Since 2015, at least five states have passed laws requiring emergency departments to provide additional support for opioid overdose patients, such as initiating MOUD treatment. Over the next five years, and her research team will examine whether state policies that mandate evidence-based treatments for opioid use disorder ultimately save lives.

Opioid use disorder is a life-threatening health condition that affects more than 2 million people in the U.S.

For those experiencing opioid overdose, MOUDs like buprenorphine and methadone can reduce the risk of death by 50%.

An associate professor in the College of Community Innovation and Education’s , Andraka-Christou focuses much of her research efforts on expanding access to life-saving medications for substance use disorder.

Expanding Life-Saving Care

Funded by a five-year, $3.5 million NIH grant, Andraka-Christou is collaborating with University of Michigan health economist and multiple principal investigator Thuy Nguyen on this legal epidemiology project. Using policy surveillance and difference-in-difference analyses, they’ll assess how state emergency department laws affect patient health outcomes. The findings could inform broader development, refinement and implementation of similar policies, ultimately improving care for people experiencing overdose and helping prevent future overdoses.

She adds that the specific requirements of each law may make a difference. For example, an overdose patient who’s handed a phone number for an addiction clinic may be less likely to connect and continue receiving treatments than someone who’s provided with an MOUD in the emergency department and guided through setting up an appointment in the community, she says.

“It’s one thing to start someone on MOUDs, but an emergency department is a unique setting,” Andraka-Christou says. “We don’t want people to have to repeat the cycle and keep going back to the emergency room. There needs to be an intermediary step — perhaps a warm handoff to a primary care doctor, an addiction clinic or a methadone clinic — so that they can continue to see that person after initial treatment. That’s currently a big gray area, and outcomes can potentially depend on how prescriptive these laws are.”

Building a First-Of-Its-Kind Database

Andraka-Christou and her team are creating a longitudinal database of all state statutes, regulations and executive orders effective between 2014 and 2024 related to facilitating MOUD use after emergency department visits for opioid overdose. This requires assessing thousands of laws for relevance before interpreting legal jargon, summarizing and transforming them into a quantitative policy dataset.

The team will then use three sets of claims data — Medicaid, Medicare and commercial insurance — to describe trends in MOUD initiation and retention rates after emergency department visits, examining the effects of different policies. Researchers will also comb through the data to find and describe key patient, provider, geographic and demographic characteristics associated with treatment after these visits. Such factors include rurality, income level and covariates like age or co-occurring conditions.

“With overdoses, there are so many claim codes that are relevant, such as poisoning, intoxication and overdose,” Andraka-Christou says. “They’re also divided by the type of opioid. Within all of these, we will also examine the type of medication that they’re receiving — such as methadone, buprenorphine or naltrexone — and how any legal issues surrounding them influence retention. We’ll need to look at differences in effects of the law by type of poisoning, and there might also be variation in the effects of these laws depending on each population of insurance.”

Shifting How Standards of Care Are Enforced

Andraka-Christou says that at a higher level, the project should provide an interesting analysis of what happens when state law requires specific action in medicine. Instead, best practices may not occur until patients or their families initiate malpractice lawsuits for violation of the standard of care — something that also requires health literacy and legal knowledge to do. If top-down state laws in this study are found to be effective at increasing the use of evidence-based treatment, they could serve as catalysts for a paradigm shift in how quality of care is enforced in hospitals.

“If we find that the states that implemented a law requiring MOUD provision see more opioid-use disorder patients staying on the medications, that bodes well and could have massive implications for public health,” she says. “At that point, there’s a good argument to be made that, for this situation and population, we may need to take a more top-down approach to enforce the standard of care.”

Researcher Credentials

Andraka-Christou received both her juris doctorate and Doctor of Philosophy in law and social science from Indiana University Bloomington. She is a licensed attorney. She joined Â鶹ӳ»­´«Ă˝â€™s School of Global Health Management and Informatics in 2017 and holds a joint secondary appointment in the College of Medicine. Her areas of expertise include health services, health policy and substance use disorder treatment. Andraka-Christou also leads Â鶹ӳ»­´«Ă˝â€™s  research team.

However, a new Â鶹ӳ»­´«Ă˝ study recently published in Health Affairs shows that one of the most effective medications for treating opioid addiction is one of the least covered by insurance plans often used by patients with substance use disorder.

Researchers found that although most plans covered the immediate-release sublingual form of buprenorphine, extended-release buprenorphine injections were covered by less than half of commercial plans and less than a fifth of Medicare Advantage Plans. Furthermore, while most Medicaid plans did cover it, more than a third presented a barrier by requiring prior authorization before prescription.

The study’s lead author, , says her key passion in research is trying to understand how to expand access to these life-saving treatments.

“Approximately 20% of people actually use buprenorphine or another similar medication called methadone for treatment of opioid-use disorder,” she says. “Most people don’t get any treatment, or if they do get treatment, they’re getting something that’s less effective. Unfortunately, there have been a lot of barriers to accessing it, and some of those have been either lack of insurance coverage or various prior-authorization requirements.”

Buprenorphine can be prescribed by any clinician licensed by the Drug Enforcement Administration and comes in two overall forms: an oral immediate release version that is taken daily or a monthly extended-release intramuscular injection. Since some of the oral versions of the medication are available in generic form, they tend to be the cheaper option. The injection is newer and still under patent, making it the more expensive option.

How the Research Was Performed

Andraka-Christou, an associate professor in the at Â鶹ӳ»­´«Ă˝, teamed up with Thuy Nguyen from the University of Michigan, W. David Bradford from the University of Georgia and Kosali Simon from Indiana University to examine Medicaid, Medicare Advantage and commercial insurance formulary files to compare insurance-imposed restrictions for buprenorphine from 2017-21.

They studied factors like insurance coverage, prior-authorization requirements, and other potential access barriers like step therapy and quantitative limits across commercial providers, Medicaid, and Medicare.

“Medicaid covers about a third of people in the U.S. with opioid-use disorder and Medicare covers both the elderly and disabled populations,” she says. “That’s important because among older Americans, the rates of opioid overdoses have also been increasing. Because people flow in and out of different types of insurance, it’s very important to look at all insurance sectors.”

What Andraka-Christou and her team found were stark differences in coverage and prior authorization barriers depending on the form of buprenorphine requested. Nearly all plans covered at least one form of immediate-release buprenorphine in 2021, and prior-authorization requirements and quantity limits gradually decreased for immediate-release buprenorphine.

The intramuscular, extended-release injection was subject to the most variance by insurer type. Their research determined that Medicare and commercial insurance were less likely to cover the cost of the buprenorphine injection — with only 46% of commercial plans and 19% of Medicare Advantage plans covering it — as compared to Medicaid. On the other hand, most Medicaid plans covered the extended-release version in 2021, although 37% still required prior authorization.

Despite the oral version now being largely covered by insurers, Andraka-Christou says there is a downside in that it’s easier for opioid-use disorder patients to relapse if they skip doses. With the monthly intramuscular injection, that is less likely to happen.

“The reason prior-authorization requirements are a problem is that someone with an addiction may have a short window of time during which they’re willing to go and get treatment,” Andraka-Christou says. “From a public health standpoint, it’s very important to not have prior-authorization requirements for these types of medicines. The injection is also very expensive because it’s still on patent, so those requirements probably exist to cut costs. However, if someone had to wait days for the injection and has an overdose in that timeframe, then it might be less costly to not require prior authorization.”

The barriers related to the oral version of buprenorphine have been a topic of conversation in U.S. healthcare for a while, but Andraka-Christou’s team found that prior-authorization requirements for oral versions are minimal today compared to 10 years ago. With this new finding, she urges researchers, advocates and policymakers to shift their attention to the intramuscular injection version and work on addressing those barriers.

“I think providing access to life-saving treatment needs to be a priority for policymakers and community advocates, and that’s where my passion comes from,” Andraka-Christou says. “The fact is that we have this ongoing, horrific crisis, but we also have tools like buprenorphine and methadone that could cut the risk of overdose deaths in half if they weren’t so underused. State lawmakers could help lead this effort by requiring insurers to cover extended-release buprenorphine without prior authorization.”

Researcher Credentials

Andraka-Christou received both her juris doctorate and doctorate in law and social science from Indiana University Bloomington. She joined Â鶹ӳ»­´«Ă˝â€™s School of Global Health Management and Informatics, part of Â鶹ӳ»­´«Ă˝â€™s , in 2017. Her areas of expertise include health services, health policy and substance-use disorder treatment. Much of her research on the evolving opioid epidemic is summarized in her book The Opioid Fix: America’s Addiction Crisis and the Solution They Don’t Want You to Have (Johns Hopkins University Press, 2020).