Background
The opioid epidemic continues to claim many lives. At least two million Americans are estimated to have opioid use disorder (OUD),¹ and nearly 47,000 lives were lost in 2018 alone.²
Experts in addiction medicine recognize that OUD is a chronic disease and point to the strength of the evidence base supporting the use of medications for treating OUD.
They also believe the health system has the means to build capabilities to work smarter and harder to reduce the personal burden of all those impacted by OUD, its stigma and the societal costs impacting so many areas of American life.
The evidence is clear from a large set of studies³,⁴,⁵,⁶,⁷ on the value of buprenorphine or methadone as the best treatment currently available.
However, many individuals with OUD continue to receive other less effective forms of treatment (or no treatment) resulting in higher risks of adverse outcomes like overdose, and higher costs, according to the National Institute for Drug Abuse.
A recent study from researchers at Massachusetts General Hospital, Boston Medical Center, and OptumLabs adds new evidence that fortifies this case.
The study shows that individuals initiating OUD treatment with either buprenorphine or methadone had better clinical and cost outcomes in several areas than those beginning their OUD treatment via an alternative care pathway like inpatient detox/residential treatment, outpatient counseling or receiving no treatment.
The results of this work were published in JAMA Network Open and Medical Care.
Major takeaways
The study shows that those initiating treatment with buprenorphine or methadone on average had more favorable outcomes than those whose OUD treatment care pathway was one of five other initiating pathways:
- Outpatient-only behavioral health counseling
- Intensive outpatient/partial hospitalization treatment
- Treatment with naltrexone (another medication for treating OUD)
- Inpatient detoxification/residential treatment
- No treatment
Individuals initiating treatment with buprenorphine or methadone had significantly better outcomes, on average, in all of these areas:
- Overdose rates — a 76% reduction in overdose at 3 months and a 59% reduction at 12 months compared to no treatment
- Opioid-related ED visits or inpatient (IP) hospitalizations — a 32% relative reduction in serious opioid-related acute care use at 3 months and a 26% relative reduction at 12 months
- Rates of IP detoxification and residential treatment episodes
- Total cost of care at 3 months and 12 months
OUD Treatment Pathways Study
This observational OptumLabs study of more than 40,000 individuals with a diagnosis of OUD is the largest of its kind.
The project was done in collaboration with addiction medicine clinician researchers from Massachusetts General Hospital and Boston Medical Center and sponsored by Optum Behavioral Health. It examined the comparative effectiveness associated with six treatment pathways:
- Inpatient detoxification/residential treatment center (RTC) with or without medication use
- Intensive behavioral health care that included intensive outpatient or partial hospitalization
- Buprenorphine or methadone (with or without counseling)
- Naltrexone occurring in the absence of inpatient detoxification (with or without counseling)
- Outpatient behavioral health services only
- No treatment
This claims-based study was conducted using de-identified data from the OptumLabs Data Warehouse. The cohort included commercially insured and Medicare Advantage enrollees diagnosed with OUD between 2015 and 2017.
Initiated OUD treatment pathway frequencies
The first phase of this work examined the frequency of various OUD treatment types that occur in real-world settings.
Researchers found that “behavioral health outpatient services only” (59.3%) was the dominant care pathway patients initiated in the first 90 days after diagnosis. Inpatient detoxification/residential treatment was the second most common initial treatment (15.8%)
Only 12.5% of our cohort initiated treatment with buprenorphine or methadone.
Not receiving any treatment for OUD was more common in this cohort (5.2%) than initiation of treatment with naltrexone in the absence of a detoxification stay (2.4%) or initiation through intensive behavioral health treatment that included intensive outpatient or partial hospitalization (4.8%).
Comparative cohort: Initiating treatment pathways
| Total: 40,885 | 100.00 |
| No treatment | 5.2 |
| Detox/RTC: Inpatient | 15.8 |
| BH: Intensive outpatient/partial hospitalization | 4.8 |
| Buprenophine or methadone | 12.5 |
| Naltrexone | 2.4 |
| BH: Outpatient | 59.0 |
Clinical outcomes
The second phase of the study evaluated the clinical outcomes for those who had 3, 6 and 12 months of continuous enrollment via insurance coverage after their treatment initiation. The research team compared the outcomes of the five different treatment pathways to those receiving no treatment.
Individuals initiating treatment with buprenorphine or methadone had the fewest overdoses and fewest subsequent detoxification stays. There was a 76% reduction in overdose at 3 months post-diagnosis and a 59% reduction in overdose at 12 months after OUD diagnosis compared to no treatment.
The buprenorphine/methadone group also saw similar, lower rates of opioid-related inpatient (IP) or emergency department (ED) utilization. There was a 32% relative rate of reduction in serious opioid-related acute care use (IP and ED use) at 3 months and a 26% relative rate of reduction at 12 months compared with no treatment.
Notably, those initiating treatment with IP detoxification/residential care had the highest likelihood of a subsequent IP detoxification stay or opioid-related IP or ED visit.
The group initiating with detoxification/residential care also had similar, higher rates of overdose as the no treatment group. Compared to no treatment, this treatment modality produced no benefit with regard to preventing overdose or serious opioid-related acute care utilization at either 3 months or 12 months of follow-up.
Cost outcomes
The opioid crisis can also be examined through the health care cost lens. The researchers assessed total cost of care (including opioid-related and non-opioid-related care) over the 3 month period starting on the date individuals first received their initial treatment, and at 6 and 12 months.
Among those with OUD, initiating treatment with buprenorphine or methadone had the lowest total cost of care in the 3 months after treatment initiation. Costs were approximately 33% less than those receiving no treatment and 70% less than those initiating with IP detoxification/ residential care.
Overall, those initiating treatment with inpatient detoxification/residential care had the highest costs at 3, 6, and 12 months of continuous enrollment.
The researchers did not find that the cost advantage of initiating with buprenorphine or methadone persisted at 12 months for the population that was retained through continuous enrollment.
The reason for the lack of persistence in lower costs for buprenorphine/methadone is unclear. However, these cost data alone should not be used as the basis to favor naltrexone over buprenorphine or methadone in coverage policies.
Notably, an analysis of a randomized clinical trial found buprenorphine to have superior cost-effectiveness compared with extended-release naltrexone.8 Additionally, like other studies, this study showed low rates of retention with naltrexone (12%).
The clinical outcomes associated with using medications for treating OUD are significant and both reinforce and add to the impacts shown in previously published studies.
Evaluation of the cost of care was another research aim and a separate paper on cost differences is pending publication. The researchers have assessed total cost of care over the 3-month period starting on the date individuals first received their initial treatment, and at 3, 6 and 12 months.
Responding with a plan for action
The outcomes associated with using medications for treating OUD are significant and both reinforce and add to the impacts shown in previously published studies. The relatively low use of medication in treating opioid use disorder seen in this study as well as many other published studies make the strong case for continued investment in expanding access to these medications.
Strategies include expanding access to waiver training for providers to enable buprenorphine prescribing in many settings from many medical and behavioral health practitioner types and increasing efforts to educate patients and clinicians about the value of medications for opioid use disorder.
This study’s findings reinforce the importance of ongoing Optum efforts to increase access to medications as the standard of care for OUD.
More on the organizational response from Optum in terms of provider education, elimination of prior authorization for medications for OUD and increasing access through support lines and telemedicine can be found here.
Citations
1. Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: Results from the 2018 National Survey on Drug Use and Health (HHS Publication No. PEP19-5068, NSDUH Series H-54). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, 2019.
2. Hedegaard H, Miniño AM, Warner M. Drug overdose deaths in the United States, 1999-2018. NCHS Data Brief. Jan 2020;356.
3. Katz J, Sanger-Katz M. "’The numbers are so staggering.’ Overdose deaths set a record last year." New York Times. 29 Nov 2018, https://www.nytimes.com/interactive/2018/11/29/upshot/fentanyl-drug-overdose-deaths.html.
4. Krupitsky E, Nunes EV, Ling W, Illeperuma A, Gastfriend DR, Silverman BL. Injectable extended-release naltrexone for opioid dependence: a double-blind, placebo-controlled, multicentre randomised trial. Lancet. 2011;377(9776):1506-1513.
5. Mattick RP, Breen C, Kimber J, Davoli M. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database Syst Rev. 2009(3):CD002209.
6. Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2014(2):CD002207.
7. Larochelle MR, Bernson D, Land T, et al. Medication for opioid use disorder after nonfatal opioid overdose and association with mortality: A cohort study. Annals of Internal Medicine. 2018;169(3):137-145.
8. Murphy SM, McCollister KE, Leff JA, et al. Cost-Effectiveness of Buprenorphine-Naloxone Versus Extended-Release Naltrexone to Prevent Opioid Relapse. Ann Intern Med. 2018.
