Study Suggests Few Disruptions in Treatment for OUD During the Pandemic

Disruptions in health care services during the COVID-19 pandemic did not significantly reduce the ability of adults to remain in treatment for opioid use disorder (OUD), suggests a report published this week in Psychiatric Services. The authors believe that access to telehealth services was partially responsible for the continuation of care during this period.

“Among a group of adults with commercial insurance or Medicare Advantage who had received opioid use disorder treatment before the COVID-19 pandemic, we observed minimal changes in outpatient and [medications for OUD] treatment utilization in the 2 years after pandemic onset,” wrote Kayla N. Tormohlen, Ph.D., M.P.H., of Johns Hopkins Bloomberg School of Public Health and colleagues. The authors noted it is unclear if the same applies to patients covered by Medicaid and patients without insurance.

The researchers analyzed deidentified administrative insurance claims for adults aged 18 or older who were covered by commercial insurance or Medicare Advantage from March 2018 to February 2022. To compare OUD treatment trends before the start of the pandemic with those in the years that followed, only patients who had an insurance claim indicating inpatient or outpatient treatment for OUD between March 2018 and February 2019 were included in the analysis. The final sample included 13,113 adults.

In March 2019, 10.6% of the patients had an OUD outpatient visit; by February 2022, 7.8% of the patients had an OUD outpatient visit—a decline of 2.8 percentage points, Tormohlen and colleagues reported. The proportion of patients receiving medication for OUD declined by 0.3 percentage points from March 2019 to February 2022.

Other findings included the following:

• Between March 2019 and February 2020, 98.6% of the patients who received outpatient opioid use disorder treatment obtained care via in-person settings only.
• Between March 2020 and February 2021, 46.0% of the patients received at least some opioid use disorder treatment via telehealth, 34.6% received a combination of telehealth and in-person care, and 11.4% received telehealth services only.
• Between March 2021 and February 2022, 34.9% of the patients received at least some outpatient care via telehealth, 23.4% received both telehealth and in-person care, and 11.5% received care via telehealth only.

“[T]he pandemic spurred widespread policy changes, including flexibility in the delivery of telehealth for opioid use disorder treatment, that may have enhanced treatment access,” they wrote. Even with these policy changes, however, the researchers noted that the “findings suggest that telehealth did not completely replace in-person services for opioid use disorder in either the first year of the COVID-19 pandemic or 2 years after its onset.”

They concluded, “Future research may examine how these policies affect receipt of care and explore how to optimally target in-person, telehealth, or a combination of treatment modalities to patients with opioid use disorder.”

For related information, see the Psychiatric News articles “Expanded Buprenorphine Prescribing Authority Gains Traction During Pandemic” and “Pandemic Creates Challenges, New Opportunities for Treating Patients With Substance Use Disorder.”

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Patients Who Take Medication for OUD Found Less Likely to Seek Hospital Care, Study Finds

Medication for opioid use disorder—which include buprenorphine, methadone, and extended-release naltrexone—is known to improve health outcomes in patients with opioid use disorder (OUD). A report published Monday in Psychiatric Services now suggests that patients who take their medication for OUD (MOUD) more frequently are less likely to end up hospitalized or in the emergency room than those who take their MOUD less frequently.

These findings, as reported by Manesh Gopaldas, M.D., of New York State Psychiatric Institute and Columbia University Irving Medical Center and colleagues were based on a secondary analysis of data from a National Institute on Drug Abuse (NIDA) comparative effectiveness trial. In the NIDA trial, individuals seeking treatment for OUD were randomly assigned to receive extended-release naltrexone or buprenorphine-naloxone for 24 weeks. The average age of the 570 participants who received medication was 34 years old; most were male (70%), White (74%), and had completed high school or its equivalent (78%). They were followed for 36 weeks.

Adherence to MOUD was defined as the percentage of days in a month in which a participant took a prescribed medication. The participants were grouped into three levels of adherence: low (less than 20%), medium (20% to 79%), or high (80% or greater).

Gopaldas and colleagues found that those who took their medication 80% or more of the time used inpatient addiction treatment 17.87 fewer days and acute care (such as emergency room) 3.32 fewer days than those who took their MOUD less than 20% of the time. In contrast, those who took their medication 80% or more of the time were more likely to seek care at outpatient settings; for example, those in the high adherence group sought outpatient addiction treatment and other outpatient services 1.28 and 10.45 more days, respectively, than those in the low adherence group. Participants who fell into the medium adherence group were also more likely to seek outpatient treatment (8.90 more days) compared with those in the low adherence group.

Gopaldes and colleagues noted that adherence to medication deteriorated over the course of the study.

“Examining predictors of adherence may be helpful in designing interventions,” they wrote. “Understanding whether negative prognostic indicators (such as severe psychiatric or general medical problems) and indicators of socioeconomic status (such as educational attainment and employment) predict adherence to MOUD, and whether MOUD type and dosage are associated with adherence, would be valuable.”

They concluded, “Our results reinforced the view that greater MOUD adherence is associated with reduced usage of high-cost inpatient addiction treatment and acute care services and increased utilization of outpatient care. Causation cannot be inferred from these data, but the data suggested that interventions that increase MOUD uptake and adherence can reduce health care costs.”

For related information see the Psychiatric News article “Opioid Crisis: Reluctance to Prescribe Lifesaving Medications Must Stop.”

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Hospital Incentive Program Found to Increase Buprenorphine Prescriptions for Patients With OUD

Pennsylvania patients with opioid use disorder (OUD) were more likely to receive a prescription for buprenorphine within 30 days of a visit to the emergency department (ED) if they were seen at a hospital participating in the state’s Opioid Hospital Quality Improvement Program than those seen at a hospital that did not participate in this program. These findings are described in a recent report in JAMA Health Forum.

“With surging rates of opioid overdose deaths, ED encounters present a crucial opportunity to engage patients with OUD treatment,” wrote Keisha T. Solomon, Ph.D., of Howard University and colleagues. “The [Opioid Hospital Quality Improvement Program] may be a new policy approach to expanding access to evidence-based treatment for OUD across a diverse and large population of hospitals.”

In response to high opioid overdose death rates, the Pennsylvania Department of Human Services in 2019 implemented the Opioid Hospital Quality Improvement Program—a statewide program that provides financial incentives to any hospital in the state that agreed to implement changes to increase the number of OUD patients who transition from the ED to follow-up OUD treatment, including buprenorphine.

The researchers analyzed data on 17,428 adults (about 57% male) who were enrolled in Medicaid and were seen in an ED for an opioid-related cause (for example, opioid withdrawal or opioid overdose) between January 1, 2016, and December 31, 2020. The main outcome was patients’ receipt of buprenorphine within 30 days of their ED visit.

A total of 14,585 patients with OUD sought care at a hospital ED that was participating in the Opioid Hospital Quality Improvement Program; 2,843 patients sought care at a hospital ED that was not participating in the program. Prior to the Opioid Hospital Quality Improvement Program, the baseline rate for patients prescribed buprenorphine within 30 days of their ED visit for an opioid overdose was similar between hospitals that were and were not participating in the program (5.0% and 5.7%, respectively), Solomon and colleagues noted. However, the researchers found that patients who visited an ED at a hospital participating in the program in 2020 were 3.6 percentage points more likely to receive buprenorphine treatment within 30 days than patients treated at nonparticipating hospitals.

“State programs that use financial incentives to drive OUD treatment practice changes in hospitals may be effective in improving quality and care transitions,” Solomon and colleagues wrote. “Similar programs across the nation should be considered as part of a multifaceted approach to mitigating the opioid epidemic.”

For related information, see the Psychiatric News article “High-Dose Buprenorphine in the ED Effective for OUD.”

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Certain Patients With OUD Remain at Risk of Overdose After Entering Treatment

Patients who enrolled in a trial of medication treatment for opioid use disorder (OUD) who did not start or complete their assigned medication were at greater risk of experiencing an overdose than those who took their medication, according to a study published in The American Journal of Psychiatry.

“A substantial body of evidence has shown that treatment with medication for opioid use disorder (MOUD) can decrease both overdose risk and all-cause mortality among people with opioid use disorder,” wrote Laura Brandt, Ph.D., of City College of New York and colleagues. “The aim of this study was to estimate the risk of overdose events once a patient is diagnosed with OUD and engaged in MOUD treatment and to test whether the assignment to a medication (methadone, buprenorphine, extended-release naltrexone) influences this risk.”

Brandt and colleagues used data from three large MOUD clinical trials that included 2,199 adult participants with OUD:

• In the first study, participants received outpatient methadone or buprenorphine treatment for 24 weeks. Adverse events such as overdoses were reported weekly.
• For the second study, participants received counseling and buprenorphine for three to four weeks and were followed for an additional four to eight weeks. Those who did not maintain abstinence received buprenorphine treatment for 12 weeks followed by a four-week taper period. Adverse events were reported biweekly.
• Participants in the third study received outpatient buprenorphine or extended-release naltrexone over 24 weeks. Adverse events were reported weekly.

Fifty-seven overdose events occurred in the three studies, experienced by 51 participants. Fifteen overdoses occurred among 283 participants assigned to naltrexone (5.3%), eight among 529 participants assigned to methadone (1.51%), and 16 among 1,387 patients assigned to buprenorphine (1.15%). Nearly 28% of the participants assigned to naltrexone never started the medication, compared with only 2.2% of those assigned to buprenorphine and 1.7% of those assigned to methadone. Those who did not start naltrexone had an overdose rate of 8.9% compared with 3.9% among those who did start the medication.

Overall, the risk of experiencing an overdose was significantly higher among those who never started their assigned medication or who stopped their medication. Further, taking benzodiazepines at baseline was associated with an increased risk of an overdose among participants in all three medication groups.

“Patients should be educated about overdose risk, the protective effect of MOUD, and the danger of discontinuing medication,” the authors concluded. “Benzodiazepine use is also a signal of risk, and patients taking benzodiazepines should be evaluated and treated for mental health problems as part of an effort to wean them off benzodiazepines.”

For related information, see the Psychiatric Services article “Factors Associated With Initial Treatment Choice, Engagement, and Discontinuation for Patients With Opioid Use Disorder.”

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Experts Offer Six Steps for Increasing Universal Access to Medication for OUD

Universal access to medications for opioid use disorder (MOUD)—such as methadone, buprenorphine, and naltrexone—could save lives and reduce health care costs, but multiple barriers stand in the way. So wrote Rahul Gupta, M.D., M.P.H., director of the White House Office of National Drug Control Policy, and colleagues in a perspective article appearing in the New England Journal of Medicine (NEJM).

“We believe there are about 8 million above the age of 12 [with opioid use disorder], and less than 5% of those individuals are able to get treatment for opioid use disorder,” Gupta said in an interview with Stephen Morrissey, Ph.D., executive managing editor of the NEJM.

President Joe Biden’s 2022 National Drug Control Strategy (NDCS), which is spearheaded by the Office of National Drug Control Policy, calls for access to MOUD for any person with OUD by 2025. The authors recommended six steps that could assist in meeting this goal:

1. Bolster educational opportunities for health professionals: The federal government, along with medical education accreditation bodies, “could bolster addiction-treatment and education infrastructure” by “enhancing content related to MOUD in medical education curricula for all health-related professions and further building workforce capacity in addiction medicine by means of continuing education.”
2. Increase access to prescription MOUD in clinic- and community-based programs: One way to increase access to prescription MOUD may be through “low-threshold” buprenorphine treatment (an approach that embraces the harm-reduction philosophy of meeting patients where they are). “Low-threshold treatment programs have shown promise in enrolling people with OUD who may avoid conventional health care settings, where they often face stigma, and whose only point of contact with the health care system might be the emergency department.”
3. Ease restrictions on telemedicine: “On the basis of emerging evidence supporting the critical role of telemedicine in increasing access to buprenorphine, the NDCS calls for permanently extending pandemic-era telehealth waivers and flexibility that have permitted the initiation and maintenance of buprenorphine treatment.”
4. Increase access to treatment for people who are incarcerated: “Many people who use drugs have frequent interactions with the justice system, and overdose risk in the weeks after release from incarceration is extraordinarily high. … In addition to reducing mortality after release, offering MOUD during incarceration may reduce recidivism.”
5. Develop and support programs to address social determinants of health: “Food insecurity, income inequality, discrimination, housing instability, and homelessness have long been recognized as social drivers of population health and can affect retention in MOUD treatment.”
6. Take steps to reduce stigma in the health care system against people with OUD: Stigma can reduce the likelihood of initiating and continuing use of MOUD. By using patient-first language (for example, a “person with substance use disorder” rather than an “addict”) and publicizing the benefits of MOUD, clinicians and researchers may be able to help to reduce OUD-related stigma.

Gupta emphasized the role that health care professionals can play in ensuring their patients with OUD have access to MOUD. “The success of the national strategy will ultimately depend on the ability, willingness and the actions by individual providers in communities to act with urgency and make sure that we’re doing the most we can do save lives and get people into treatment,” he said.

For related information, see the Psychiatric News article “Most Youth With OUD Who Need Medication Treatment Do Not Receive It.”

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