Providers Underuse OUD Treatments That Significantly Reduce Overdose Rates

Two long-available medications, methadone and buprenorphine, are highly effective in treating opioid use disorder (OUD) but remain underutilized by physicians, according to a study published in February in the Journal of the American Medical Association.

Researchers, led by Dr. Sarah E. Wakeman of Massachusetts General Hospital, examined six approaches to helping people with OUD, including the use of methadone and buprenorphine. The others were no treatment, inpatient detoxification or residential services, intensive outpatient or partial hospitalization, the drug naltrexone, and outpatient counseling.

Using no treatment as the control for the study, Wakeman and her team found that only treatment with buprenorphine or methadone led to significant reductions in overdoses and serious opioid-related acute care use at both three and 12 months of follow-up. The latter is defined as an emergency department visit or hospitalization. The other pathways studied were not significantly associated with overdose reduction at those time periods.

Despite the effectiveness of methadone and buprenorphine, only a limited number of patients can access these treatments, in large part because of numerous regulatory hurdles, prior authorization requirements, and high co-payments.

The study analyzed both private payer and Medicare Advantage claims data for nearly 41,000 individuals with OUD and compared the effectiveness of the six approaches on key outcomes. The results show that:

• Buprenorphine or methadone was associated with a 76 percent reduced risk of overdose at three months of follow-up and a 59 percent reduction at 12 months, compared with rates for those who had no treatment.
• Buprenorphine or methadone was associated with a 32 percent reduced risk of serious opioid-related acute care use at three months of follow-up and a 25 percent reduction at 12 months. In contrast, inpatient detoxification, intensive behavioral health, and naltrexone did not significantly reduce the risk of overdose or of serious opioid-related acute care use at three or 12 months.
• Outpatient counseling alone, meanwhile, was associated with a 31 percent reduced risk of overdose at 12 months, but no statistically significant change at three months, as well as a reduced risk of opioid-related acute care use at both three (41 percent) and 12 months (40 percent).

Despite strong evidence that the medications are effective in treating OUD, the study reported that only 12.5 percent of the participants received buprenorphine or methadone.

Unlike buprenorphine or methadone, the other treatment pathways studied were not significantly associated with overdose reduction at both three and 12 months of follow-up. Furthermore, compared with these two medications, the other approaches were more likely to lead to post-treatment admission for inpatient detoxification.

As the overdose crisis continues across the country, these findings are more important than ever. More than 2 million Americans struggle with OUD. In 2018 alone, opioids were linked to 46,802 overdose deaths.

Although the use of medications, including buprenorphine or methadone, can reduce the number of deaths, most people with OUD do not get any treatment. Nationwide, physicians face hurdles in prescribing buprenorphine, including the need to obtain waivers from the Drug Enforcement Administration that require additional training. That means few offer this treatment. Furthermore, stigma—both internalized and perceived—surrounding OUD remains a problem, with many patients feeling shame about themselves or experiencing judgment from others.

Regulations also serve as barriers to prescribing methadone. Federal law forbids methadone for OUD treatment from being obtained outside of opioid treatment programs (OTP), which may be unavailable or inaccessible in many communities. Furthermore, OTPs must abide by cumbersome government accreditation and certification processes.

Federal rules also impose treatment requirements related to methadone for OUD, such as the need for mandatory behavioral health counseling. Patients receiving the medication must also typically undergo daily supervised dosing. Many states and localities have additional policies that restrict the number of OTPs, often unnecessarily, which can limit access to this life-saving drug.

The JAMA article details the findings in one of many recent studies that demonstrate the importance of buprenorphine or methadone in treating OUD. In 2019, for example, a report by the National Academy of Sciences included a thorough review of the benefits of medications to treat OUD. Given the overwhelming evidence, restrictions to accessing these drugs must be eliminated so more people suffering from OUD can get the essential help they need.

Beth Connolly directs The Pew Charitable Trusts’ substance use prevention and treatment initiative.