Medication for Opioid Overdose Underused

Doctor holding medicine and talking to male patient

According to data published by the Centers for Disease Control (CDC), the overdose crisis has claimed over a million lives in the United States since 1999. Among these overdose fatalities, roughly three-quarters involved opioids. In 2021, overdose fatalities reached a grim milestone: over a hundred thousand people – 106,699 to be exact – died of fatal overdose. That’s an increase of 52 percent from 2017, and an increase of 533 percent since the beginning of the opioid overdose crisis in 1999. One reason these figures are disturbing is that we have an effective medication for opioid overdose available, which we’ll discuss below.

In 2020, opioids were involved in 68,630 overdose deaths, accounting for 74.8 percent of overdose fatalities. If that trend persists when verified data for 2021 becomes available, we can expect an increase of 15 percent, with an estimated total of 80,250 opioid-related overdose fatalities.

Those numbers are overwhelming. That’s why we continue to write and publish articles on the opioid and overdose crisis. We retrieved those statistics from the 2021 National Survey on Drug Use and Health. For an overview on the opioid crisis and the various federal programs in place to help support individuals, families, and communities harmed by the crisis, please read this article on the blog section of our website:

The Opioid Crisis: A New National Strategy

That article is a solid overview of where we are now.

In this article, we’ll focus on a specific component of OUD and OUD treatment: people with OUD who receive support with medications for opioid use disorder (MOUD) in federally licensed medication-assisted treatment (MAT) programs. The medications we refer to below are all considered medications that prevent opioid overdose, as well.

Here’s the latest data on MAT rates in the U.S.:

Medication-Assisted Treatment (MAT) for OUD

  • A total of 5.6 million people had OUD, including people with heroin use disorder, prescription opioid use disorder, and/or other opioid-related SUDs
  • 2 million people with OUD received treatment for OUD
  • 533,000 people with OUD received MAT for OUD

These figures are important because MAT with MOUD – medication assisted treatment with medication for opioid use disorder – is recognized worldwide as the gold standard treatment for opioid use disorder, and that data reveals something disturbing: 90 percent of people with opioid disorder do not get medication that prevents opioid overdose, which is the best available treatment for OUD,

But why?

Medication For Opioid Overdose and Opioid Use Disorder: A Nationwide Analysis

To explore this phenomenon – and share what we learn here – we’ll discuss a study published in May 2022 called ” Comparative Effectiveness Associated With Buprenorphine and Naltrexone in Opioid Use Disorder and Cooccurring Polysubstance Use.” This study explores the outcomes of patients with OUD or polysubstance use who were prescribed either buprenorphine or naltrexone, two medications for opioid use disorder, which are also medications that reduce opioid overdose. In addition to outcomes, the study examines rates of treatment with the two medications, and differences in prescription rates between people with OUD and people with co-occurring substance use disorders.

Note: in this study and this article, the phrase cooccurring substance use disorders will refer to the polysubstance misuse. That’s the clinical term for the misuse of two or more substances at the same time. We mention this because in general, the term cooccurring disorders refers to the simultaneous presence of a substance use disorder and a mental health disorder, rather than the simultaneous presence of two or more substance use disorders.

With that said, let’s tale a look how researchers conducted the study.

Here’s how the researchers framed the work:

“This observational comparative effectiveness study used insurance claims from 2011 to 2016 to study initiation of medications for OUD (MOUD) among treatment-seeking individuals aged 12 to 64 years with a primary diagnosis of OUD. Cooccurring SUD was defined as SUD diagnosed concurrent with or in the 6 months prior to OUD treatment initiation.”

The research team examined insurance claim records for 179,280 individuals with opioid use disorder (OUD). Here’s the basic demographic information on this sample set.

MOUD/MAT Study: Participant Characteristics

  • Average age: 33
  • Gender:
    • Male: 50.5%
    • Female: 49.5%
  • Race/ethnicity:
    • White: 83%
    • Black: 7%
    • Hispanic: 1.2%
    • Other: 8.8%
  • Presence of cooccurring SUD:
    • Alcohol use disorder: 17.2%
    • Stimulant use disorder: 14.6%
    • Sedative use disorder: 9.4%
  • Presence of cooccurring mental health disorder:
    • Mood disorder: 40.9%
    • Psychotic disorder: 3.2%
    • Personality disorder: 2.9%
    • Anxiety disorder: 34.6%

We should point out that a study reporting on a sample size this large is valuable for people treatment providers and policymakers alike. Large sample sizes allow us to generalize to population-level conclusions. That means that from a sample this large, it’s safe – and statistically verifiable – to say that the reported rates and percentages are consistent nationwide, and valid benchmarks for the rest of the population.

Now let’s take a look at the results.

Treatment for OUD: MAT Initiation

First, let’s look at the type of treatment each of these individuals received during their first treatment experience.

First Treatment: People With OUD With and Without Cooccurring SUD

Sample Size: 179,280

  • Received psychosocial treatment without MOUD: 57.4%:
    • Among those with cooccurring SUD: 70.4% received psychosocial treatment but not MOUD
    • Among those without cooccurring SUD: 52.7% received psychosocial treatment but not MOUD
  • Received buprenorphine: 37.5%
    • Among those with cooccurring SUD: 20.3% received buprenorphine
    • Among those without cooccurring SUD: 43.7% received buprenorphine
  • Administered extended-release (ER) naltrexone: 1.7%
    • Among those with cooccurring SUD: 2.4% administered ER naltrexone
    • Among those without cooccurring SUD: 1.5% administered ER naltrexone
  • Received oral naltrexone:
    • Among those with cooccurring SUD: 6.8% received oral naltrexone
    • Among those without cooccurring SUD: 2.1% received oral naltrexone

These numbers underscore the problem we introduce above. Although MAT is recognized as the most effective available treatment for people with OUD, it’s underutilized – especially for people who may need it most. These figures show us that seventy percent of people with OUD and co-occurring SUD did not receive MAT, compare to fifty percent of people with OUD but without co-occurring SUD. In addition, twice as many people without cooccurring SUD received buprenorphine than those with cooccurring SUD. And finally, over three times as many people with co-occurring SUD received naltrexone, compared to people without co-occurring SUD.

Let’s clarify something: naltrexone is an opioid receptor antagonist, meaning it blocks anything from binding to an activating opioid receptors in the brain, whereas buprenorphine is an opioid receptor agonist, meaning it binds and activates opioid receptors. Since buprenorphine is an opioid medication, it has a very mild euphoric effect. That’s why some treatment professionals avoid prescribing buprenorphine.

Dr. Kevin Xu, a resident physician at Washington University, interviewed in an article published in the online science magazine Science Daily, discusses this practice:

“For a long time, people thought that blocking the receptor [ed. with naltrexone] would be just as good as using a drug, like buprenorphine, to activate the opioid receptor. But 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.”

The next set of data we share will foreground the scope of that challenge.

Let’s take a look.

Treatment for OUD and Medication for Opioid Overdose: Buprenorphine With or Without Cooccurring SUD

Here’s the issue: people with co-occurring SUD are at increased risk of experiencing negative outcomes, compared to people with only one SUD. That’s why offering people in this group the treatment that gives them the best chance of success makes the most sense, overall.

That’s also why the following data on treatment for people with OUD and cooccurring disorders is troubling. Cooccurring SUD was associated with:

  • Decreased odds of initiating buprenorphine:
    • People with cooccurring SUD were 45% less likely to receive buprenorphine, compared to people without cooccurring SUD
  • Increased odds of initiating naltrexone:
    • People with cooccurring SUD were 10% more likely to receive ER naltrexone, compared to people without cooccurring SUD
    • People with cooccurring SUD were 95% more likely to receive oral naltrexone, compared to people without cooccurring SUD

It’s troubling in the broad sense, in that some providers are reluctant to prescribe the most effective medication for a patient with OUD. It’s also troubling in the narrow sense, in light of the following data:

  • Buprenorphine treatment days were associated with decreased poisonings [ed. overdose] compared with days without MOUD for individuals with cooccurring SUD
  • Buprenorphine treatment days were associated with decreased poisonings [ed. overdose] compared with days without MOUD for individuals without cooccurring SUD

We’ll translate: for people with or without cooccurring SUD, treatment with buprenorphine decreased overdose risk.

But that’s not all.

In assessing individual cooccurring SUD, researchers observed decreased likelihood of buprenorphine initiation for people with cooccurring SUD, compared to people without SUD. Here’s the data:

  • Alcohol use disorder: 40% decreased likelihood of receiving buprenorphine
  • Stimulant use disorder: 34% decreased likelihood of receiving buprenorphine
  • Sedative use disorder: 27% decreased likelihood of receiving buprenorphine

Again – considering what we know about the benefits of buprenorphine – this data highlights the challenges elucidate by Dr. Xu, above.

Protective Effect of Buprenorphine: Does it Help People With Cooccurring SUD?

In comparing the effectiveness of buprenorphine for people with cooccurring SUDs, researchers observed protective associations between buprenorphine and people with:

  • Alcohol use disorder: 33% reduced likelihood of overdose and/or discontinuing treatment
  • Stimulant use disorder: 22% reduced likelihood of overdose and/or discontinuing treatment
  • Sedative use disorder: 21% reduced likelihood of overdose and/or discontinuing treatment

These protective effects of buprenorphine – measured by overdose rates and treatment retention – were almost the same for people without cooccurring substance use disorder. In addition, extended-release naltrexone was associated with protective effects for people with or without cooccurring SUD, while oral naltrexone was not associated with protective effects for people with or without cooccurring SUD. This confirms earlier research that showed that, in comparison to buprenorphine, treatment of OUD with naltrexone alone was associated with:

  • Less time-in-treatment
  • Increased overdose rates

This means the practice of excluding individuals with OUD from MAT with oral naltrexone rather than buprenorphine is not supported buy data. In fact, this practice may cause harm instead of reduce harm. Here’s how Dr. Laura J. Bierut, Professor of Psychiatry at Washington University – also interviewed in the online science magazine Science Daily, describes the practice:

“This is equivalent to giving those with advanced cancer a less aggressive treatment. 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.”

Stated in that way, the choice to prescribe or not prescribe buprenorphine seems clear. Since buprenorphine decreases overdose risk and improves time-in-treatment, those reasons alone should make it the go-to option for people diagnosed with opioid use disorder, regardless of the presence of a cooccurring SUD.

However, those are not the only benefits of medication-assisted treatment.

How MAT Helps People with OUD

This study shows us that nationwide, the gold-standard approach to treating OUD, known as medication-assisted treatment (MAT), is underutilized. Providers have various reasons for declining to prescribe MAT for people with OUD, but with each new paper published on the benefits of MAT, those reasons lose their evidentiary base, and become less tenable – especially in light of the ongoing harm caused by the opioid overdose crisis.

We’ll close this article with a list of the benefits of MAT beyond reduced risk of overdose and increased time-in-treatment, which we discuss above. First, though, we suggest reading the following articles about MAT. They’re located on the blog section of our website, like the article we link to above:

The Opioid Crisis: Does Time-in-Treatment Decrease Overdose Risk for People on MAT?

Pew Center Research Report: Removing Barriers to Methadone Treatment Can Save Lives

Methadone or Suboxone? If I have OUD, How Do I Decide?

Those articles – along with our own MAT Page – will give you a good idea about the importance of MAT, and offer context for understanding the nationwide effort to reduce rates of overdose fatality and improve outcomes for people with OUD or OUD and cooccurring SUD.

The reason MAT is considered the gold standard treatment for OUD is simple: decades of evidence show it works. The Substance Abuse and Mental Health Services Administration (SAMHSA) identifies the following benefits:

  • Decreased opioid use
  • Decreased risk of relapse to opioid use
  • Reduce involvement with the criminal justice system
  • Increased social, academic, and family functioning
  • Increased ability to find work and stay employed
  • Decreased opioid related mortality

In other words, for people with OUD, MAT improves life across almost every important metric, from opioid use, to relapse, to reduced criminal activity, to improved work, school, and family life. But the most important metric of all is the last one: reduced opioid-related mortality.

We’ll translate: MAT can save lives.

The materials provided on the Pinnacle Blog are for information and educational purposes only. No behavioral health or any other professional services are provided through the Blog and the information obtained through the Blog is not a substitute for consultation with a qualified health professional. If you are in need of medical or behavioral health treatment, please contact a qualified health professional directly, and if you are in need of emergency help, please go to your nearest emergency room or dial 911.