Opioid dependency and associated mortality is a significant public health and societal problem. Much has been written about the opioid problem, but it is proven to be so dynamic that in spite of our public health and interdiction efforts that centered on shutting down the pill mills—did just that—the opioid epidemic rolls on. Contrary to the popularized notion that unscrupulous or uneducated doctors were “addicting” unsuspecting people who had suffered an injury and were given unusually high and dangerous amounts of opioids, and continued overprescribing for profit, was sensational and grabbed headlines but was simply not based in fact. Sure it happened, especially in southern Florida, but it was primarily the drug addicts and dealers who were buying thousands of pills to sell or to support their habit. When the pill mills were shut down, the addicts and dealers found a cheap substitute. Mexican heroin cut with homemade fentanyl is now the newest scourge on our land—addicting and killing thousands of people each year. For the medical professionals, treating the addict is our imperative—and there is some good news on this front.
Buprenorphine with or without naloxone has proven to be an effective medication in both detoxing opioid addicts and maintaining the smaller percentage of those who cannot totally quit. Buprenorphine, a scheduled drug, is a novel, partial agonist/antagonist medication that binds directly to the Mu-1 opioid receptors, blocking the ability for other opioids to attach and cause intense euphoria. The use of this medication has evolved to improve access for more addicts. Ongoing research has proven its safety when combined with outpatient detoxification and optimal, patient centered treatment.
The objectives of the study by Kessel, et al (2018) were to determine if the use of buprenorphine induction (with or without naloxone) in an opioid-dependent population with commercial insurance improved both clinical and cost outcomes when compared with buprenorphine without induction with placebo.
The investigator employed a retrospective observational review of 648 medical claims of Cigna customers within a pre and post treatment window of four months, in order to analyze the medical, behavioral health outcomes, as well as the pharmacy utilization patterns and cost for all levels of all three groups.
The outcomes were robust. Differences before and after treatment among the three groups (buprenorphine with induction, buprenorphine without induction, and no buprenorphine) utilized a linear regression analysis to compare adjusted cost ratios.
The induction and non-induction of buprenorphine treatment were associated with significantly reduced inpatient utilization (81.8% reduction in hospitalizations vs 43.1% reduction in the no-treatment group (P<.05)) and lower total medical, behavioral health, outpatient, and pharmacy costs (cost ratio, 0.52:1; P<.001).
Most significantly there was a cost and utilization shift from inpatient toward outpatient treatment and the investigators observed a shift in pharmacy claims from medical to behavioral health services, with a cost ratio of 1.58:1 for total pharmacy (P<.05) and 2.26:1 for non-psychotropic pharmacy (P<.0001). These findings support the use of buprenorphine with and without induction as an effective means to decrease inpatient utilization and substantially lower total medical, behavioral health, and pharmacy costs.
Long ago, I was involved in the research of what should follow opioid detoxification or naloxone reversal. We hoped to both provide a safe way to deal with overdose and investigate the possibility of long term naloxone treatment. Naltrexone became available and we gave liquid Naltrexone or pill form to prevent relapse. It was a perfect drug, but none of the addicts who were not mandated to treatment took it.
Mainstream use of opioids by the middle-class population took decades. Many recall the uproar over a late 1990s advertising campaign dubbed “Heroin chic” which was touting a fragrance by using photos of emaciated models to sell their cologne. Super model Kate Moss was one of the poster kids for the campaign; she soon became addicted and nearly died. The prevailing thought at the time was middle class and upper class prep school kids would never cross the so called “needle barrier”. But today, we know for certain that they have—in droves and they are dying in droves.
Certainly we hope that a prevention program will emerge and lessen the demand. Until that time, it is our duty to treat those with this insidious disease. Medically Assisted Treatments (MATs), is one approach that is affordable and can provide short term efficacy, especially when outcomes are defined as overdose deaths. Given this new evidence, treatment just became affordable for millions more of the 23 million current addicts in the U.S. This is good news but, it’s not nearly enough. So we soldier on with more research and the development of new, novel, evidence-based, affordable treatment.
Kessel JB, Castel LD, Nemecek, DA. Clinical and Cost Outcomes of Buprenorphine Treatment in a Commercial Benefit Plan Population. Am J Pharm Benefits. 2018;10(1):84-89