Three Key Factors Significantly Reduce Opioid-Related Deaths

Nancy A. Melville

July 07, 2017

Three key factors may help reduce opioid-related deaths by nearly one third in individuals with opioid use disorder (OUD), new research shows.

Quarterly physician visits, psychosocial care, and no opioid or benzodiazepine prescribing were associated with a significantly reduced mortality risk in a large study of veterans with OUD.

"We found in this population of veterans with opioid use disorders that delivering care that is consistent with these three indicators was linked to significant reductions in mortality by almost a third," lead author Katherine Watkins, MD, a senior physician policy researcher and faculty member with the Pardee RAND Graduate School, in Santa Monica, California, told Medscape Medical News.

"This is the first study to show an association between process measures and mortality in patients with opioid use disorders and provides initial evidence for their use as quality measures," the authors write.

The study was published online June 27 in Drug and Alcohol Dependence.

High Mortality

Mortality rates among individuals who misuse prescription opioids and heroin are six to 20 times greater than in the general population, and although quality care measures are in place for people with substance use disorders, no measures exist for those with opioid addiction, Dr Watkins noted.

"There are currently no measures of quality care that are reliable and valid or that have been endorsed by the National Quality Forum that are specific for opioid addiction," she said.

For the study, the investigators evaluated data on 32,422 patients who were treated in the Veterans Affairs (VA) health system during 2007 and who were identified as having OUD.

The investigators analyzed mortality data associated with seven process measures at 12 and 24 months. These included the following:

  • Hepatitis screening

  • HIV screening

  • No prescription of opioids or benzodiazepines

  • Receipt of any OUD pharmacotherapy

  • Receipt of OUD pharmacotherapy for at least 3 months

  • Psychosocial treatment

  • Quarterly physician visits

Of these measures, only quarterly physician visits, receiving any psychosocial treatment, and no prescribing of benzodiazepines or opioids significantly reduced mortality.

Quarterly physician visits were associated with an 18% (P < .01) and 15% (P < .001) reduction in mortality at 12 and 24 months, respectively. Receiving at least one psychosocial treatment was tied to a 24% (P < .001) reduction in mortality at 12 months and an 18% (P < .001) reduction at 24 months. No prescribing of opioids or benzodiazepines was associated with a 29% reduction in mortality at 12 months and a 27% (P < .001) reduction at 24 months (P < .001).

Important Implications

"This is a very large drop in mortality, and we need to conduct more research to see if these findings hold up in other patient care settings," Dr Watkins said in a statement. "But our initial findings suggest that these quality measures could go a long way toward improving patient outcomes among those who suffer from opioid addiction.

"With physician visits, the relationship was more linear, so the more visits, the better, but with psychosocial treatment, we just asked the question, 'Did you get at least one treatment?,' and there was a broad interpretation. It could have included group therapy or talking to a counselor or a mental health group, so any kind of psychosocial treatment was helpful," said Dr Watkins.

Some factors that were expected to be associated with reduced mortality, including hepatitis and HIV screening or pharmacotherapy for OUD, did not have a significant impact on mortality.

"Surprisingly, we did not find an association with either opioid use disorder pharmacotherapy initiation or maintenance and mortality," the investigators write.

Factors that may explain the lack of an association between pharmacotherapy for OUD include differences between the VA population and populations in other studies, the types of services being offered, or the reported higher risk for mortality when treatment of OUD is interrupted after a short period.

"Our population likely included a mix of people treated with medication for opioid use disorder who stayed on it long term and those who only took it for a short period, so that may have factored into the findings," Dr Watkins said.

Less surprising is the lower mortality associated with no prescriptions for opioids and benzodiazepines. It is well known that prescribing the two in combination has a synergistic effect on the sedative properties of each drug and plays an important role in increasing overdose risk.

Other risks are also associated with use of opioids or benzodiazepines, including falls, fractures, and automobile accidents.

"Our study adds to the data warning physicians about the risk of prescribing opioids and benzodiazepines, showing these are concretely associated with an increased risk of death at 1 and 2 years among those with opioid use disorder."

However, the findings carry a positive message in terms of showing the measures that can make a difference, Dr Watkins said.

"We know that many people with addictions don't think they have a problem and furthermore don't want treatment, so the findings are encouraging, suggesting that there are still things the healthcare system can provide even for people who don't want treatment – that for me is the biggest finding."

Important limitations, she said, include not being able to distinguish between those with OUDs related to prescription opioid misuse and OUDs related to illicit heroin misuse and not knowing whether the findings would extend beyond the VA system.

The study was conducted by the RAND corporation. Dr Watkins has disclosed no relevant financial relationships.

Drug Alcohol Depend. Published online June 27, 2017. Abstract

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