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Abstract
With increasing demand for substance use disorder (SUD) treatment among older adults and a rapidly aging population, improved access to evidence-based medication treatment for this population is critical. As of 2021, there are three FDA-approved medications for opioid use disorder (MOUD) including buprenorphine, injectable naltrexone, and methadone and four FDA-approved medications for alcohol use disorder (MAUD) including oral naltrexone, injectable naltrexone, acamprosate, and disulfiram. This dissertation is comprised of three essays that examine the availability of SUD treatment medications for Medicare beneficiaries. The first essay examines the availability of MOUD within the specialty treatment system, where the majority of Americans receive treatment. Findings show that only 13.8 percent of specialty programs offered buprenorphine or injectable naltrexone for older adults who used Medicare to pay for treatment in 2016. The second essay examines the availability of buprenorphine in Medicare Part D following implementation of the Comprehensive Addiction and Recovery Act (CARA) of 2016, which extended buprenorphine prescribing authority to Nurse Practitioners (NPs) and Physician Assistants (PAs). Findings show that following CARA, counties in states with full NP scope of practice experienced a 15 percent increase in the availability of buprenorphine in Medicare Part D relative to states with less generous NP scope of practice laws, conditional on having any buprenorphine providers in the county. Effects were concentrated in urban areas. The third essay examines the availability of MAUD in Medicare Part D at the county-level from 2010 to 2018. Results show that the percentage of counties with a provider offering any MAUD in Medicare Part D increased from 25 percent in 2010 to 34 percent in 2018, which was largely driven by increased availability of oral naltrexone. While these essays show modest improvement in MOUD and MAUD availability, gaps in access remain particularly in rural counties and the South. Targeted efforts to improve availability should include workforce training in the identification and treatment of SUD among older adults, increased availability of specifically tailored SUD treatment services for older adults, and enhanced delivery of evidence-based medication treatment in specialty and non-specialty treatment settings.