Treatment of opioid use disorders: population …


Discussion

Among adults needing treatment for drug use disorder in 2022, only 25% received medication for drug use disorder; 30% received treatment for drug use disorder without these medications. These findings highlight disparities in treatment and the need to increase the use of medications for drug use disorder. Lower percentages of black and Hispanic adults, who have been particularly affected by the increase in overdose deaths (3), received no OUD treatment compared to white adults. Among adults who received OUD treatment, lower percentages of women and younger and older adults received medication. Higher proportions of people using or abusing other drugs or with previous arrests and bookings received medication for OUD; these findings could reflect greater awareness of the need for treatment or contact with systems linking people to OUD treatment. Higher percentages receiving medication among adults with severe OUD could reflect greater clinician perception or recognition of the need for treatment among adults with six or more OUD symptoms. Yet among adults with severe OUD, less than half (80.7% of the 53.0% who received OUD treatment) received medication for OUD, highlighting the wide gap in receipt of OUD. ‘evidence-based treatment, even for this highly affected group.

About 43% of adults needing OUD treatment did not think they needed it, consistent with previous findings that large proportions of people with SUDs did not think they needed treatment.¶¶ Patients who take opioids only as prescribed (who make up the majority of people meeting criteria for drug use disorder***) are particularly unlikely to perceive the need for treatment for substance use disorder. use drugs, even if they have symptoms of drug use disorder. If clinicians suspect that patients prescribed opioids for pain have a drug use disorder because of their concerns or behaviors, or if patients experience opioid-related harms or choose to gradually reduce their opioid use but are unable to do so, clinicians should discuss their concerns with the patient, provide the patient with an opportunity to communicate any related concerns or issues, and assess the opioid use disorder. drugs using the DSM-5 criteria (4). Non-judgmental, supportive and harm reduction approaches can build rapport, build trust, and reduce overdoses and other risks in people who are not ready for treatment.†††

Several factors limit access to drugs for drug use disorder (DUD) despite strong recommendations regarding their use (4,5). Some clinicians prefer an approach that does not include medications, and some believe that medications for the treatment of substance use disorder (OCD) are equated with the use of illegal substances (6). Methadone for OUD can only be dispensed through an opioid treatment program (OTP) certified by the Substance Abuse and Mental Health Services Administration; many U.S. counties do not have OTPs.§§§ Buprenorphine or naltrexone can be prescribed in any setting, but several barriers exist. Many drug use disorder facilities do not offer these medications; some do not accept clients who are taking medications for drug use disorder.¶¶¶ Additionally, a large portion of pharmacies do not stock buprenorphine.**** Payers, including many state Medicaid programs, have restrictions (such as prior authorization) that may delay dispensing of certain formulations buprenorphine (7). Less than 10% of doctors†††† obtained the waiver that, until 2023, was necessary to prescribe buprenorphine for OUD. Primary care physicians reported barriers to obtaining the waiver and prescribing buprenorphine, including lack of experience treating OUD, fear of being inundated with requests for buprenorphine, lack of access to addiction or behavioral health specialists and acquisition of the training required to obtain a waiver (8).

Boundaries

The results of this report are subject to at least five limitations. First, the number of people requiring treatment for drug use disorder (DUD) presented in this report is likely underestimated; The NSDUH is a household survey, it includes homeless people only if they use shelters and does not include residents of institutional group housing such as prisons. Second, NSDUH response rates in 2021 and 2022 were lower than in previous years, which could increase the risk of non-response bias leading to over or underestimates. Third, the sample size limited some comparisons of TOD treatment across racial and ethnic groups, prohibited comparisons across health insurance coverage, and excluded treatment estimates specific to people with mild or moderate TOD. . Medications for TOD are highly recommended, especially for moderate or severe TOD (4,5). However, Food and Drug Administration approvals for obsessive-compulsive disorder (OCD) medications were based on data from patients with opioid addiction as defined by Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; the application to mild OUD defined by DSM-5 is less clear (5). It would be interesting to better understand the specific treatment needs of patients with mild drug use disorder. Fourth, responses to the cross-sectional survey did not allow for determination of the presence of drug use disorder symptoms prior to the previous year. Finally, drug use disorder was an indirect diagnosis based on respondents’ responses to questions that met diagnostic criteria; respondents were not asked whether they had ever received a clinical diagnosis of drug use disorder.

Implications for public health practice

The shift from heroin to illegally manufactured fentanyl has increased the likelihood that overdoses will be fatal (9), which adds to the urgency of providing effective care to people with OCD (2). This need is particularly acute for black and Hispanic adults (3,ten), women, and younger and older adults. Population-wide interventions in diverse settings are needed to connect people to care,§§§§,¶¶¶¶ initiate medications for OUD, ***** and support sustained treatment and recovery.

Expanded communication about the effectiveness of OUD medications is needed to reduce nonfatal and fatal overdoses. Increasing awareness of the effectiveness of OUD medications among people who use drugs and their families, friends, and other contacts is essential.††††† Clinicians and treatment providers should offer or arrange evidence-based treatment, including medications for OUD (4). As of 2023, a waiver is no longer required to prescribe buprenorphine. All clinicians with a current registration with the Drug Enforcement Administration, including Schedule III authority, may prescribe buprenorphine for OUD if permitted by applicable state law.§§§§§ Advice (4,5) and mentoring¶¶¶¶¶ are available for the diagnosis and management of opioid use disorders. Pharmacists and payers can work to make these life-saving medications available without delay.



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