Immediate access to opioid agonist therapy, some statistics, and another bad law

a recent article using modeling assessed the overall costs and benefits of different approaches for the treatment of opioid use disorder in California's publicly-funded treatment programs, finding large human and monetary benefits for a system with easy access to unlimited opiate agonist treatment (see Krebs E. Ann Intern Med 2018; 168: 10).​    

Background:

--California has some pretty unique circumstances:

    --the largest number of persons with opiate use disorder (OUD) in the US

    --California's regulations are quite restrictive: limiting the duration of medically managed withdrawal to 21 days, and requiring documentation of 2 or more failed treatments with medically managed withdrawal before opiate agonist therapy (OAT) can be started (methadone and buprenorphine)

    --There are many exemptions from this regulation. but still the observation is that 54.3% begin therapy with medically managed withdrawal

Details:
--their model: 35-yo patients receiving initial OUD therapy. 35.8% women, 62.9% primarily used heroin/37.1% prescription opiates, 7.1% of those on prescription opiates had HIV and 25% of them were on treatment [all numbers based on statistics from other sources]
--they compared various outcomes: following the California regulations, vs doing what actually happens in California (where 54.3% of patients followed the regulations), vs a hypothetical strategy where everyone had immediate and long-term access to opioid agonist therapy (OAT)

Results:​
--their model did well in predicting 5-year mortality (within 3.1% of the observed mortality in California), proportion of time spent in treatment (within 9.6%), though the model was substantially lower than CDC estimates of HIV transmission
--30-year outcomes, comparing initial longterm OAT vs the reality in California (current care) vs following the strict California guidelines:
    --survival %: 53.6% immediate OAT vs 50.9% current care vs 49.3% guideline care
    --HIV incidence/1000 persons: 1.37 immediate OAT vs 1.64 current care vs 2.20 guideline care
    --incarceration (months): 14.4 immediate OAT vs 16.8 current care vs 18.0 guideline care
--lifetime costs of care (in 2016 $$) [societal perspective includes the health sector plus patient out-of-pocket health costs, crime-related costs, social service interventions]
    --societal perspective: $946,804 immediate OAT vs $1,025,061 current care vs $1,112,080 guideline care

    --health sector perspective: $518,389 immediate OAT vs $551,362 current care vs $587,628 guideline care

--yearly projected savings for the entire cohort, from societal perspective:

    --immediate OAT vs current care: $3.852 billion

    --immediate OAT vs guideline care: $7.974 billion

Commentary:
--the largest lifetime costs (51.2%) were for health resource use, followed by criminal justice and victimization (46.2%) and treatment (2.6%)
--initial OAT decreased lifetime costs per person: $78,257, associated with an increase in quality-adjusted life-years of 0.42
--a few background statistics:
    --OUD has increased dramatically in the US, from 1.4 million in 2003 to 2.4 million in 2013
    --BUT, the rates of use of OUD treatment has not increased in this time period
    ​--the estimate is that nearly 80% of people with OUD in 2015 did not receive treatment
    ​--and, though the Affordable Care Act improved insurance coverage, about 40% of patients admitted to OUD treatment in 2014 still had no health insurance
--international standards, including the WHO, as well as Cochrane reviews, promote initial access to OAT with no restriction on the duration of treatment
--and, in fact the California  Society of Addiction Medicine acknowledges that "medically managed withdrawal by itself should not be considered treatment of opioid use disorder"
--one really important statistic is that treatment interruption is associated with a 30-fold increased risk of death in the subsequent 2 weeks. Though there is a 4.5-fold mortality in opioid-dependent people, this was much lower in those in-treatment (1.8-fold) vs those out-of-treatment (6.1-fold), with the highest mortality risk occurring during the 2 weeks after treatment exit. And these risks were more than twice as high for people in detox vs OAT (see Evans E. Addiction 2015; 110: 996)
--one of the real values of the above study is that it took into account not just the medically-related expenses but also includes other social costs of the different approaches to treating OUD, including the costs of incarceration, crime, etc.  However, it does not really address the hard-to-quantify but perhaps most important issue:  patients with OUD who enter supportive long-term OATprograms allows them in many cases to lead normal productive lives: reuniting with family, developing more supportive social networks, getting jobs, etc.  And this has been my clear experience with buprenorphine-naloxone: many patients are “given their lives back” by this therapy.
--there are the usual concerns about this type of study: they are making assumptions about percentages, numbers of people, costs, medical issues (HIV, etc) based on other databases, which really may not reflect the effect of a large-scale specific program in California. they also did not include other potential benefits of immediate access to OAT (eg, hepatitis C prevention, perhaps decreasing other medical injuries/infections related to IDU), effects of spreading HIV or other diseases into the non-drug using population, or even some variables associated with treatment (such as patients in OAT who successfully wean off meds at some point, with more cost savings). And generalizability of these results to other parts of the country or to other countries may not be appropriate, no matter how accurate/applicable the numbers are for California.

so, this article reinforces many decades of experience (as in: 50+ years) showing that opiate users who want to stop do much better with long-term substitution therapy (most studies using methadone) than with detox programs.  not so different from other chronic or relapsing medical diseases (eg using steroid inhalers continuously for many asthmatic patients). and these results reinforce the current studies showing benefits of getting people in these programs with minimal hassle: starting opiate substitution therapy in the ER, in jails, etc.

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And, some statistics:

https://www.cdc.gov/nchs/data/databriefs/db294.pdf​ , a cdc publication on age-related rate of drug overdoses in 2016, with trends from 1999.  

    --there were 63,600 drug overdose deaths in 2016, increasing at at average of 10%/yr from 1999-2006, then 3%/yr from 2006-2014, then 18%/yr from 2014-16, with about twice the rate in males vs females

    --the rates continue to be higher in those 25-54 yo, with the steepest increases in this age group (though the rates in people 55-64 are somewhat lower, the rate of increase over the last year is the same as the 25-54 yo's)

    --the really dramatic increases in the past 2 years were in "synthetic opioids other than methadone" (eg fentanyl, fentanyl analogs, tramadol) and "heroin"

   --the map of drug overdose deaths is spread out across the country, with highest in west virginia, ohio, new hampshire and pennsylvania, and lowest in iowa, north dakota, texas, south dakota, and nebraska.

https://www.cdc.gov/nchs/data/databriefs/db293.pdf, another cdc publication assessing mortality in the US in 2016 vs 2015, noting that this is the second year in a row that life expectancy has decreased (see earlier blog)

    --life expectancy from birth decreased in 2016: overall was 78.7, now 78.6; males decreased from 76.3 to 76.1; females remained at 81.1

    --life expectancy from age 65 increased in 2016: overall was 19.3 yrs, now 19.4; males remained the same at 18.0 yrs; females increased from 20.5 to 20.6 yrs

    --statistically significant decrease in death rate in white females, but increase in black males

    --statistically significant increase in death rate in those 15-44 yo, but decrease in those 65 and older as noted above

    ​--statistically significant decrease in death rate from heart disease, cancer, chronic lower resp diseases, stroke, diabetes, flu/pneumonia, kidney disease;  but increase from suicide, alzheimer's, and the largest increase in unintentional injuries (burns, drowning, falls poisoning, and road traffic; this includes drug overdose deaths)

    ​--infant death rates decreased overall, though there was an increase from congenital malformations, respiratory distress of newborn, and diseases of the circulatory system

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And, another rather disturbing turn of events, in light of all of these statistics:

http://www.bostonglobe.com/news/nation/2017/10/15/drug-industry-quashed-dea-efforts-block-opioids/3SxGgPvE6J5oOCbUuVMi9J/story.html?et_rid=1822210348&s_campaign=todaysheadlines:newsletter​ is an article based on the Washington Post article describing how the drug industry effectively rallied Congress to block the DEA and Dept of Justice efforts during the Obama era to "stanch the flow of pain pills", including "weakening aggressive DEA enforcement efforts against drug distribution companies that were supplying corrupt doctors and pharmacists who peddled narcotics to the black market".  This law effectively blocks any action by the DEA to freeze suspicious narcotic shipments. And, the chief advocate of this law blocking the DEA was the Pennsylvania Republican Tom Marino, who was Trump's choice to be drug czar !!!! (though he withdrew his name after these reports emerged)

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