US NEWS / February 5, 2020

Far too people with opioid addiction have had access to the most effective treatments in recent years, a new study suggests.

Getting people into high-quality, evidence-based addiction treatment is seen as key to curbing the nation’s deadly opioid epidemic. The new study, published Wednesday in JAMA Network Open, indicates that treatment using buprenorphine or methadone – medications that can help people manage opioid withdrawal – is by far the most effective way to prevent overdoses and hospitalizations, but that people were much less likely to have access to these medications than to other treatments.

The analysis included nearly 41,000 people with opioid use disorder who had commercial health insurance or Medicare Advantage plans from approximately 2015 to 2017 – three years when nearly 123,000 people died of opioid overdoses. The study found that just 12.5% of patients were treated with buprenorphine or methadone, compared with 59.3% who received outpatient counseling only and 15.8% who went into residential rehabilitation or detox services.

“We’ve known for years that methadone and buprenorphine are the most effective treatments we have for opioid use disorder,” says Dr. Sarah Wakeman, the study’s lead author and medical director of Massachusetts General Hospital’s substance use disorders initiative. “I think there’s been a real gap between what science has shown us is most effective and then what actually happens in real-world clinical practice.”

To measure the effectiveness of different addiction treatments, researchers split people diagnosed with an opioid addiction into one of six categories: those who received no further treatment; those placed into inpatient detox or residential rehabilitation; those who received intensive behavioral health treatment through an outpatient setting or partial hospitalization; those who got outpatient counseling; patients given buprenorphine or methadone; or patients given naltrexone, the third federally approved drug to treat opioid addiction.

Researchers then measured how many people either had overdosed or received “serious opioid-related acute care” – defined as an emergency department visit or hospitalization for an opioid-related issue – at three and 12 months after their initial treatment visit.

Overall, 1.7% of patients overdosed and 1.9% were hospitalized or had visited an ER within three months. But compared with patients who received no treatment, those treated with buprenorphine or methadone were 76% less likely to overdose within three months and 59% less likely to overdose within a year, the analysis showed. They were also 32% less likely to be hospitalized or go to the ER within three months, and 26% less likely to have an acute care episode 12 months later.

None of the other treatment methods were associated with significant declines in both overdoses and acute care at the three- and 12-month marks.

“These medications save lives,” Wakeman says. “They keep people healthy and they keep them out of the emergency department. And we need to be doing everything we possibly can to make them broadly accessible.”

Yet for many in throes of addiction, even for those with health insurance, buprenorphine and methadone remain largely out of reach. Few physicians have obtained a federal waiver to prescribe buprenorphine, and methadone is only available through tightly regulated clinics.

“Unfortunately, many of our treatment models make it really hard to stay engaged in care,” Wakeman says. “We’ve set up all sorts of barriers – whether it’s arbitrary counseling requirements, insurance prior authorizations, copays or even just an unwelcoming environment where people have to come to get their treatment – that make it really hard for people to stay engaged over the long term.”

Getting people access to buprenorphine or methadone may not be enough, though, as researchers found a “dramatic” difference in outcomes between people who stayed on their medication long-term and those who tapered off earlier, Wakeman says.

After one year, 6.4% of people who used these medications for a month or less overdosed, the study showed, while 8.2% had a serious acute care episode. Among people who were on the medication for more than 180 days, 1.1% overdosed and 2.6% had an acute care visit. The average medication treatment period was about 150 days.

“I think it’s really on us in the treatment community to change our whole model,” Wakeman says. “If our fundamental goal is, how do we get people in the door, get them started on lifesaving treatment, and then keep them with us, that really forces us to think about an entirely different structure and approach to taking care of individuals.”