Several effective medications are now available for treating opioid use disorder but many patients who could benefit do not receive them. Some patients who receive the medications face challenges to staying in treatment.
Morgan J.R., Schackman, B.R., Leff, J.A., et al. Injectable naltrexone, oral naltrexone, and buprenorphine utilization and discontinuation among individuals treated for opioid use disorder in a United States commercially insured population. J Subst Abuse Treat 85:90-96, 2018.
A study found that:
- Among more than 100 million Americans with commercial health insurance, the prevalence of opioid use disorder (OUD) diagnoses quadrupled from 2010 to 2014.
- The number of prescriptions for medications to treat OUD (MOUD) in this population also increased but did not keep up with the rise in diagnoses.
- Patients continued taking sublingual and oral-mucosal buprenorphine/naloxone longer than they continued taking other MOUDs.
The image shows the hands of a doctor and patient sitting across from each other at a desk. The doctor is gesturing and the patient is sitting with hands clasped in front of him. The title reads “As Opioid Use Disorders Increase, Prescriptions for Treatment Have Not Kept Pace.”
Dr. Jake R. Morgan and colleagues at Boston Medical Center analyzed medical records in a nationally representative database of people with employer-sponsored commercial health insurance. Of 100 million individuals in the database, 340,000 spent some time living with a diagnosis of OUD during the years 2010 to 2014. The proportion of the population with an OUD diagnosis increased from year to year and was four times higher in 2014 compared with 2010.
Chart shows how the diagnoses of OUD quadrupled from 2010 to 2014. The horizontal x-axis shows the percentage of individuals diagnosed with OUD, from 0 to 0.6%. The light blue bar represents the percentage for 2010 and the dark blue bar represents the percentage for 2014. In 2010, 0.12% of people received a diagnosis for OUD, compared with 2014, when 0.48% received an OUD diagnosis.
Of the more than 340,000 patients who carried an OUD diagnosis during some or all of the time during the period from 2010 to 2014, only 11 percent were prescribed an MOUD.
A pie chart shows the proportion of patients with OUD who were prescribed an MOUD from 2010 to 2014. As indicated by the green slice of the pie, during this time, only 11 percent of patients with OUD were prescribed an MOUD. As indicated by the blue slice of the chart, the majority of patients (89%) were not treated with an MOUD.
For each year, the researchers computed the total number of months that patients spent with an OUD diagnosis (OUD months). They compared the OUD months with the total number of months that were covered by prescriptions for OUD medications (MOUD months). Both OUD months and MOUD months increased from year to year, but OUD months increased faster than MOUD months. Physicians’ MOUD prescriptions covered 25 percent of OUD months in 2010, and only 16 percent in 2014.
Dr. Morgan says that several factors may have contributed to the widening gap, including:
- Increases in OUD prevalence and rising awareness among health care providers and patients may lead to more diagnoses.
- Barriers may limit treatment with MOUD. For example, health care providers need a waiver to prescribe buprenorphine and can only treat a certain number of patients with the medication. The requirement to become abstinent as a precondition for initiating treatment initiation with naltrexone may pose a barrier to wider use of that medication.
Increases in MOUD prescriptions did not keep pace with increased treatment need. The vertical y-axis represents the number of patient months per year, and the horizontal x-axis shows the years analyzed. The chart compares the total number of OUD months, calculated as the number of patients with OUD times the number of months they needed treatment in a given year (blue bars) and the number of patient months for which MOUD prescriptions were written (green bars). In 2010, of about 400,000 total OUD months, MOUD medications were prescribed for 25% of that time. In 2011, of 800,000 total OUD months, the proportion of MOUD months was 21.3%. In 2012, of nearly 1,200,000 total OUD months, the total MOUD months only accounted for 19.1%. In 2013, of about 1,200,000 total OUD months, the proportion of MOUD months was 18.1%. In 2014 of about 1,600,000 total OUD months, total MOUD months accounted for 16%.
Doctors were most likely to prescribe buprenorphine/naloxone in sublingual or oral-mucosal formulation (S/O BUP/NAL; Suboxone® and generic), followed by sublingual buprenorphine (BUP; generic) and oral naltrexone (Oral NTX; ReVia®). Extended-release naltrexone (XR-NTX; Vivitrol®) and transdermal buprenorphine were introduced during this period. Although they added to patients’ treatment choices, doctors did not prescribe them often enough to prevent the widening gap between OUD and MOUD.
Newly introduced MOUDs accounted for a small proportion of prescriptions. The slide compares prescriptions for medications in 2010 (blue bars) vs. 2014 (yellow bars). The vertical y-axis represents the proportion of prescriptions written from 0 to 100%). The proportion for S/O BUP/NAL was about 93% in 2010 vs. about 86% in 2014. Sublingual BUP accounted for about 6% in 2010 vs. about 9% in 2014, Oral NTX accounted for 3% in 2010 vs. 4% in 2014, XR-NTX accounted for about 2% in 2019 vs. 3% in 2014, and Transdermal BUP accounted for about 0% in 2010 vs. about 4.5% in 2014.
Many patients who received MOUD prescriptions stopped taking the medication within the first 30 days. Patients were least likely to stop taking S/O BUP/NAL (31 percent) and most likely to stop taking oral NTX (70 percent).
Dr. Morgan cites several reasons why patients might be more likely to discontinue some medications than others:
- Patients who stop taking NTX do not experience withdrawal symptoms, making it easier to discontinue that medication. In contrast, stopping opioid agonists, such as BUP, leads to withdrawal symptoms.
- Opioid agonists, such as BUP, may have greater rewarding effects.
- The logistics of treatment (e.g., frequency of administration, oral administration vs. injection) may influence medication compliance.
Patients are more likely to stop taking certain medications. Chart contrasts the percentage of patients who discontinue treatment within 30 days vs. the type of medication they were taking. The vertical y-axis shows the percentage of patients discontinuing treatment within 30 days from 0 to 80%. The horizontal x-axis shows the medications analyzed. Discontinuation for S/O BUP/NAL (light blue bar) was about 30%; for sublingual BUP (yellow bar) it was about 59%, for Oral NTX (golden bar) it was about 70%, for XR-NTX (purple bar) it was about 51%, and for Transdermal BUP (green bar) it was about 50%.
Patients discontinued sublingual and oral-mucosal buprenorphine at lower rates than other MOUDs over the longer term, as well. However, other factors, such as patient demographics (e.g., age) and treatment settings (e.g., inpatient or office-based), also played a role in long-term quit rates.
Most OUD patients stop treatment within 2 years. Graph shows how the proportion of patients with current prescriptions and how that changes over time. The vertical y-axis represents the proportion of patients with a current prescription, from 0% to 100%, and the horizontal x-axis indicates the time to discontinuation from 0 to 720 days. S/O BUP/NAL (light blue curve) starts at 100% and drops quickly in the first 90 days, with only about 20% at 270 days, and about 10% at 720 days. Sublingual BUP (yellow curve) starts at 100%, dropping to 20% by about 180 days, with only about 5% at 720 days. Oral NTX (golden curve) starts at 100%, drops to 10% by 90 days and remains low, at about 2%, from 270 through 720 days. XR-NTX (purple curve) starts at 100%, drops to about 22 percent at 90 days and about 10% at 180 days. It continues to drop until usage stops at about 450 days. Transdermal BUP (green curve) starts at 100% and drops to about 30% by 90 days. It continues to drop to under 20% at 180 days, leveling off to about 8% at 360 days until the end of the study.
- These findings suggest that clinicians underutilize available OUD medications.
- Clinicians have a greater menu of OUD medication options than ever before.
- Some patients still face significant barriers to staying in treatment, jeopardizing successful outcomes.
The image shows a doctor in a white coat handing a medication bottle to a patient. The patient is sitting on an exam table. Bullets summarize the study findings and read: These findings suggest that clinicians underutilize available OUD medications; clinicians have a greater menu of OUD medication options than ever before; some patients still face significant barriers to staying in treatment, jeopardizing successful outcomes.
Dr. Morgan says, “The findings from this study suggest that in the current opioid crisis, clinicians underutilize the available OUD medications.”
He adds, “We have made important strides in treating opioid use disorder. Doctors and patients can now choose among several highly efficacious medications. However, even a highly efficacious medication is only effective for those who take it. Our real-world analysis indicates that significant barriers to staying on treatment remain, even in a commercially insured population that was able to initiate injectable naltrexone treatment.”
Dr. Morgan notes that his study did not include people on Medicaid. He comments, “While we are unable to directly compare our prevalence estimates to the Medicaid population, we believe that the central message of our research—that treatment rates and retention are low and threaten the benefits of highly efficacious medications—is generalizable to this population.”
The study was supported by NIH grants DA040500 and DA031059.