Life-saving medication for opioid use disorder underprescribed in US

Buprenorphine, a life-saving medication for opioid use disorder, is underutilized by physicians, according to researchers.

Kevin Xu, MD, MPH, a resident physician in psychiatry at the Washington University School of Medicine in St. Louis, and colleagues discovered that buprenorphine, which has been shown to reduce the risk for overdose, was prescribed to only about half of patients in the United States who were seeking treatment for opioid use disorder (OUD). The number was even lower for those with polysubstance use disorder — a disorder in which opioid users also misuse other substances — at roughly 30%.

“This is equivalent to giving those with advanced cancer a less aggressive treatment,” senior investigator Laura J. Bierut, MD, the Alumni Endowed Professor of Psychiatry at Washington University, said in a press release about the study. “It seems obvious to many of us that we should be giving the most aggressive and effective treatments to those who are most seriously ill.”

Xu and colleagues conducted an observational competitive effectiveness trial that used insurance claims across 5 years to study the initiation of medications for OUD (MOUD) among patients seeking treatment.

Of the 179,280 individuals with OUD, 102,930 received psychosocial treatment without MOUD, about 57.4%.

Among 47,488 individuals with co-occurring substance use disorders (SUDs), 33,449 — or 70.4% — did not receive MOUD. Comparatively, only 52.7% of individuals without co-occurring SUD did not receive medication.

Xu said in the press release that he was concerned that “the majority of people misusing multiple substances don’t appear to be getting the lifesaving medication they really need.”

The researchers also note, however, that co-occurring SUD was associated with decreased odds of initiating buprenorphine (RR = 0.55; 95% CI, 0.54-0.56) but increased odds of initiating naltrexone (extended release: RR = 1.12; 95% CI, 1.05-1.2; oral: RR = 1.95; 95% CI, 1.86-2.03), “despite buprenorphine’s protective associations against drug-related poisoning.”

In a subcohort of 12,485 people who were treating their disorder with MOUD and experienced at least one drug-related poisoning during insurance enrollment, researchers found that buprenorphine treatment days were associated with decreased poisonings compared with days without MOUD for individuals with co-occurring SUDs (OR = 0.56; 95% CI, 0.48-0.65) and without co-occurring SUDs (OR = 0.57; 95% CI, 0.53-0.63).

Overall, the findings suggest, according to the study authors, that people with OUD and polysubstance use were “less likely to initiate buprenorphine and naltrexone than individuals without polysubstance use.”

One explanation for this, Xu said in the release, is that buprenorphine is an opioid, and therefore physicians may be wary of prescribing it to people with OUD. Additionally, buprenorphine does not require daily trips to a clinic and can be taken at home. That “lack of supervision, as well as a lack of data about the drug’s effectiveness in those who misuse multiple substances,” means that some physicians are “reluctant to prescribe it,” according to the press release.

“Buprenorphine appears to [be] a safe opioid,” Xu said in the release. “It’s specifically designed to be different from other opioid drugs in that it won’t cause a user to stop breathing, which pretty much every other type of opioid will do. That means it can be taken safely at home, which is very helpful, even essential, to recovery.”

Though the other drug examined in the study, naltrexone, also lowers the risk of future overdoses, Xu said “recent data suggest buprenorphine is substantially more effective.”

“Now the challenge will be convincing more doctors to prescribe this safe and effective drug for the patients who need it,” he said.

References:

Medication that lowers risk of overdose underused. https://www.eurekalert.org/news-releases/952149. Published May 10, 2022. Accessed May 19, 2022.

Xu KY, et al. JAMA Netw Open. 2022;doi:10.1001/jamanetworkopen.2022.11363.