Opioid Use Disorder, Outpatient Treatment, and Relapse

In the U.S., the drug overdose crisis – also called the opioid crisis – continues to impact individuals, families, and communities nationwide.

Despite the best efforts of treatment professionals, public and private officials, and countless community organizers and advocates, rates of opioid use disorder (OUD) and fatal overdose have increased dramatically over the past three decades. The COVID-19 pandemic exacerbated the overdose crisis, which has claimed over two hundred fifty thousand lives since 2019, with three quarters of those overdose fatalities attributed to opioids.

Every overdose death is tragic, and the pain experienced by friends and loved ones is foregrounded by the fact that right now, life-saving, evidence-based treatment for opioid use disorder exists, and is available in every state in the country.

There are two primary evidence-based interventions that can reduce opioid-involved overdose deaths among patients with OUD:

• Initiation of medication-assisted treatment (MAT) with medication for opioid use disorder (MOUD) approved by the Food and Drug Administration (FDA)
• Retention in MAT program with FDA-approved medication for opioid use disorder (MOUD)

For people with OUD, data shows that current participation in MAT programs that use methadone, buprenorphine, and/or naltrexone reduces overall risk of mortality by close to 75 percent, compared to people with OUD who do not currently participate in MAT programs.

That’s why MAT, using FDA-approved medications for opioid use disorder (MOUD), is considered the gold-standard treatment for opioid use disorder. That’s also why researchers want to learn as much as possible about the factors that promote MOUD initiation and MOUD retention. Previous research shows that at least three factors predict successful treatment, reduction of mortality, and reduction of relapse.

Relapse and Overdose Prevention: What We Know

1. Initiating treatment within 14 days of diagnosis reduces overdose and relapse risk
2. Participating in at least two outpatient visits within 30 days of initiating treatment reduces overdose and relapse risk
3. Continuous participation in MAT program using MOUD for a minimum of six months reduces overdose and relapse risk

Treatment professionals who work with people with SUD derive those first two factors from a group of health metrics called the Health Effectiveness and Data Information Set (HEDIS), a resource the Centers for Medicare and Medicaid Services (CMS) use to gauge treatment outcomes, monitor treatment progress, and make decisions about reimbursement for various healthcare treatment services. The third factor comes from an extensive evidence base on the use of MAT for treating OUD, as described by the Substance Abuse and Mental Health Services Administration (SAMHSA).

Those three metrics are important not only because they indicate the effectiveness of MAT for OUD  but also because payors – like CMS and private insurers – use them to make decisions about what types of treatment they’ll cover, and for how long. They’re important, but they haven’t been subject to the same type of scrutiny as the metrics used to gauge treatment success – and determine reimbursement – for non-SUD medical conditions.

Earlier this year, a group of researchers decide to fill that gap in our knowledge, and engage in a thorough review of the first two metrics on the list above.

Medication-Assisted Treatment for Opioid Use Disorder: Verifying Our Metrics

In a publication released in October 2022 called “Performance Measurement for Opioid Use Disorder Medication Treatment and Care Retention,” a group of researchers analyzed the three treatment predictors/metrics to ensure they’re accurate and contribute – in a positive way – to our nationwide efforts to mitigate the harm cause by the overdose crisis.

Here’s what they wanted to verify:

• Whether initiating treatment within two weeks of diagnosis predicted treatment outcomes
• Whether participating in at least two outpatient visits within a month of treatment initiation predicted treatment outcomes
• Among people with OUD who met the first two metrics, whether those metrics would predict participation in MAT programs for at least six months
• Among people with OUD who met the first two metrics, whether those metrics would predict participation in MAT programs for longer durations, such as 12 months or 24 months

Here’s how they conducted their analysis. The research team:

• Collected and analyzed data on 19,4867 patients in MAT treatment with buprenorphine between January 1, 2011, and April 15^th, 2019
  • Average age: 35
  • Gender: 42% female, 58% male
• Tracked treatment initiation and participation over 24 months post-initiation
  • Defined discontinuation of treatment as a period of 60+ days without engaging in treatment
• Used data verify predictive quality of metric #1 – treatment initiation – and metric #2 – outpatient engagement – to estimate treatment engagement at 6 months, 12 months, and 24 months post-initiation

Let’s quickly review why this research is important.

First:

Close to 200 people in the U.S. die of opioid-related overdose every day: that’s something we, as a society, need to fix.

Second, evidence-based treatment with MAT can prevent relapse and overdose: that’s something we know, but can use more data to support the increased use of MAT nationwide. Third, CMS uses these metrics to make decisions or reimbursement for past care and approval of ongoing care: without access to care, individuals with OUD may not get the treatment they need.

Therefore, in order to keep people with OUD in the treatment programs that can save their lives, we need to know whether our methods for measuring and predicting treatment outcomes are valid, or need further research.

Let’s take a look at what the researchers found.

Medication-Assisted Treatment for Opioid Use Disorder: The Role of Outpatient Engagement

The first thing the researchers wanted to know was the rate of successful treatment initiation among all individuals in the study. Out of the 19,4867 patient records they analyzed, the data indicated the following:

• 16,063 – that’s 82.4% – successfully engaged in care
• 3,424 – that’s 17.6% – did not successfully engage in care

We’ll note that 82.4 percent is a good rate of engagement – and more than we expected. That’s a positive result, that indicates a majority of patients with OUD demonstrate a willingness to participate in MAT. We’ll also note that while that result is encouraging, what we really want to know is whether this level of engagement persisted for at least six months. One more thing: in this context, successful engagement means participants started MAT within 14 days of diagnosis and participated in at least two outpatient visits within 30 days of diagnosis.

Next, we’ll look at the key metric that we’re most curious about:

Eight out of ten individuals in the study successfully initiated treatment, but how long did they stay in treatment?

Let’s see.

Among those successfully engaging in care:

• 47% remained in care for a minimum of 6 months
  • 3% did not meet measurement criteria for successful initial engagement, but remained in care for 6 months
• 33% remained in care for a minimum of 12 months
  • 1.5% did not meet measurement criteria for successful initial engagement, but remained in care for 12 months
• 20% remained in care for a minimum of 24 months
  • 0.01% did not meet measurement criteria for successful initial engagement, but remained in care for 24 months

These results, while not inspiring, are also encouraging. They’re not inspiring because a retention rate of 47 percent is not what we want. We prefer that number to be 100 percent. However, we know that’s not realistic. We also know that when we consider relapse rates for OUD, which hover between 30 percent and 70 percent, 47 percent retention is not ideal, but it is acceptable – and a sign of progress in our efforts to reduce the harm caused by OUD.

Did Early Engagement Predict Treatment Retention After Six Months?

The original goal of the research we discuss in this article was to confirm and validate metrics used by Medicare and Medicaid – via CMS – to determine approval and reimbursement for individuals in medication-assisted treatment programs (MAT) for opioid use disorder (OUD) using MOUD.

Based on that goal, the research effort was successful: successful treatment engagement predicted a 47 percent retention rate six months after initiation of care.

That’s what the data we share above mean. There’s something else in the numbers we should mention, though: 3 percent of individuals who did not initiate MAT within two weeks of diagnosis and did not participate in at least two outpatient visits within 30 days of diagnosis, did, in fact, remain in care for at least six months. What that means is that for some people – 3 percent, at least – early engagement and participation in outpatient treatment did not predict treatment success. This subgroup stayed in treatment for six months, which means they substantially reduced their risk of relapse and overdose, compared to people with OUD who don’t stay in treatment for at least six months.

That percentage does appear small. It’s not small, though, when you consider the big-picture numbers. In 2021, over 73,453 people died of opioid-related overdose. Three percent of 73,453 is 2,203. That means over 2,000 people – friends, siblings, parents, children – decreased their likelihood of relapse and fatal overdose. Here’s how study co-author Dr. Robin Williams describes this finding:

“This is critically meaningful and could guide intervention development to prioritize stabilization of high-risk patients early in treatment. Without early engagement, the great majority of patients will be lost to relapse and possible death.”

We agree.

We should not give up on those who don’t immediately engage, but rather, make plans to follow up with them. The results show that even if they don’t seek treatment right away, they may engage in their own way – and find their own path towards treatment success.

Outpatient Visits and Treatment Retention

There’s one more finding to report: people who did engage in treatment right away – meaning within two weeks of diagnosis of OUD, with at least two outpatient visits within one month – were twenty times more likely to stay in treatment for at least six months.

Study co-author Dr. Stephen Crystal makes this observation:

“Engagement in outpatient visits or professional services appears to be a necessary condition for adequate care retention. Monitoring this engagement may help identify and address barriers and disparities in outcomes.”

This finding is the meat and potatoes of this research. It confirms that early engagement increases likelihood of treatment retention, which does two things: first, it confirms the metrics we introduce in the beginning of this article as valid, and second, it teaches us that we need to redouble our efforts to get people diagnosed with OUD into treatment as soon as possible. Early engagement means longer retention, longer retention means reduced risk relapse, and reduced risk of relapse means reduced risk of mortality.

In short, what this study tells us is something we tell almost anyone who reaches out to us for support: the sooner a person with OUD initiates evidence-based treatment for OUD, the more likely they are to experience treatment success. Or, in other words, early engagement in MAT treatment and outpatient support can save lives.

That’s something anyone with OUD, or anyone with a friend, family member, or loved one with OUD should know. If you read this article – and know someone who needs help – we encourage you to share this information with them as soon as possible.