June 1, 2022
There is no cure for opioid use disorder (OUD) and treatments do not work the same for everyone. There are many factors that create barriers to accessing medications like buprenorphine, which is intended to help patients reduce harmful opioid use. While there has been a focus on increasing access to treatments and recovery programs, the delivery of those treatments can be very different depending on the provider. And making sure treatment is accessible and effective is more important than ever.
“Things are worse than they’ve ever been,” said Alex Gertner, MD, PhD, who will be a resident in the UNC Department of Psychiatry in July. “Overdose deaths are increasing. There were some signs of hope before the COVID-19 pandemic began, but we have seen dramatic rises during the pandemic. There’s no more important time to address this issue than right now.”
Gertner has been researching OUD and its treatments during his time as a student in the UNC School of Medicine and the Department of Health Policy and Management at the UNC Gillings School of Global Public Health. A recent graduate of the UNC MD-PhD Program, his dissertation on the subject resulted in multiple research publications. His latest one, published in the International Journal of Drug Policy, looks at the difference in treatment delivery methods for opioid use disorder between providers with high and low patient retention.
“There’s not much research on retention or continuity of treatment for OUD,” Gertner said. “We need to learn what providers can do to keep patients in treatment longer, because the longer patients stay in treatment, the less likely they are to die of an overdose.”
More than 107,000 Americans died of drug overdoses in 2021, the highest number on record according to the Centers for Disease Control and Prevention (CDC). Overdoses involving synthetic opioids, such as fentanyl, accounted for 71,000 of those deaths, up 23% from the year before.
One of the best treatments for OUD is buprenorphine. Currently, the minimum recommended length of treatment for patients on buprenorphine is 180 days, as this is the minimum amount of time believed to have meaningful benefit from the treatment. Gertner used 180 days as the target treatment time when evaluating Medicaid claims data from providers prescribing buprenorphine in North Carolina. Gertner and fellow researchers found a notable difference in the amount of time patients spent in different programs. By compensating for patient differences and taking into account program requirements and each provider’s beliefs and training, Gertner and colleagues saw a clear difference between treatment programs with high retention versus low retention.
Providers with high-threshold practices had lower retention, while providers with low-threshold practices had more successful longer courses of treatment. High-threshold practices include requirements and restrictions like mandating participation in counseling sessions, strictly limiting buprenorphine dosages, dismissing patients if they fail urine testing or miss an appointment, and office or facility-based inductions into treatment.
“High-threshold practices can make access to treatment more difficult for patients, while low-threshold practices allow more flexibility and can meet patients in their current life situation,” Gertner said. “We saw that providers who use high-threshold practices have usually been in practice longer. There is currently a paradigm shift with newer providers who believe in more flexible treatment programs that encourage access to treatment but aren’t burdensome with the delivery method.”
The study also found that low-retention providers more often encouraged people to stop using buprenorphine once the providers thought they were ready, while high-retention providers discussed the decision to come off treatment with patients individually, following the more current guidelines that people should stay on the treatment as long as they need, even indefinitely.
While the information gained from this study is helpful to inform more successful OUD treatment methods, it’s not what Gertner was expecting. He and study co-author Hendrée Jones, PhD, executive director of UNC Horizons and professor in the Department of Obstetrics and Gynecology at the UNC School of Medicine, were surprised to find these key differences. UNC Horizons is a substance use disorder treatment program for women, including those who are pregnant, parenting, and/or whose lives have been touched by abuse and violence. It is a comprehensive program designed for a very specific patient type that has successfully treated more than 5,000 patients and their children over the last 30 years.
“We need to learn more about what drives people to stay in treatment,” said Jones. “We need to know what characteristics a provider has that leads to low or high retention, and what characteristics a patient has that affect retention. When we have this information we can make modifications to programs that will ensure more successful treatment outcomes.”
UNC Horizons has been adapting its program since its inception, growing and changing to provide more services and the most up-to-date substance use disorder treatments available. Before 2010, buprenorphine was not available for treatment of OUD in pregnant people. Jones led a multi-site randomized controlled clinical trial that upheld the relative safety and efficacy of buprenorphine compared to methadone in pregnant people, which helped lead to the treatment becoming available for that population. UNC Horizons continues to lead the way in successful treatment of this population because Jones and her colleagues consistently look for ways to improve.
While this most recent study found that the general population seeking OUD treatment could benefit from more flexibility, more research needs to be done on population subsets, including pregnant and/or parenting people, for which a more comprehensive program can be beneficial. But, it gives specialists like Jones something to consider going forward.
“This study provides a good opportunity for discussion about what we can do to increase retention in the perinatal OB-GYN patient population,” Jones said. “What can we do to further tailor our response to our patients’ needs and quickly mobilize to start providing care as soon as someone shows up at our door?”
Gertner hopes his research makes an impression on decision makers and policy creators.
“Legislators have created policies that highly regulate the field of addiction care, and sometimes programs like Medicaid put strict limits on what providers can do in clinical care settings, making treatment even harder to access,” Gertner said. “Professional societies should take this research into consideration as well when they create their guidelines. If more people acknowledged that taking flexible approaches in OUD treatment would benefit their patients, we could save more lives.”
Additional researchers in this study include
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