Polysubstance use and association with opioid use disorder treatment in the US Veterans Health Administration

Abstract

Aims To understand the role of comorbid substance use disorders (SUDs), or polysubstance use, in the treatment of opioid use disorder (OUD), this study compared patients with OUD only to those with additional SUDs and examined association with OUD treatment receipt. Design, setting and participants Retrospective national cohort study of Veterans diagnosed with OUD (n = 65 741) receiving care from the US Veterans Health Administration (VHA) in fiscal year (FY) 2017. Measurements Patient characteristics were compared among those diagnosed with OUD only versus those with one other SUD (OUD + 1 SUD) and with multiple SUDs (OUD + ≥ 2 SUDs). The study examined the relationship between comorbid SUDs and receipt of buprenorphine, methadone and SUD outpatient treatment during 1‐year follow‐up, adjusting for patient demographic characteristics and clinical conditions. Findings Among the 65 741 Veterans with OUD in FY 2017, 41.2% had OUD only, 22.9% had OUD + 1 SUD and 35.9% had OUD + ≥ 2 SUDs. Common comorbid SUDs included alcohol use disorder (41.3%), cocaine/stimulant use disorder (30.0%) and cannabis use disorder (22.4%). Adjusting for patient characteristics, patients with OUD + 1 SUD [adjusted odds ratio (aOR) = 0.87, 95% confidence interval (CI) = 0.82–0.93] and patients with OUD +≥ 2 SUDs (aOR = 0.65, 95% CI = 0.61–0.69) had lower odds of receiving buprenorphine compared with OUD only patients. There were also lower odds of receiving methadone for patients with OUD + 1 SUD (aOR = 0.91, 95% CI = 0.86–0.97)and for those with OUD + ≥2 SUDs (aOR = 0.79, 95% CI = 0.74–0.84). Patients with OUD + 1 SUD (aOR = 1.85, 95% CI = 1.77–1.93) and patients with OUD + ≥2 SUDs (aOR = 3.25, 95% CI = 3.103.41) were much more likely to have a SUD clinic visit. Conclusions The majority of Veterans in the US Veterans Health Administration diagnosed with opioid use disorder appeared to have at least one comorbid substance use disorder and many have multiple substance use disorders. Despite the higher likelihood of a substance use disorder clinic visit, having a non‐opioid substance use disorder is associated with lower likelihood of buprenorphine treatment, suggesting the importance of addressing polysubstance use within efforts to expand treatment for opioid use disorder.

Impacts of the COVID-19 pandemic on healthcare access among patients receiving medication for opioid use disorder

“…Put simply, those who presented to treatment with minimal use were less likely to experience negative COVID-19-related impacts than those with more active and varied patterns of use. Our findings that patients with polysubstance use experienced more negative COVID-19-related impacts are consistent with extant literature documenting associations between polysubstance use and poor MOUD treatment retention and outcomes ( Lin et al 2020 ; Wang et al 2017 ). This work suggests patients with polysubstance use might benefit from targeted outreach during the COVID-19 pandemic.…”

Commentary on Lin et al.: Saving lives during the opioid crisis—widening the focus from opioid use disorder to polysubstance use disorder and to multimorbidity

“…Amid the persistent opioid addiction crisis in United States (US), Lin et al . [1] highlight the often under recognized fact that most patients who seek treatment for opioid use disorder (OUD) present with polysubstance use disorder (PSUD). In addition, PSUD is associated with a higher burden of psychiatric and medical comorbidity, transforming OUD and other substance use disorders (SUDs) into a “multimorbidity” state (multiple comorbidities interacting with each other in complex ways), exacerbating dysfunction and posing hydra‐like treatment challenges [1–4].…”

“…[1] highlight the often under recognized fact that most patients who seek treatment for opioid use disorder (OUD) present with polysubstance use disorder (PSUD). In addition, PSUD is associated with a higher burden of psychiatric and medical comorbidity, transforming OUD and other substance use disorders (SUDs) into a “multimorbidity” state (multiple comorbidities interacting with each other in complex ways), exacerbating dysfunction and posing hydra‐like treatment challenges [1–4]. Population‐based studies from the United States and elsewhere have also shown a similarly high prevalence of PSUD among individuals with OUD and comorbidities among those with PSUD [3,5].…”

“…However, data provided by Lin et al . [1] illustrate that PSUD is associated with lower rate of initiation of buprenorphine treatment for OUD despite also being associated with a higher rate of engagement in SUD care. Long‐acting injectable naltrexone, a seemingly less risky OUD medication treatment (albeit with poorer retention and without demonstrable association with decreased mortality) is used more among those with PSUD and multimorbidity [14–16].…”

“…As Lin et al . point out [1], no treatment framework has emerged to guide management of complex clinical conditions involving OUD, PSUD, pain, psychiatric comorbidities, and its exacerbating functional consequences such as homelessness, incarceration, and suicide attempts. It has been suggested than an integrative approach to the management of multimorbidity by an interdisciplinary team may be more effective than one‐by‐one treatment of each individual SUD and each comorbidity by an independent specialist [4].…”