Journal Article Annotations
2023, 2nd Quarter

Addiction

Annotations by Julian J. Raffoul, MD, PhD
July, 2023

Impact of Medication-Based Treatment on Health Care Utilization Among Individuals with Opioid Use Disorder

PUBLICATION #1 — Addiction

Impact of Medication-Based Treatment on Health Care Utilization Among Individuals with Opioid Use Disorder

Manesh Gopaldas, Kevin Wenzel, Aimee N C Campbell, Ali Jalali, Marc Fishman, John Rotrosen, Edward V Nunes, Sean M Murphy

Abstract: Psychiatr Serv. 2023 Jun 20;appips20220549. doi: 10.1176/appi.ps.20220549. Online ahead of print.

Objective:
This study evaluated the association between medication for opioid use disorder (MOUD) and health care utilization over time among a sample of treatment-seeking individuals with opioid use disorder. In contrast to previous studies, this study used a novel measure of MOUD adherence, more comprehensive utilization data, and analyses that controlled for detailed individual and social determinants of health.

Methods:
This study was a secondary analysis of a comparative effectiveness trial (N=570) of extended-release naltrexone versus buprenorphine-naloxone. The outcome of interest was usage of nonstudy acute care, inpatient and outpatient addiction services, and other outpatient services across 36 weeks of assessment. Adherence (percentage of days taking MOUD) was defined as low (<20%), medium (≥20% but <80%), or high (≥80%). A two-part model evaluated the probability of utilizing a resource and the quantity (utilization days) of the resource consumed. A time-varying approach was used to examine the effect of adherence in a given month on utilization in the same month, with analyses controlling for a wide range of person-level characteristics.

Results:
Participants with high adherence (vs. low) were significantly less likely to use inpatient addiction (p<0.001) and acute care (p<0.001) services and significantly more likely to engage in outpatient addiction (p=0.045) and other outpatient (p=0.042) services.

Conclusions:
These findings reinforce the understanding that greater MOUD adherence is associated with reduced usage of high-cost health services and increased usage of outpatient care. The results further suggest the need for enhanced access to MOUD and for interventions that improve adherence.

Annotation

The finding:
The opioid crisis continues: overdose deaths are at an all-time high and complications of opioid use, including injection drug use, contribute to increased visits to the emergency department and hospitalization. Medication for opioid use disorder (MOUD) is known to improve patient health outcomes. The findings published by this secondary analysis of data from the National Institute on Drug Abuse comparative effectiveness trial known as X:BOT, a 24-week randomized controlled trial comparing the effectiveness of treatment with extended-release naltrexone (XR-NTX) versus sublingual buprenorphine-naloxone (BUP-NX), demonstrated that patients with high adherence (≥ 80% of days taking MOUD) compared with low adherence (< 20%) to MOUD were significantly less likely to use both high-cost inpatient and acute care services and were significantly more likely to engage in outpatient care. Interventions that increase MOUD uptake and adherence may reduce health care costs.

Strength and weaknesses:
A novel methodological approach was used in this study to examine the association between adherence to MOUD and health care utilization over time among participants allowed for more precise measures of MOUD adherence and health care utilization over time, as well as an extensive list of individual and social determinants of health, measured at the participant level. Additional strengths included the relatively large community-based sample (XR-NTX N=283 versus BUP-NX N=287) and the use of repeated-measures analysis with time-dependent adherence. Limitations of the study include self-reported data regarding adherence and service utilization and as a secondary analysis, this study was not part of the parent study’s a priori design. Lastly, non-adherence and deterioration of adherence over time was observed in this study. Causation cannot be inferred from the data, but the data suggested that interventions that increase MOUD uptake and adherence can reduce healthcare costs.

Relevance:
MOUD are known to be an effective treatment for patients with an OUD and are associated with both decreased morbidity and mortality. Research has also consistently shown that a major gap exists between the number of patients in need of treatment for OUD and the number of physicians available or willing to prescribe treatment. This study highlights the important role that C-L psychiatrists may play when consulted on patients who present to the emergency department or require hospitalization due to an OUD. Recommending the use of MOUD for these patients will help save lives and reduce the strain on an already burdened health care system.