Three keys to lowering mortality rates in opioid disorder patients

Avoiding prescribed opioids or benzodiazepines, providing psychosocial counseling, and providing quarterly physician visits were associated with a much lower risk of death in patients with opioid use disorders (OUDs), researchers from the RAND Corporation have found. Following these three measures could cut mortality in these patients by as much as one-third, according to the study, published online June 27 in Drug and Alcohol Dependence.

The researchers analyzed treatment in the Veterans Affairs system. Their study, “Association Between Process Measures and Mortality in Individuals with Opioid Use Disorders,” is one of the first to identify quality measures for how care should be provided to people with OUDs.

“While they have not been tested in other systems, given that we tested them in the entire VA system, there is no reason they shouldn't be applicable to other populations with characteristics similar to the veteran population,” lead author Katherine Watkins, MD, tells Addiction Professional. “The VA population has more men in it and is generally sicker and poorer,” says Watkins, senior natural scientist with RAND.

However, she isn’t sure if the same measures would apply to women—“although there is no reason they shouldn’t,” she says—“or to people from a higher socioeconomic status or people who are generally healthier.”

In general, people with OUDs die at rates six to 20 times higher than the general population. Opioid-related deaths have been on the increase, especially due to overdoses, in the past two decades.

There are quality measures for providing care to people with substance use disorders in general. However, there are no specific quality care measures for people with opioid use disorders, according to the study.

Details of study

For the study, which was supported by the National Institute on Drug Abuse (NIDA), the researchers analyzed the medical records of 32,422 patients treated in the VA health system during 2007. The researchers looked at seven possible quality measures to see if they were related to deaths over the next two years. The measures were:

• Not being prescribed opioids or benzodiazepines.

• Receiving psychosocial treatment.

• Quarterly physician visits.

• Hepatitis screening.

• HIV screening.

• Initiation of medication-assisted treatment (pharmacotherapy with methadone, buprenorphine, or naltrexone).

• Maintenance of MAT for three months.

For patients whose care followed the first three quality measures, deaths dropped from 6% to 4% over a year. The other four quality measures did not produce any significant effect on death rates, the researchers found.

At 12 months, 1,165 individuals (3.7%) had died, and the percentage increased to 7.2% at 24 months.

Of the patients with OUDs, 96% were male, and the average age was 52; 68% had at least one new substance use disorder treatment episode, and 23% had co-occurring post-traumatic stress disorder (PTSD).

The measure with the highest adherence rate was psychosocial treatment (79%), and the lowest was HIV screening (12%). Ten percent of the patients were prescribed benzodiazepines, 41% were prescribed opioids, and 45% were prescribed either a benzodiazepine or an opioid. Twenty-five percent received MAT and 19% received this for at least three months. Thirty-three percent saw a physician at least once a quarter.

Analyzing MAT results

There are questions about the MAT results. The researchers were surprised not to find an association with MAT and mortality. Many other studies have shown such an association, and it’s possible that this VA population differed from others. However, this is an observational study and the researchers could not make causal inferences.

“Our findings underscore the importance of examining the relationship between OUD pharmacotherapy and mortality in different populations receiving services in a range of real world settings, and of creating OUD pharmacotherapy measures that take into account the variations in mortality risk associated with pharmacotherapy initiation, maintenance and cessation,” the researchers wrote.

The findings of lower mortality rates with psychosocial treatment are consistent with other studies, showing that this treatment results in decreased drug use and increased abstinence. “As the number of opioid-related deaths continues to increase, clinicians and policy makers need to consider how best to ensure that the population of individuals with OUD are able to receive effective psychosocial treatment,” the researchers wrote.

Many studies have already shown that prescribing benzodiazepines or opioids to people with opioid use disorders may lead to increased mortality, by overdose, falls, fractures, automobile accidents, and pulmonary-related illnesses. Combining opioids and benzodiazepines in particular can be particularly dangerous because the combination “increases the independent and synergistic sedative properties of both medications,” the researchers wrote.

Why would patients with opioid use disorders be prescribed opioids or benzodiazepines? Opioids remain the best way to treat acute pain, says Watkins. But benzodiazepines are sometimes used to treat comorbid anxiety, and there are alternatives, she says.

Quarterly physician visits, the third measure that led to improved outcomes, enable doctors to identify changes in the patient, such as an impending relapse or other physical health conditions.

Other measures in development

The American Society of Addiction Medicine (ASAM) and the U.S. Department of Health and Human Services (HHS) are also working on measure development for OUDs, the study authors wrote. The American Psychiatric Association (APA) has proposed finding the proportion of people with OUDs who were counseled regarding treatment options, and the Washington Circle has tested an opioid pharmacotherapy initiation measure. Also, the National Committee for Quality Assurance (NCQA) is developing a measure on HIV testing in injection drug users.

“Unfortunately there is no agreed upon standard for how reliable and valid a measure should be before it is accepted and used in public reporting, quality improvement efforts or pay for performance programs,” the RAND researchers wrote.

The three measures that showed positive results in their study can be implemented and reported easily, and also can provide timely information to health care systems about areas that need improvement, the researchers concluded.

“At a time when health care systems are increasingly focused on measuring, assessing, and providing incentives to improve quality, the lag in the development of behavioral health measures as compared to physical health measures is concerning,” they wrote.