Opioid agonist treatment and fatal overdose risk in a state‐wide US population receiving opioid use disorder services

Abstract

Background and aims Evidence from randomized controlled trials establishes that medication treatment with methadone and buprenorphine reduces opioid use and improves treatment retention. However, little is known about the role of such medications compared with non‐medication treatments in mitigating overdose risk among US patient populations receiving treatment in usual care settings. This study compared overdose mortality among those in medication versus non‐medication treatments in specialty care settings. Design Retrospective cohort study using state‐wide treatment data linked to death records. Survival analysis was used to analyze data in a time‐to‐event framework. Setting Services delivered by 757 providers in publicly funded out‐patient specialty treatment programs in Maryland, USA between 1 January 2015 and 31 December 2016. Participants A total of 48 274 adults admitted to out‐patient specialty treatment programs in 2015–16 for primary diagnosis of opioid use disorder. Measurements Main exposure was time in medication treatment (methadone/buprenorphine), time following medication treatment, time exposed to non‐medication treatments and time following non‐medication treatment. Main outcome was opioid overdose death during and after treatment. Hazard ratios were calculated using Cox proportional hazard regression. Propensity score weights were adjusted for patient information on sex, age, race, region of residence, marital and veteran status, employment, homelessness, primary opioid, mental health treatment, arrests and criminal justice referral. Findings The study population experienced 371 opioid overdose deaths. Periods in medication treatment were associated with substantially reduced hazard of opioid overdose death compared with periods in non‐medication treatment [adjusted hazard ratio (aHR) = 0.18, 95% confidence interval (CI) = 0.08–0.40]. Periods after discharge from non‐medication treatment (aHR = 5.45, 95% CI = 2.80–9.53) and medication treatment (aHR = 5.85, 95% CI = 3.10–11.02) had similar and substantially elevated risks compared with periods in non‐medication treatments. Conclusions Among Maryland patients in specialty opioid treatment, periods in treatment are protective against overdose compared with periods out of care. Methadone and buprenorphine are associated with significantly lower overdose death compared with non‐medication treatments during care but not after treatment is discontinued.

Three-Month Outcomes from a Patient-Centered Program to Treat Opioid use Disorder

“…We measured treatment retention and other outcomes for 3 months, but as treatment retention is associated with reduced mortality (17), treatment retention should be measured in years, not months. Longer duration of treatment, however, is built on a foundation of early treatment retention.…”

“…After treatment initiation, a key component to successful outcomes is continuation of treatment. A recent study showed that medication for addiction treatment (MAT) reduced mortality rates for people with OUD by 80%, but this bene t occurred as long as the person remained in treatment (17). Relapse risk and mortality rates increase after treatment ends, so in order to sustain desired outcomes from treatment, it is critical to keep people actively engaged.…”

Commentary on Krawczyk et al. (2020): Reinforcing the case for evidence‐based treatment of opioid use disorder

“…For people receiving outpatient treatment for opioid use disorder (OUD), Krawczyk et al found that the hazard of overdose death was 80% lower on opioid agonist treatment (OAT), including methadone and buprenorphine, compared to non-medication-based treatment options [1]. They also found that retention was an order of magnitude longer for those in OAT versus those in non-medication treatments (248 versus 22 days) [1]. An overwhelming body of evidence from randomized control trials and observational studies suggests that people with OUD are retained in OAT longer than other forms of treatment [2], and all-cause mortality is reduced with a rate ratio of 3.20 (95% confidence interval: 2.65, 3.86) for methadone and 2.20 (1.34, 3.61) for buprenorphine, compared to periods off treatment [3].…”

“…Despite ample evidence, OAT remains underused in the U.S. treatment system. Findings from Krawczyk and colleagues [1] underscore the need to expand access to evidence-based interventions in the United States, including OAT and complementary interventions to reduce the harms associated with opioid and other drug use.…”

“…psychological interventions), there is little evidence suggesting they are effective on their own. [1,11,12] There is a need for improved evidence on when, how, and for whom non-medication treatments can benefit people with OUD. More importantly, however, there is a need to rapidly scale up the evidence-based approaches that we already know work [1,12,13].…”