Despite having a greater menu of medications to treat opioid use disorder than ever, clinicians underutilize the available medication options. Some patients still face significant barriers to staying in treatment.

1. A study found that:
• Among more than 100 million Americans
with commercial health insurance, the
prevalence of opioid use disorder (OUD)
diagnoses quadrupled from 2010 to 2014.
• The number of prescriptions for medications
to treat OUD (MOUD) in this population also
increased but did not keep up with the rise
in diagnoses.
• Patients continued taking sublingual and
oral-mucosal buprenorphine/naloxone
longer than they continued taking other
MOUDs.
As Opioid Use Disorders Increase, Prescriptions
for Treatment Have Not Kept Pace

2. Dr. Jake R. Morgan and colleagues at Boston Medical Center analyzed medical records in a
nationally representative database of people with employer-sponsored commercial health
insurance. Of 100 million individuals in the database, 340,000 spent some time living with a
diagnosis of OUD during the years 2010 to 2014. The proportion of the population with an OUD
diagnosis increased from year to year and was four times higher in 2014 compared with 2010.
Diagnoses of OUD Quadrupled From 2010 to 2014

3. Of the more than 340,000 patients diagnosed with OUD at any time during the period from 2010 to
2014, only 11 percent were prescribed an MOUD.
From 2010 to 2014, Only 11 Percent of Patients
With OUD Were Prescribed on MOUD

4. For each year, the researchers computed the total number
of months that patients spent with an OUD diagnosis (OUD
months). They compared the OUD months with the total
number of months that were covered by prescriptions for
OUD medications (MOUD months). Both OUD months and
MOUD months increased from year to year, but OUD
months increased faster than MOUD months. Physicians’
MOUD prescriptions covered 25 percent of OUD months in
2010, and only 16 percent in 2014.
Dr. Morgan says that several factors may have contributed
to the widening gap, including:
• Increases in OUD prevalence and rising awareness
among health care providers and patients may lead to
more diagnoses.
• Barriers may limit treatment with MOUD. For example,
health care providers need a waiver to prescribe
buprenorphine and can only treat a certain number of
patients with the medication. The requirement to
become abstinent as a precondition for initiating
treatment initiation with naltrexone may pose a barrier
to wider use of that medication.
Increases in MOUD Prescriptions Did Not
Keep Pace With Increased Treatment Need

5. Doctors were most likely to prescribe
buprenorphine/naloxone in sublingual or oral-
mucosal formulation (S/O BUP/NAL; Suboxone®
and generic), followed by sublingual
buprenorphine (BUP; generic) and oral
naltrexone (Oral NTX; ReVia®). Extended-release
naltrexone (XR-NTX; Vivitrol®) and transdermal
buprenorphine were introduced during this
period. Although they added to patients’
treatment choices, doctors did not prescribe
them often enough to prevent the widening gap
between OUD and MOUD.
Newly Introduced MOUDs Accounted for
A Small Proportion of prescriptions

6. Many patients who received MOUD prescriptions
stopped taking the medication within the first 30
days. Patients were least likely to stop taking S/O
BUP/NAL (31 percent) and most likely to stop
taking oral NTX (70 percent).
Dr. Morgan cites several reasons why patients
might be more likely to discontinue some
medications than others:
• Patients who stop taking NTX do not
experience withdrawal symptoms, making it
easier to discontinue that medication. In
contrast, stopping opioid agonists, such as
BUP, leads to withdrawal symptoms.
• Opioid agonists, such as BUP, may have
greater rewarding effects.
• The logistics of treatment (e.g., frequency of
administration, oral administration vs.
injection) may influence medication
compliance.
Patients Are More Likely To Stop
Taking Certain Medications

7. Patients discontinued sublingual and oral-mucosal buprenorphine at lower rates than other MOUDs
over the longer term, as well. However, other factors, such as patient demographics (e.g., age) and
treatment settings (e.g., inpatient or office-based), also played a role in long-term quit rates.
Most OUD Patients Stop Treatment Within 2 Years

8. • These finding suggest that
clinicians underutilize available
OUD medications.
• Clinicians have a greater menu
of OUD medication options than
ever before.
• Some patients still face
significant barriers to staying in
treatment, jeopardizing
successful outcomes.

9. Dr. Morgan says, “The findings from this study suggest that in the current opioid crisis, clinicians
underutilize the available OUD medications.”
He adds, “We have made important strides in treating opioid use disorder. Doctors and patients can
now choose among several highly efficacious medications. However, even a highly efficacious
medication is only effective for those who take it. Our real-world analysis indicates that significant
barriers to staying on treatment remain, even in a commercially insured population that was able to
initiate injectable naltrexone treatment.”
Dr. Morgan notes that his study did not include people on Medicaid. He comments, “While we are
unable to directly compare our prevalence estimates to the Medicaid population, we believe that the
central message of our research—that treatment rates and retention are low and threaten the
benefits of highly efficacious medications—is generalizable to this population.”
The study was supported by NIH grants DA040500 and DA031059.
Source:
Morgan J.R., Schackman, B.R., Leff, J.A., et al. Injectable naltrexone, oral naltrexone, and
buprenorphine utilization and discontinuation among individuals treated for opioid use disorder in a
United States commercially insured population. J Subst Abuse Treat 85:90-96, 2018.