Medications for Opioid Use Disorder: Who is Receiving Which Treatment?

In response to the growing opioid epidemic in the United States, there is an increased focus on expanding evidence-based treatment using medications prescribed for substance use disorder, especially medications that can be prescribed in outpatient settings including buprenorphine and naltrexone. The Surgeon General’s report on facing addiction in America describes substance use disorders as chronic illnesses requiring long term treatment similar to other less stigmatized illnesses, but until now there were no studies that compared several medications for opioid use disorder head-to-head in real-world outpatient settings. Using the MarketScan database of commercially insured beneficiaries, CHERISH investigator Jake Morgan, PhD along with CHERISH colleagues Bruce Schackman, PhD, Benjamin Linas, MD, MPH, and Jared Leff, MS and Boston Medical Center colleague Alexander Walley MD, MSc analyzed prescribing patterns and subsequent treatment discontinuation for injectable naltrexone, oral naltrexone, sublingual buprenorphine/naloxone, sublingual buprenorphine and transdermal buprenorphine medications for opioid use disorder (MOUDs).

From 2010 to 2014, Dr. Morgan found that the proportion of commercially insured individuals in the database diagnosed with opiate use disorder (OUD) increased 4 fold but the proportion of individuals with OUD receiving these medications decreased, indicating that the proportion of individuals diagnosed with OUD outpaced the utilization of MOUDs. Individuals who received MOUDs were more likely to be male, younger and have a co-occurring substance use disorder than those with OUD who were not receiving the medications. While the proportion of all individuals receiving MOUDs who received naltrexone (injectable or oral) and transdermal buprenorphine grew, it remains small at approximately 5% of all MOUDs analyzed. Discontinuation rates after 30 days were high among all treatment groups, ranging from 31% for sublingual buprenorphine/naloxone to 70% for oral naltrexone. After the first 30 days, the discontinuation rate was higher among those receiving naltrexone (injectable or oral) and transdermal buprenorphine.

The MarketScan database is a nationally representative database of commercially insured individuals that allows investigators to track the pattern of filled OUD therapy medications. However, stigma is one of the largest barriers to treatment and thus these data underestimate the prevalence of OUD since they only include individuals with an OUD diagnosis. The results may not be generalizable to publicly insured individuals who may face additional barriers to MOUD treatment. The high discontinuation rates reported in this study suggest that more efforts are needed at the provider, health system and policy level in order to increase access to MOUD and reduce treatment discontinuation.