Buprenorphine, Methadone May Be Best Medical Treatments for Opioid Abuse

By Will Boggs MD

February 25, 2020

NEW YORK (Reuters Health) - Buprenorphine and methadone appear to cut the risk of overdose and serious opioid-related acute-care use better than other medical treatments for opioid-use disorder, according to a database study.

"Our study builds on the decades of research demonstrating that buprenorphine and methadone are first-line treatments for opioid use disorder and are associated with improved outcomes and reduced overdose," said Dr. Sarah E. Wakeman of Massachusetts General Hospital in Boston.

"Management of patients with opioid-use disorder should include immediate, no-barrier access to these medications, and ongoing care should prioritize retention and engagement," she told Reuters Health by email.

Despite the demonstrated effectiveness of medications for opioid-use disorder (OUD), an estimated 1 million people go untreated annually because they don’t have access to treatment.

In order to inform treatment decisions made by policymakers, insurers, practitioners and patients, Dr. Wakeman and colleagues used data from the OptumLabs Data Warehouse to evaluate the effectiveness of medications for OUD compared with nonpharmacologic treatment.

Specifically, they compared six pathways: no treatment; inpatient detoxification or residential services; intensive (outpatient or partial hospitalization) behavioral health; buprenorphine or methadone; naltrexone; and nonintensive (outpatient) behavioral health.

Nonintensive behavioral health was the most common treatment pathway (59.3% of patients), followed by inpatient detoxification or residential services (15.8%) and buprenorphine or methadone (12.5%).

By 12 months after the index date, 45.5% of individuals receiving nonintensive behavioral health were disenrolled, compared with 53.8% of those receiving buprenorphine or methadone and 54.0% of those treated with naltrexone.

During the three months' follow-up, 1.7% of patients experienced an overdose and 1.9% had an episode of serious opioid-related acute-care use. Compared with individuals receiving no treatment, those on buprenorphine or methadone were 76% less likely to experience an overdose and 32% less likely to require serious opioid-related acute care during follow-up, both significant risk reductions.

The risk of overdose or serious opioid-related acute care during follow-up did not differ significantly between those on no treatment and on inpatient detoxification or residential services, naltrexone, or intensive behavioral-health services, respectively.

Nonintensive behavioral services did not reduce the risk of overdose, but did reduce the risk of serious opioid-related acute-care use, the researchers report in JAMA Network Open.

Compared with buprenorphine or methadone treatment, all other treatment groups were significantly more likely to have a posttreatment admission to inpatient detoxification.

Mean medical treatment duration was relatively short during 12 months' follow-up: only 74 days for naltrexone and 150 days for buprenorphine or methadone. Longer-duration treatment with buprenorphine or methadone was associated with lower rates of overdose and serious opioid-related acute-care use.

"Opioid use disorder is a treatable illness, and physicians can help improve health and save lives for patients by getting waivered to prescribe buprenorphine and learning how to directly refer to methadone treatment," Dr. Wakeman said.

Dr. Louis Baxter from the Professional Assistance Program of New Jersey, Inc. (PAPNJ), in Princeton, New Jersey, which focuses on healthcare and other professionals in recovery from impairing medical conditions and illnesses, told Reuters Health by email, "Medication-assisted therapy is not only appropriate for some patients, but it is also essential for patients who are at increased risk for relapse and overdoses. Clearly it is an important consideration for those patients who have had a history of multiple treatment experiences and who have had multiple relapses and overdose histories."

"It is important to always remember that opioid-use disorders, like other substance-use disorders, and some psychiatric illnesses are chronic medical illnesses and as such require chronic medical care," he said. "In all cases, that requires periodic follow-up to check on the patient's ongoing continued wellness (recovery) and the need for continued medical management if indicated or required."

"Just as we treat other chronic medical illnesses, there should not be a time-limited approach to the use of medication-assisted therapy," said Dr. Baxter, who was not involved in the study.

Dr. Thomas Kosten of Baylor College of Medicine, in Houston, Texas, who studies opioid-use disorder, told Reuters Health by email, "We should not be reimbursing for expensive residential and inpatient care, as well as detox alone, which are clearly not effective and need to be discouraged as viable alternatives to getting no care at all or more positively to getting medications for OUD care."

"We need to drive patients towards this effective treatment from a simple public-health perspective," said Dr. Kosten, who also was not part of the research. "Other treatments are simply profit centers for those companies which offer them."

Dr. Kosten reiterated "that detox is not treatment. It is an entryway into treatment with agents such as naltrexone. Furthermore, no detox is needed to start methadone or buprenorphine. We need public-health campaigns to remove whatever stigma exists for not supporting and pushing OUD patients into medications for OUD and (to stop) allowing insurance money to be wasted on ineffective treatments, as documented by 'hard data' such as these on overdoses, deaths, and acute emergency care."

The study did not have commercial funding.

SOURCE: https://bit.ly/39rQnSI JAMA Network Open, online February 5, 2020.

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