Comparative Effectiveness of Different Treatment Pathways for Opioid Use Disorder
Comparative Effectiveness of Different Treatment Pathways for Opioid Use Disorder
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DOI：
10.1001/jamanetworkopen.2019.20622
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发表时间：
2020-02-01
影响因子：
13.8
通讯作者：
Sanghavi, Darshak M.
中科院分区：
文献类型：
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作者：
Wakeman, Sarah E.;Larochelle, Marc R.;Sanghavi, Darshak M.
这项比较有效性研究探讨阿片类药物使用障碍治疗途径与过量和阿片类药物相关的急性护理使用之间的关联，作为阿片类药物使用障碍复发的代理。在这项对40885名阿片类药物使用障碍成年人进行的比较有效性研究中，比较了6种不同的治疗途径，在3个月和12个月的随访期间，与没有治疗相比，只有丁丙诺啡或美沙酮治疗与过量和严重阿片类药物相关急性护理使用的风险降低相关。MeaningMeaningMeaningMeaningMeaningMeaningMeaningMeaningMeaningMeaningMeaningMeaningMeaningMeaningMeaningMeaningMeaningMeaningMeaningMeaningMeaningMeaningMeaningMeaningMeaningMeaningMeaningMeaningMeaningMeaningMeaningMeaningMeaningMeaningMeaningMeaningMeaningMeaning与阿片类药物拮抗剂治疗、住院治疗或强化门诊行为干预相比，美沙酮和丁丙诺啡可降低过量和阿片类药物相关的发病率，可作为阿片类药物使用障碍的一线治疗。缺乏关于现实世界治疗途径相对有效性的国家数据。目的研究阿片类药物使用障碍（OUD）治疗途径与过量和阿片类药物相关急性护理使用之间的相关性，作为OUD复发的替代。设计、设置和患者这项回顾性比较有效性研究评估了OptumLabs数据仓库中16岁或16岁以上OUD和商业或医疗保险优势覆盖范围的个人的去识别索赔。阿片类药物使用障碍的确定基于1个或多个住院患者或2个或多个门诊患者在3个月内对OUD诊断代码的索赔; 1个或多个OUD索赔加上阿片类药物相关过量、注射相关感染或住院戒毒或住院服务的诊断代码;或2015年1月1日至2017年9月30日之间的MOUD索赔。数据分析时间为2018年4月1日至2019年6月30日。暴露6种相互排斥的治疗途径之一，包括（1）不治疗，（2）住院戒毒或住院服务，（3）强化行为健康，（4）丁丙诺啡或美沙酮，（5）纳洛酮，（6）非强化行为健康。主要结局和测量初始治疗后3个月和12个月期间阿片类药物相关过量或严重急性护理使用。结果共发现40885例OUD患者（平均[SD]年龄47.73 [17.25]岁; 22172例[54.2%]男性; 30332例[74.2%]白色）。对于OUD治疗，24258例（59.3%）接受非强化行为健康，6455例（15.8%）接受住院戒毒或住院服务，5123例（12.5%）接受丁丙诺啡或美沙酮MOUD治疗，1970例（4.8%）接受强化行为健康，963例（2.4%）接受纳洛酮MOUD治疗。在3个月的随访期间，707名参与者（1.7%）经历了药物过量，773名（1.9%）有严重的阿片类药物相关急性护理使用。仅丁丙诺啡或美沙酮治疗与3个月（校正风险比[AHR]，0.24; 95% CI，0.14-0.41）和12个月（AHR，0.41; 95% CI，0.31-0.55）随访期间药物过量风险降低相关。丁丙诺啡或美沙酮治疗也与3个月（AHR，0.68; 95% CI，0.47-0.99）和12个月（AHR，0.74; 95% CI，0.58-0.95）随访期间严重阿片类药物相关急性护理使用的减少相关。结论和相关性与其他治疗相比，丁丙诺啡或美沙酮治疗与过量和严重阿片类药物相关急性护理使用的减少相关。需要制定解决MOUD使用不足问题的策略。
This comparative effectiveness research study examines associations between opioid use disorder treatment pathways and overdose and opioid-related acute care use as proxies for opioid use disorder recurrence.Key PointsQuestionWhat is the real-world effectiveness of different treatment pathways for opioid use disorder? FindingsIn this comparative effectiveness research study of 40885 adults with opioid use disorder that compared 6 different treatment pathways, only treatment with buprenorphine or methadone was associated with reduced risk of overdose and serious opioid-related acute care use compared with no treatment during 3 and 12 months of follow-up. MeaningMethadone and buprenorphine were associated with reduced overdose and opioid-related morbidity compared with opioid antagonist therapy, inpatient treatment, or intensive outpatient behavioral interventions and may be used as first-line treatments for opioid use disorder.ImportanceAlthough clinical trials demonstrate the superior effectiveness of medication for opioid use disorder (MOUD) compared with nonpharmacologic treatment, national data on the comparative effectiveness of real-world treatment pathways are lacking. ObjectiveTo examine associations between opioid use disorder (OUD) treatment pathways and overdose and opioid-related acute care use as proxies for OUD recurrence. Design, Setting, and ParticipantsThis retrospective comparative effectiveness research study assessed deidentified claims from the OptumLabs Data Warehouse from individuals aged 16 years or older with OUD and commercial or Medicare Advantage coverage. Opioid use disorder was identified based on 1 or more inpatient or 2 or more outpatient claims for OUD diagnosis codes within 3 months of each other; 1 or more claims for OUD plus diagnosis codes for opioid-related overdose, injection-related infection, or inpatient detoxification or residential services; or MOUD claims between January 1, 2015, and September 30, 2017. Data analysis was performed from April 1, 2018, to June 30, 2019. ExposuresOne of 6 mutually exclusive treatment pathways, including (1) no treatment, (2) inpatient detoxification or residential services, (3) intensive behavioral health, (4) buprenorphine or methadone, (5) naltrexone, and (6) nonintensive behavioral health. Main Outcomes and MeasuresOpioid-related overdose or serious acute care use during 3 and 12 months after initial treatment. ResultsA total of 40885 individuals with OUD (mean [SD] age, 47.73 [17.25] years; 22172 [54.2%] male; 30332 [74.2%] white) were identified. For OUD treatment, 24258 (59.3%) received nonintensive behavioral health, 6455 (15.8%) received inpatient detoxification or residential services, 5123 (12.5%) received MOUD treatment with buprenorphine or methadone, 1970 (4.8%) received intensive behavioral health, and 963 (2.4%) received MOUD treatment with naltrexone. During 3-month follow-up, 707 participants (1.7%) experienced an overdose, and 773 (1.9%) had serious opioid-related acute care use. Only treatment with buprenorphine or methadone was associated with a reduced risk of overdose during 3-month (adjusted hazard ratio [AHR], 0.24; 95% CI, 0.14-0.41) and 12-month (AHR, 0.41; 95% CI, 0.31-0.55) follow-up. Treatment with buprenorphine or methadone was also associated with reduction in serious opioid-related acute care use during 3-month (AHR, 0.68; 95% CI, 0.47-0.99) and 12-month (AHR, 0.74; 95% CI, 0.58-0.95) follow-up. Conclusions and RelevanceTreatment with buprenorphine or methadone was associated with reductions in overdose and serious opioid-related acute care use compared with other treatments. Strategies to address the underuse of MOUD are needed.