Comparative Effectiveness of Different Treatment Pathways for Opioid Use Disorder

Abstract

IMPORTANCE Although clinical trials demonstrate the superior effectiveness of medication for opioid use disorder (MOUD) compared with nonpharmacologic treatment, national data on the comparative effectiveness of real-world treatment pathways are lacking.OBJECTIVE To examine associations between opioid use disorder (OUD) treatment pathways and overdose and opioid-related acute care use as proxies for OUD recurrence. DESIGN, SETTING, AND PARTICIPANTS This retrospective comparative effectiveness researchstudy assessed deidentified claims from the OptumLabs Data Warehouse from individuals aged 16 years or older with OUD and commercial or Medicare Advantage coverage. Opioid use disorder was identified based on 1 or more inpatient or 2 or more outpatient claims for OUD diagnosis codes within 3 months of each other; 1 or more claims for OUD plus diagnosis codes for opioid-related overdose, injection-related infection, or inpatient detoxification or residential services; or MOUD claims EXPOSURES One of 6 mutually exclusive treatment pathways, including (1) no treatment, (2) inpatient detoxification or residential services, (3) intensive behavioral health, (4) buprenorphine or methadone, (5) naltrexone, and (6) nonintensive behavioral health. MAIN OUTCOMES AND MEASURES Opioid-related overdose or serious acute care use during 3 and 12 months after initial treatment. RESULTS A total of 40 885 individuals with OUD (mean [SD] age, 47.73 [17.25] years; 22 172 [54.2%] male; 30 332 [74.2%] white) were identified. For OUD treatment, 24 258 (59.3%) received nonintensive behavioral health, 6455 (15.8%) received inpatient detoxification or residential services, 5123 (12.5%) received MOUD treatment with buprenorphine or methadone, 1970 (4.8%) received intensive behavioral health, and 963 (2.4%) received MOUD treatment with naltrexone.During 3-month follow-up, 707 participants (1.7%) experienced an overdose, and 773 (1.9%) had serious opioid-related acute care use. Only treatment with buprenorphine or methadone was associated with a reduced risk of overdose during 3-month (adjusted hazard ratio [AHR], 0.24; 95% CI, 0.14-0.41) and 12-month (AHR, 0.41; 95% CI, 0.31-0.55) follow-up. Treatment with buprenorphine or methadone was also associated with reduction in serious opioid-related acute care use during 3-month (AHR, 0.68; 95% CI, 0.47-0.99) and 12-month (AHR, 0.74; 95% CI, 0.58-0.95) follow-up. (continued) Key Points Question What is the real-world effectiveness of different treatment pathways for opioid use disorder? Findings In this comparative effectiveness research study of 40 885 adults with opioid use disorder that compared 6 different treatment pathways, only treatment with buprenorphine or methadone was associated with reduced risk of overdose and serious opioid-related acute care use compared with no treatment during 3 and 12 months of follow-up. Meaning Methadone and buprenorphine were associated with reduced overdose and opioid-related morbidity compared with opioid antagonist therapy, inpatient treatment, or intensive outp...

Association of Racial/Ethnic Segregation With Treatment Capacity for Opioid Use Disorder in Counties in the United States

“…7 To date, there is little research identifying which patients with OUD will respond better to which medication. 8 Furthermore, no single medication has been endorsed as a preferred first-line treatment, 5 but a 2020 study 9 reported that treatment with either methadone or buprenorphine was effective in reducing the risk of opioid overdose and opioid-related acute care utilization compared with other nonpharmacological treatment modalities. In addition, long-term outcomes do not appear to differ substantially between individuals using either medication.…”

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“…These medications are the most effective treatment we have for opioid use disorder. They successfully reduce craving, withdrawal, drug use, overdose and acute-care utilization 5 .…”

A mixed-method comparison of physician-reported beliefs about and barriers to treatment with medications for opioid use disorder 

“…Participants believed that buprenorphine is slightly more effective than methadone at preventing opioid overdose, among other measures of e cacy, although the scholarly literature suggests that methadone and buprenorphine e cacy is comparable, with a literature review nding that methadone is slightly more effective at retaining patients in treatment than buprenorphine (44,45). Retention is critical, as longer retention with either buprenorphine or methadone is associated with lower rates of opioid overdose and opioid-related acute care use (9). In a randomized control multisite trial, 74% of patients randomized to methadone completed treatment at 24 weeks, as compared to 46% of those randomized to buprenorphine/naloxone (46).…”

“…Medications for OUD (MOUD), often in combination with behavioral therapy, are considered the gold standard for treating OUD (5). Clinical trials have demonstrated that three MOUDs-methadone, buprenorphine, and extended-release naltrexone-reduce opioid use, overdose, and other adverse health outcomes, although methadone and buprenorphine appear to be more protective against overdose than extended-release naltrexone (9). Methadone and buprenorphine treatment are associated with 53% and 37% reductions, respectively, in all-cause mortality among patients with OUD as compared to those receiving no MOUD in the 12 months following nonfatal overdose (11).…”

“…Even though methadone for OUD cannot be prescribed outside of OTPs, o ce-based physicians can refer patients to these facilities for methadone treatment; but little is known about frequency of and barriers to this referral process. Furthermore, few studies have directly compared physician beliefs about e cacy and barriers across all three MOUDs (9,33,30).…”