Has the Treatment Gap for Opioid Use Disorder Improved?

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In October 2017, the U.S. government – in an official White House Proclamation – declared the opioid use disorder epidemic a public health emergency.

That galvanized the nation and brought attention to a phenomenon that was almost two decades old: a staggering upward trend in opioid use disorder, fatal opioid overdose, and overall fatal drug overdose.

That year, there were 47,600 reported instances of fatal opioid overdose – an increase of over four hundred percent from the 8,050 instances reported in 1999. In the official proclamation, the administration outlined a three-step action plan to address the public health emergency, known as the opioid epidemic or the opioid crisis:

  1. Reduce over-prescription and demand by educating citizens about the dangers of opioid misuse and endorsing new guidelines for safe opioid prescribing.
  2. Reduce supply of illicit opioids by expanding law enforcement efforts to disrupt international and domestic supply chains.
  3. Increase funding and access to evidence-based treatment and recovery support.

In combination with the Drug Addiction Treatment Act (DATA), which approved use of new medications for opioid use disorder (MOUD), and the Comprehensive Addiction and Recovery Act (CARA), which expanded treatment, recovery, and harm-reduction services for people with substance use disorder, this announcement from the highest office in the nation signaled we were ready to do our best to end the opioid crisis once and for all.

For a year, it looked like our best was working.

Fatal overdose rates decreased in 2018 for the first time since 1999. But in 2019, fatal overdose rates increased again. We’ll explain why in a moment. Then, in 2020, the COVID-19 pandemic arrived, which exacerbated the drug misuse problem in the U.S., and led to significant increases in both rates of addiction and fatal overdose.

Let’s back up and answer an important question:

How did we get here?

It’s complicated – but we can explain.

The Opioid Crisis in the United States

The Centers for Disease Control (CDC) reports that the opioid crisis occurred in three waves, each characterized by a slightly different set of factors.

Three Waves of the Opioid Use Disorder Crisis

  • Wave One:

    • This first wave was characterized by an increase in opioid prescriptions that began around 1990. This resulted in an increase in opioid overdose by the year 2000, a trend that remained stable until 2010.
  • Wave Two:

    • Wave two began around 2010. This wave was characterized by what’s known as the prescription-to-addiction pathway, which was the unintended consequence of a nationwide effort to reduce opioid prescriptions. Without access to prescription opioids, many people turned to illicit street opioids like heroin, which led to another upward trend in fatal opioid overdose.
  • Third Wave:

    • Wave three began in 2012. It’s characterized by the presence of synthetic opioids and an increase in the availability of illicitly produced, fake-prescription opioids such as fentanyl. Data from the Drug Enforcement Agency (DEA) shows that close to 40 percent of illicit opioids confiscated between 2016 and 2019 contained fentanyl. Fentanyl is dangerous because it’s 50 times stronger than heroin and 100 times stronger than morphine, which increases risk of fatal overdose.

Those are the three waves of the opioid crisis recognized by the CDC. However, experts agree that we’re now in a new wave – Wave Four – of the opioid crisis, which is characterized by a different set of factors than the previous three waves. This wave reversed the progress we made after the White House Proclamation in 2017 and is ongoing.

We’re in the middle of Wave Four right now.

Research scientists identify the following unique components of Wave Four:

Polysubstance Misuse

  • Combining two or more substances of misuse is polysubstance misuse
    • The presence of fentanyl in non-opioid substances such as cocaine, methamphetamine, and other stimulants increases risk of overdose

Co-occurring Disorders

  • When an individual receives a diagnosis for a substance use disorder and a mental health disorder, they have co-occurring disorders and receive a dual diagnosis.
  • The increase in methamphetamine use – which is disproportionately associated with severe cognitive dysfunction – led to an increase in disruptive co-occurring disorders
  • The presence of co-occurring disorders increases risk of overdose:
    • The combined experience of symptoms of a substance use disorder and symptoms of a mental health disorder increases risk of fatal overdose

COVID-19

  • The social, psychological, and emotional stressors associated with the coronavirus pandemic increased risk and prevalence of substance use disorders and mental health disorders, both of which are associated with increased risk of fatal overdose

That’s how we got here: a series of events with serious and significant consequences for millions of people in the U.S.

Now we’re ready to address the question we pose in the title of this article:

Has the treatment gap for opioid use disorder improved?

To do that, we need to define three things: two phrases we’ve used already and one we haven’t. The two we’ve used already are treatment gap and opioid use disorder (OUD). We’ll start with the latter, move to the former, then define medication-assisted treatment, which is essential for understanding the current best-practice therapeutic modalities for people with OUD.

Opioid Use Disorder, The Treatment Gap, and Medication-Assisted Treatment

The reason the phrase opioid use disorder may not be familiar – though it’s fairly easy to figure out what it means – is because it’s part of the new, 21st century paradigm for addiction treatment. This new approach – called the integrated, comprehensive treatment model – puts people first, and works to counter the stigma associated with addiction and addiction treatment.

The stigma associated with the old approach to treatment is so strong it’s important to rethink everything, including how we talk about the subject. That means replacing a word loaded with baggage – like addiction – with a phrase that matches the medical nature of the condition: disordered use. In addition, we replace words with negative stigma – like addict, alcoholic, or junkie – with one word: person.

Therefore, we now say a person with an opioid use disorder instead of a junkie addicted to heroin and a person with alcohol use disorder instead of an alcoholic. The new language is respectful, accurate, and designed to draw people toward treatment, rather than scare them away.

Now let’s define the phrase opioid use disorder – although, as we mentioned, it’s not challenging to figure out in this context.  The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) describes opioid use disorder as “…a problematic pattern of opioid use leading to problems or distress, with at least two of eleven symptoms occurring in a 12-month period.”

An individual who meets two of the following 12 criteria in any given year meets the clinical criteria for opioid use disorder.

DSM-5 Criteria for OUD

  1. Uses more opioids over a longer period than intended
  2. Has the persistent desire to stop using opioids, or has tried without success to stop using opioids
  3. Spends significant time obtaining, using, or recovering from the effects of opioids
  4. Consistently craves opioids
  5. Has problems meeting work, school, or home obligations due to opioid use
  6. Continues opioid use despite problems at work, school, or home related to opioid use
  7. Gives up or stops typical daily activities due to opioid use
  8. Uses opioids in dangerous situations, i.e. before driving a car
  9. Continues opioid use despite physical, emotional, or psychological problems caused by opioid use
  10. Develops tolerance to opioids, i.e. needs higher dosage to achieve same effect
  11. Experiences withdrawal symptoms, or takes opioids to avoid withdrawal symptoms

That’s what we mean when we say a person has an opioid use disorder, or OUD. A qualified clinician determined they mt at least two of these criteria and arrived at a diagnosis: opioid use disorder.

Next, we’ll define treatment gap.

What is the Treatment Gap?

The treatment gap is the difference between the number of people who need treatment for a specific medial condition and the number or people who receive evidence-based treatment for that condition. For instance, if one hundred people have a condition, and eighty receive treatment, we’d say there’s a treatment gap of twenty percent.

We discussed the treatment gap in our recent article on National Recovery Month, and offered the latest statistics on the treatment gap for alcohol use disorder (AUD) and substance use disorder (SUD). To provide context for the data on the OUD treatment gap we’ll share in a moment, we’ll offer a condensed version of those treatment gap statistics here.

The AUD and SUD Treatment Gap: 2020

  • 27 million people in the U.S. diagnosed with AUD
    • 2 million received treatment for AUD
    • That’s a treatment gap of 92.6%
  • 38 million people in the U.S. diagnosed with SUD
    • 2.3 million received treatment for SUD
    • That’s a treatment gap of 93.9%

That’s the latest data on the AUD and SUD treatment gap in the U.S. That gap is obviously far too high, and is one part of the complex suite of factors that explains why opioid overdose rates continue to increase year after year. Another reason is the fact that many people with OUD don’t receive medication-assisted treatment, which is widely accepted as the most effective treatment approach for people with OUD.

We’ll now define medication-assisted treatment.

What is Medication-Assisted Treatment (MAT)?

The Substance Abuse and Mental Health Services Administration (SAMHSA) Administration provides this definition of MAT:

“MAT is the use of medications, in combination with counseling and behavioral therapies, to provide a ‘whole-patient’ approach to the treatment of substance use disorders. Medications used in MAT are approved by the Food and Drug Administration (FDA) and MAT programs are clinically driven and tailored to meet each patient’s needs.”

There three most common, FDA-approved medications used in MAT are methadone, buprenorphine, and naltrexone. SAMHSA indicates the supervised use of these medications, in combination with community support, lifestyle changes, and therapy, can lead to the following benefits:

  • Reduced opioid use
  • Reduced opioid-related overdose deaths
  • Decreased criminal activity
  • Reduced risk of infectious diseases transmission
  • Improved social functioning
  • Increased treatment adherence

In addition, evidence shows that MAT block the euphoric effect of opioids, stabilizes brain chemistry, relieves cravings, and enables individuals to participate in family, work, and school life, and also allows them to initiate and participate in therapy. It’s important to understand that medication is not the only part of MAT: it’s one piece of a comprehensive approach to OUD treatment that includes support for all the biological, psychological, and social factors related to the disordered use of opioids.

Now we’re finally ready to discuss the data we’ve wanted to share since the beginning of this article – but we had to share the information above so the data we provide now makes sense.

The OUD Treatment Gap: Data From 2010-2019

A study made available in August 2022 called “Has the Treatment Gap for Opioid Use Disorder Narrowed in The U.S.? A Yearly Assessment From 2010 To 2019” analyzed data on the use of medications for opioid use disorder (MOUD) in the context of medication-assisted treatment (MAT) for opioid use disorder (OUD) to determine the true size of the treatment gap in OUD treatment in the U.S.

Large-scale, retrospective analyses of this nature – studies that use previously collected data with population level sample sets – typically use information from two sources: the Monitoring the Future Survey (MTF) and the National Survey on Drug Use and Health (NSDUH).

The MTF and the NSDUH provide valuable data on alcohol, tobacco, and drug use across the U.S. population. The large sample size of the NSDUH – over 70,000 participants per year – and consistency – annually since 1971 – allows providers, policymakers, and researchers to understand the current state of alcohol and drug consumption in the U.S.

In this treatment gap study, researchers used NSDUH data, but with a catch: they needed to adjust the OUD prevalence numbers to define what researchers call an accurate, real world treatment gap.

With regards to illicit drug use, many experts suggest the voluntary nature of the NSDUH results in underestimates in key metrics, such as opioid use disorder (OUD). A study published in June 2022 called “What Is the Prevalence of And Trend in Opioid Use Disorder in The United States From 2010 To 2019? Using Multiplier Approaches to Estimate Prevalence for An Unknown Population Size” researchers offer the following reasons the NSDUH may underreport opioid use.

NSDUH and Underreporting Drug Use

  • Reluctance of people who use opioids to participate
  • Reluctance of people who do participate to report use accurately
  • Exclusion of specific populations, such as:
    • People experiencing homelessness
    • Incarcerated individuals
    • Hospitalized individuals
    • Otherwise institutionalized individuals

To remedy this situation, the authors of the study devised a multiplier that adjusts OUD rates in order to reflect actual rates of OUD, which they say are as much as four times higher than the current NSDUH estimates.

Here are the multiplier-adjusted figures for OUD prevalence and treatment with MOUD from 2010-2019. While reading this data, understand that MOUD, in this context, is synonymous with MAT, as described above.

OUD and MOUD 2010-2019: Non-Adjusted and Adjusted Prevalence with Adjusted Treatment Gap

  • 2010:
    • Non-adjusted: 2,105,757
    • Adjusted: 9,448,532
    • Individuals receiving MOUD: 462,047
    • Treatment gap: 95.1%
  • 2011:
    • Non-adjusted: 2,097,321
    • Adjusted: 9,410,679
    • Individuals receiving MOUD: 511,842
    • Treatment gap: 94.6%
  • 2012:
    • Non-adjusted: 2,319,213
    • Adjusted: 10,406,309
    • Individuals receiving MOUD: 568,712
    • Treatment gap: 94.5%
  • 2013:
    • Non-adjusted: 2,130,957
    • Adjusted: 9,561,604
    • Individuals receiving MOUD: 645,015
    • Treatment gap: 93.3%
  • 2014:
    • Non-adjusted: 2,269,135
    • Adjusted: 10,181,609
    • Individuals receiving MOUD: 695,273
    • Treatment gap: 93.2%
  • 2015:
    • Non-adjusted: 2,412,106
    • Adjusted: 10,823,120
    • Individuals receiving MOUD: 765,316
    • Treatment gap: 92.9%
  • 2016:
    • Non-adjusted: 2,247,523
    • Adjusted: 10,084,636
    • Individuals receiving MOUD: 787,708
    • Treatment gap: 92.2%
  • 2017:
    • Non-adjusted: 2,129,367
    • Adjusted: 9,554,470
    • Individuals receiving MOUD: 891,942
    • Treatment gap: 90.7%
  • 2018:
    • Non-adjusted: 2,044,469
    • Adjusted: 9,173,532
    • Individuals receiving MOUD: 970,831
    • Treatment gap: 89.4%
  • 2019:
    • Non-adjusted: 1,700,870
    • Adjusted: 7,631,804
    • Individuals receiving MOUD: 1,023,959
    • Treatment gap: 86.6%

While most data we share on the opioid crisis is discouraging, this data gives us hope. It shows an increase of over one hundred percent in the prevalence of MAT/MOUD treatment from 2010 to 2019 in the U.S.

In 2010, less than half a million people received MOUD, while in 2019, over a million people received MOUD – that’s encouraging.

However, it’s time for a reality check – for us and for anyone reading this.

Although the treatment gap decreased 7.9 percent – from 94.5 percent to 86.6 percent – over the ten years examined in this study, let’s put that decrease in perspective:

A treatment gap of 86.6 percent is still unacceptable.

We can all agree on that – but what can we do to reduce the treatment gap?

How This Study Helps

First, we’ll acknowledge the answer to the question posed in the title of this article:

Yes, the treatment gap for opioid used disorder has improved.

However, as we mention above, it’s still far too large.

This study helps our efforts to reduce the treatment gap in one simple way: it gives us real knowledge about the true size of treatment gap. We can inform colleagues, friends, and family that less than fifteen percent of the people who need treatment for OUD get the gold-standard treatment for OUD, which is MAT with one of the MOUDs listed above: buprenorphine, methadone, or naltrexone. We can also inform them the factors that often prevent people from treatment – such as stigma and barriers to care caused by structural inequity – are not immutable or predetermined. If we work together to reduce stigma and help people overcome barriers to care, we can reduce the treatment gap.

Many people have no idea the scope of the problem is so large. Nor do they know that we have the resources and the knowledge to directly address the problems and close the gap. That’s why we write articles like this one. Our goal is to keep our eye on the ball, help everyone who needs help by offering the latest, evidence-based treatment, and keep working every day until we eliminate the treatment gap entirely.

That’s a lofty goal, but we believe it’s within our reach.