A study finds that despite the ability of medication-assisted treatment drugs like methadone and buprenorphine to save the lives of people who've overdosed on opioids, they continue to be underutilized.
The study, published Monday in the medical journal Annals of Internal Medicine, identified and tracked nearly 18,000 adults in Massachusetts who had gone to an emergency room because of a non-fatal drug overdose between 2012 and 2014. It found that only about 30% received any sort of Food and Drug Administration-approved medication-assisted treatment for opioid addiction.
Such treatment is considered the gold standard for opioid addiction and combines behavioral therapy with one of three approved drugs: methadone; buprenorphine, which is sold as Suboxone; and naltrexone, commonly sold as Vivitrol.
"We were shocked by the fact that so few people are getting medication," said Dr. Marc Larochelle, lead author of the study and an internist and researcher at Boston Medical Center's Grayken Center for Addiction.
Reducing risk of death
Larochelle and his colleagues found that when looking at the entire group a year after their overdoses, nearly 5% of the individuals had died, and about 2% of those deaths were due directly to opioids.
Overall, among those who received methadone, the one-year mortality rate dropped to 2.5%, and for those given buprenorphine, it dropped to 3% -- meaning, one year later, those who were treated with methadone or buprenorphine had reduced their risk of death by 60% and 40%, respectively.
There was no significant difference found in those patients who were treated with naltrexone. However, the study also cautioned that the number of patients using naltrexone was much more limited, which could have affected the finding.
Of the patients followed, researchers found that about 17% used buprenorphine, with median use of the drug around four months; 11% used methadone, with a median use of around five months; and just 6% used naltrexone, with a median use of about one month.
Caleb Banta-Green, who studies drug abuse epidemiology at the University of Washington's School of Public Health, said it's an important limitation, but he also noted that the limited use of just one month was still a noteworthy finding.
Dr. Sharon Stancliff agreed. "If you can't start a treatment, that says a lot about its effectiveness," said Stancliff, a practicing clinician in New York and a former adviser to the Harm Reduction Coalition. Neither she nor Banta-Green was involved in the new study.
There have been high dropout rates when it comes to naltrexone, possibly due to the fact that those starting the regimen cannot used any opioids for at least seven to 10 days. In contrast, methadone and buprenorphine can be started much sooner.
The hurdle in getting people to start naltrexone is also well-known. Randomized clinical trials have compared naltrexone to buprenorphine and found they were similarly effective in keeping people off opioids. But getting patients to start naltrexone has been difficult in these studies, as well.
Limited options when it comes to treatment
The latest study is the first side-by-side comparison in the United States of the impact these three drugs may have on mortality and accounts for how people actually use them.
"People chose to take these drugs out in the real world. And then this is what happened," Banta-Green said, calling it the real world apples-to-apples comparison that many clinicians have been hoping for.
Stancliff said, "this is a study that should be driving policy."
In recent years, Vivitrol, the long-acting injectable version of naltrexone, has become a popular treatment option in the criminal justice system -- and sometimes the only option.
"There's clearly no evidence it should be a preferred treatment, because it is clearly being pushed in some settings where people aren't being offered any other options," Larochelle said.
Fewer than half of all treatment programs prescribe one of the three FDA-approved medications, and only 3%provide all three. The FDA has taken additional steps to make these treatments more accessible. Most notably, in recent months, FDA Commissioner Dr. Scott Gottlieb has prioritized the development of new medication-assisted treatment option.
In the United States, the number of fatal opioid overdoses has continued to rise over the past two decades, and the most recent estimates have nearly 50,000 opioid-related overdoses in 2017. Opioid overdoses kill more people than breast cancer every year.
Larochelle and his colleagues also found that despite having had an overdose, 34% of people were prescribed opioids, and another 26% were prescribed benzodiazepines in the year after their overdoses.
What was clear from the study, Larochelle said, is that more people need to be accessing treatment. "We're not doing enough to reach enough people," he said.