Besides showing that agonist medications for opioid use disorder (OUD) strongly protect against overdose death during treatment, a newly published data analysis has found that the period after medication treatment ends carries substantial risk of mortality.
Published online late last month in Addiction, the study makes a strong case for stepped-up efforts to improve patient retention in methadone or buprenorphine treatment and to enhance overdose prevention measures post-treatment, such as through naloxone distribution. The study compared outcomes for individuals receiving medication and non-medication treatment for OUD and found that regardless of which treatment they received, their risk of overdose death was significantly elevated once they no longer were receiving treatment.
“The protective effect of these medications was detected only when patients were engaged in treatment,” lead author Noa Krawczyk, PhD, assistant professor in the Department of Population Health at the NYU Grossman School of Medicine, tells Addiction Professional.
The researchers examined outpatient claims for publicly funded substance use treatment in Maryland for 2015 and 2016, linking these claims with opioid overdose death records. Because they looked at services delivered only in specialty addiction treatment settings, they were not able to analyze effects of office-based buprenorphine treatment. In addition, because of a small sample size of individuals who received injectable naltrexone treatment for OUD, the researchers excluded from the analysis those patients who had received that medication option.
For non-medication treatment, the researchers excluded claims for case management and peer services, so this analysis encompassed other non-medication services delivered in outpatient, intensive outpatient, partial hospitalization and ambulatory detox settings
The final data set encompassed more than 48,000 patients. Those who received medication treatment for OUD were more likely to be female, employed, not homeless, and not justice-involved. The researchers found that overdose death rates were substantially lower during medication treatment compared with non-medication treatment (0.48 deaths per 1,000 person-years compared with 4.13 deaths per 1,000 person-years).
The data also showed a protective effect of being in treatment regardless of type, as both the medication and non-medication groups had a substantially elevated risk of overdose death in periods after treatment. Also, “Risk was significantly higher during the first four weeks since treatment discharge compared to the remainder of time out of treatment for both patients who received medication and non-medication treatment,” authors of the study wrote.
Analyses adjusted for various demographic and treatment variables generally supported the study's main conclusions, the researchers reported.
“This really confirms what we had known previously but hadn't been able to document,” Krawczyk says of the main finding on the effect of medication treatment on fatal overdose risk.
She adds that while non-medication treatment did not exhibit the same degree of protective effect as medication treatment, it is still reassuring that non-medication treatment led to better results than no treatment.
The study's findings point to the importance of increasing access to medication treatment for OUD in community settings, the researchers stated, as well as the need to improve retention in treatment through strategies such as promoting maintenance therapy as the standard of care and eliminating barriers to medication treatment. “For example, addressing medication stigma and removing burdensome treatment requirements, such as daily attendance or zero tolerance, may encourage better and longer engagement,” they wrote.
Krawczyk says she is involved in additional research that should shed further light on the protective effect of agonist medications. A study now in review uses the same Maryland database to determine the effects of agonists on justice-involved populations, including both individuals in custody and those in community corrections.