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

By Daniel T. Brown DO ABPM-ADM, Regional Medical Director in Ohio and Pennsylvania, Pinnacle Treatment Centers

If you follow the news about the opioid crisis in the U.S., you know the past two years have been difficult. They’ve been difficult for people with opioid use disorder (OUD), they’ve been difficult for people who provide treatment for OUD, and they’ve been difficult for policymakers who decide where to allocate resources to mitigate the harm caused by the opioid crisis.

Why?

Your first answer is likely because of the pandemic.

And that’s partially correct.

The COVID-19 pandemic did have an adverse impact on people with OUD. A study published in February 2022 showed that people diagnosed with substance use disorder (SUD) or opioid used disorder (OUD) were at increased risk of harm from COVID-related disruptions if they:

• Lived at or below the poverty level
• Lived in rural/isolated areas
• Had limited access to:
  • Reliable transportation
  • Social support programs
  • Family support
  • Addiction treatment
  • Mental health treatment
• Experienced homelessness
• Experienced food insecurity

That study showed the pandemic made everything about getting treatment for OUD challenging. But that’s not the whole story. The whole story is more complex. The opioid crisis began in the early 1990s, when a new generation of opioid pain relievers appeared. Prescription rates skyrocketed. Between 1999 and 2014, the rate of opioid overdose in the United States quadrupled.

That’s when people around the country raised the alarm. States like Ohio, Pennsylvania, and Kentucky implemented programs to address the crisis. By 2018, we began to see progress: many of these programs were effective. Opioid prescribing rates decreased, nationwide. Overdose fatalities for all drugs decreased, nationwide. Opioid-related overdose fatalities decreased, nationwide. After close to twenty years of rapid increase, the numbers gave people hope.

Then two things happened: fentanyl and the COVID-19 pandemic.

Opioid Crisis 2017-2021: One Step Forward, and Then…

Let’s take a look at the overdose numbers to get an idea of where we are now in the ongoing opioid crisis. Here’s the latest available data on drug overdose in the U.S. These are the updated total fatal opioid overdoses recorded for 2019-2021, according to the CDC:

• 2017: 47,885
• 2018: 47,096
• 2019: 50,178
• 2020: 69,061
• 2021: 80,725

These are the updated total fatal overdoses for any/all drugs:

• 2017: 70,699
• 2018: 67,850
• 2019: 67,697
• 2020: 92,478
• 2021: 107,306

Now you can see what we mean. After a 400 percent increase from 1999-2014, then a 40 percent increase from 2014-2017, we saw significant decreases in overall drug overdose fatality between 2017 and 2019.

That was real progress. Finally, we had good news.

But this is where it gets complicated.

Fentanyl and Overdose

The numbers above clearly indicate that from 2017-2018, fatal opioid overdose decreased alongside all overdose fatalities. But from 2018 to 2019 – while overall overdose fatalities decreased – opioid overdose increased.

Why?

An influx of illicit fentanyl – an opioid drug that’s fifty to a hundred times more powerful than morphine – changed the situation. In 2017, the DEA issued warnings about the increased presence of fentanyl in black market opioids, illicit prescription medication, and drugs like heroin, indicating the strength of the drug significantly elevated risk of fatal overdose.

Unfortunately, they were right. The decrease in opioid overdose fatality from 2017 to 2018 did not become a trend: in 2019, fatal opioid overdose increased, surpassing the previous yearly maximum by over three thousand deaths.

Then the pandemic happened. The combination of fentanyl and COVID-related disruption resulted in dramatic increases in both overall drug overdose fatality and opioid overdose fatality. From 2019 to 2021, overall overdose fatality increased 60 percent, and fatal opioid overdose increased 59 percent.

That’s why the last two years – three, really – have been difficult. We made progress in the opioid crisis. We took a real step forward from 2017 to 2018. Then, the one-two punch of fentanyl and the pandemic slowed our progress. That’s actually not accurate. The one-two punch reversed our progress, and now we’re dealing with a situation that’s more challenging than the one we faced in 2017.

However, there are rays of hope.

One area where we see progress is in expanded access the medication-assisted treatment (MAT) for people with opioid use disorder (OUD). In 2020, the federal government eased restrictions on access to medication designed for people with opioid use disorder, called medication for opioid use disorder (MOUD).

This increased access is important, because MAT is the most effective treatment we have for people with OUD.

What is MAT?

A study on medication-assisted treatment published in June 2022 analyzed the relationship between time-in-treatment and overdose risk for people with opioid use disorder (OUD) who take medication for opioid use disorder (MOUD).

Before we look at the results of that study, we’ll define MAT and describe the medications used in MAT.

According to the Substance Abuse and Mental Health Services Administration (SAMHSA):

“Medication-assisted treatment (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.”

Evidence shows that MAT is a lifesaving treatment associated with the following positive outcomes:

• Reduced overdose fatalities
• Increased treatment adherence
• Reduced opioid use
• Reduced criminal behavior
• Decreased infectious disease transmission
• Improved likelihood to finding and maintaining work/employment
• Improved ability to participate in family and social life

There are three medications approved by the FDA as MOUD: methadone, buprenorphine, and Vivitrol. SAMHSA indicates that:

• Methadone is an effective treatment for people with OUD who engage in the disordered use of prescription and illicit opioids.
• Buprenorphine is an effective treatment for people with OUD who engage in the disordered use of prescription and illicit opioids.
• Vivitrol is an effective treatment for people with alcohol use disorder (AUD) or OUD who engage in the disordered use of alcohol and/or prescription/illicit opioids.

Methadone and buprenorphine reduce opioid withdrawal symptoms and reduce opioid cravings, while vivitrol reduces opioid cravings and rates of relapse to AUD. Of the three medications, methadone is the most heavily regulated, and available in federally licensed opioid treatment programs (OTPs). Buprenorphine and vivitrol, while regulated, are available in federally licensed office based opioid treatment (OBOT) locations.

Now let’s take a look at that study on time-in-treatment for people with OUD on MOUD.

The New Study: MAT, MOUD, and Medicaid Recipients

This new publication – called “Duration of Medication Treatment for Opioid-Use Disorder and Risk of Overdose among Medicaid Enrollees in Eleven States: A Retrospective Cohort Study” examined information collected on 293,180 people aged 18-64 diagnosed with OUD who participated in addiction treatment programs using MOUD. The study involved individuals insured through Medicaid in Delaware, Kentucky, Maryland, Maine, Michigan, North Carolina, Ohio, Pennsylvania, Virginia, West Virginia, and Wisconsin.

The size of the study group and the Medicaid of the individuals in the study group status has meaning on two levels. First, the size allows us to make population-level generalizations from the data. Second, Medicaid recipients are generally low or very low income, which means that during the COVID-19 pandemic, they were at increased risk of overdose and OUD complications.

The states they examined give weight to the study, as well. Here’s the latest overdose data from each of the eleven states in the study. We retrieved the information below from the Centers for Disease Control (CDC) and the State of Pennsylvania.

Overdose Fatalities for 11 States: 2019-2020

• Delaware:
  • 2019: 435 total
    • 382 opioid-related
  • 2020: 444 total
    • 411 opioid-related
• Kentucky:
  • 2019: 1,380 total
    • 1,024 opioid-related
  • 2020: 2,083 total
    • 1,709 opioid-related
• Maryland:
  • 2019: 2,369 total
    • 2,117 opioid-related
  • 2020: 2,771 total
    • 2,509 opioid-related
• Maine:
  • 2019: 371 total
    • 270 opioid-related
  • 2020: 496 total
    • 415 opioid-related
• Michigan:
  • 2019: 2,385 total
    • 2,009 opioid-related
  • 2020: 2,759 total
    • 2,185 opioid-related
• North Carolina:
  • 2019: 2,266 total
    • 1,793 opioid-related
  • 2020: 3,146 total
    • 2,602 opioid-related
• Ohio:
  • 2019: 4,251 total
    • 3,484 opioid-related
  • 2020: 5,204 total
    • 4,397 opioid-related
• Pennsylvania:
  • 2019: 4,377 total
    • 3,727 opioid-related
  • 2020: 5,168 total
    • 4,134 opioid-related
• Virginia:
  • 2019: 1,547 total
    • 1,252 opioid-related
  • 2020: 2,240 total
    • 1,863 opioid-related
• West Virginia:
  • 2019: 870 total
    • 665 opioid-related
  • 2020: 1,330 total
    • 1,137 opioid-related
• Wisconsin:
  • 2019: 1,201 total
    • 929 opioid-related
  • 2020: 1,531 total
    • 1,257 opioid-related

The inclusion of these specific states in the study add to its importance because in each state, overdose fatalities increased for all drugs and for opioids between 2019 and 2020. That means the need for MAT with MOUD is high. In these states, any information that helps treatment providers target outreach efforts, policy makers target programs for funding, and individuals learn about the benefits of treatment can and will make a difference.

Study Results: Does Time Make a Difference?

Researchers collected data on study participants at five points in time:

1. 60 days after their first Medicaid claim for MOUD
2. 120 days after their first Medicaid claim for MOUD
3. 180 days after their first Medicaid claim for MOUD
4. 240 days after their first Medicaid claim for MOUD
5. 300 days after their first Medicaid claim for MOUD

Here’s what they found.

Compared to patients who took MOUD for less than 60 days, patients who took MOUD for 60 days or more showed:

• 61% decrease in overdose risk at 60 days
• 66% decrease in overdose risk at 120 days
• 68% decrease in overdose risk at 180 days
• 71% decrease in overdose risk at 240 days
• 72% decrease in overdose risk at 300 days

Overall, what this data shows is that with each additional sixty days of adherence to an MOUD/MAT treatment program after an initial 60 days of adherence, risk of overdose deceased by an additional ten percent.

That’s a significant reduction, and important information for people with OUD and their families. It’s also important for treatment providers and local, state, and federal policymakers. We know MOUD saves lives, and the more data we have that shows MAT for OUD is an effective approach to reducing overdose death, the more likely we are to see expanded access and increased support for treatment nationwide.

And that’s the goal: get as many people as possible into a treatment program with lifesaving medications as soon as possible.

MAT and MOUD: More Than Medication

Let’s answer the question posed in the title of this article:

Does Time-in-Treatment Decrease Overdose Risk for People on MAT?

The data in this study indicate that yes, time-in-treatment decreases overdose risk for people in MAT programs who take MOUD.

One reason this finding resonates with us is that time-in-treatment – especially for people with OUD – leads to an array of positive outcomes. As time passes in treatment, the benefits accrue. Each successful day in treatment builds self-esteem and self-confidence. With each passing day, a person in recovery from OUD who engages in an evidence-based MAT program learns more about how to live life without using opioids. Their stress management skills improve, their ability to participate in family, work, and social life improves, and their belief in their ability to achieve their long-term recovery goals increases.

It’s a virtuous cycle: the more time you have in recovery, the better you get at living the recovery lifestyle.

That’s because in most cases, people who take MOUD also participate in therapy, counseling, and other forms of essential support like vocational assistance, food assistance, housing assistance, and community groups like Alcoholics Anonymous (AA) or Narcotics Anonymous (NA). Although it’s possible to participate in MAT programs without engaging in these other types of support, people who engage in all these phases of support soon realize they work together to improve their lives. The combination of medication, therapy, and lifestyle changes helps them grow and thrive in recovery.

That’s why we say MAT is about more than medication: the benefits are lifechanging. A person in a licensed MAT program learns to move past the cycles of addiction and create patterns of behavior that get stronger with each passing day. This study shows something else: in addition to creating positive, self-sustaining behavioral change, increased time-in-treatment also reduces risk of overdose.

That’s a major finding.

But we’re not surprised: we see the healing power of MAT every day.