mg doses increased from 12.05 % in 2017 to 40.51 % in 2023 (p < 0.0001). Higher doses were associated with improved treatment outcomes compared to those on lower doses: individuals on higher dosing levels were less likely to have detoxification and rehabilitation stays (39.16 % for 17-24 mg; 60.75 % for ≤8 mg and 49.93 % for 9-16 mg; (p < 0.0001) and were more likely to remain in care (90.2 vs. 205.3 days of buprenorphine supplied on 24 mg, respectively, (p < 0.0001). Black individuals were more likely to receive lower doses compared to white patients. CONCLUSION: Higher buprenorphine doses are associated with better treatment outcomes, including reduced detoxification and rehabilitation stays. Racial disparities in dosing highlight the need for equitable access to evidence-based OUD treatment. Addressing provider hesitancy and systemic barriers to higher doses is crucial in improving outcomes, particularly in the context of fentanyl-contaminated drug supplies.