An estimated 27 million people globally suffered from opioid use disorder in 2016 (WHO, 2018). Premature mortality due to opioid use disorder is most prevalent in North America, Eastern Europe and sub-Saharan Africa (Degenhardt et al., 2014). In the United States, results from the National Survey on Drug Use and Health [NSDUH] indicate that approximately 11.8 million people over the age of 12 misused opioids in 2016, constituting 4.4% of the population(United States Department of Health and Human Services [USDHHS], 2017). The highest percentage of the population misusing opioids is among the ages of 18-25, 7.3% of the population (USDHHS, 2017). Data demonstrate disparities and potential vulnerabilities in opioid misuse within non-metropolitan communities, specifically for adolescents and young adults (USDHHS, 2017). Although the overall trend in opioid misuse has decreased from a 2006 peak (Substance Abuse and Mental Health Services Administration [SAMHSA], 2017), the number of deaths from opioid overdose has continued to rise (CDC, 2017a). It is presumed that this increase in deaths is accounted for by the transition to heroin and synthetic fentanyl as prescription opioids have become less available on the street.
The economic costs of the opioid epidemic are substantial. In the United States, the estimated economic cost of the opioid crisis in 2015 was 504 billion dollars, 2.8% of the GDP (Council of Economic Advisors, 2017), and the cumulative economic costs to society since 2001 is estimated to exceed one trillion dollars (Altarum, 2018). Societal costs are incurred in the workplace, healthcare and the criminal justice systems (Birnbaum, 2011). Costs to humanity include family disruption, child abuse and neglect, and violence (Hoban, 2017; National Advisory Committee on Rural Health and Human Services, 2016).
Opioid use disorder is a bio-psycho-social-spiritual, chronic and relapsing, illness (American Society of Addiction Medicine (ASAM), 2015). Diagnosis is made in accordance with the DSM5 substance use disorder criteria (ASAM, 2015). Effective treatments are available for opioid use disorder but less than 10% of persons with an opioid use disorder receive the needed treatment (WHO, 2018). Medication Assisted Treatment (MAT), using agonist (buprenorphine or methadone) or antagonist (naltrexone) therapies, is effective in the management of opioid use disorder among medically eligible and motivated patients. Methadone is a full opioid agonist whereas buprenorphine is a partial opioid agonist which creates a ceiling for the opioid effects thus reducing the risk of overdose and limiting the psychogenic properties (ASAM,2015). Buprenorphine is commonly provided in a formulation containing naloxone, an opioid antagonist, which limits the abuse potential of the medication. There is insufficient outcome data to support the choice of one opioid agonist over another in MAT but the availability of buprenorphine through office based settings as opposed to specialty opioid agonist treatment centers for methadone has increased the reach of MAT, particularly for rural communities (Stein, Gordon, Sorbero, Dick, Schuster & Farmer, 2012). Buprenorphine is also sometimes preferred over methadone because of the lower risk of overdose (Mccarty, Priest & Korthuis, 2018). Although demonstrated to be effective, the use of naltrexone antagonist therapy in clinical practice remains limited (Mccarty, Priest & Korthuis, 2018). Patient care for opioid use disorder using MAT involves the management of acute withdrawal, medication induction, stabilization, maintenance and eventual drug tapering as appropriate. However, research continues to demonstrate a rapid rate of return to opioid misuse among patients after discontinuation of MAT (Mccarty, Priest & Korthuis, 2018). Long-term use of opioid agonist therapy is often recommended because of the high rate of return to misuse and the risk of overdose when misuse is resumed (Mccarty, Priest & Korthuis, 2018). Complimentary behavioral health therapies are recommended concurrent with pharmaceutical management.
In specialty substance use disorder treatment, multidisciplinary, team-based, coordinated care models have demonstrated particular success in the delivery of effective and sustainable MAT services (Lagisetty, Klasa, Bush, Heisler, Chopra & Bohnert, 2017). This presentation will describe outcomes from the development of an inter-professional, team-based MAT program within a community-based substance use recovery organization in a non-metropolitan area.
Methods: This project was a collaborative development of an interprofessional, team-based MAT program within a community-based substance use recovery organization. The project was implemented within a community-based substance use recovery organization in a rural community in the United States. The target population for the project was under-served rural residents with a current opioid use disorder.
Results: MAT program retention in this project met the benchmark established in the literature. A systematic review of MAT programs benchmarked successful program retention at approximately 60% (Lagisetty, Klasa, Bush, Heisler, Chopra, Bohnert, 2018). The initial outcome data for this project indicate a 79% retention in recovery overall and a 74% retention within the MAT implementation project. Participant satisfaction with the service was excellent. System sustainability and provider satisfaction were excellent overall. Eighty-four percent of participants indicated that MAT with buprenorphine/naloxone was greatly helpful to their recovery. Ninety-two percent of participants identified the project MAT program as very important to their recovery. The project demonstrated financial sustainability and overall provider satisfaction.
Conclusions: Addressing the opioid epidemic is a public health imperative. Success in treating opioid use disorder using MAT is evident in the available literature and in this interprofessional MAT project. More research needs to be conducted on how to best sustain opioid use disorder treatment, particularly among vulnerable populations.