What is the comparative effectiveness of medication-assisted detoxification and tapering treatment for individuals with opioid dependence?

Population of interest:

Patients with opioid dependence

Subpopulations of interest:

• Low-income
• Patients with chronic pain
• Active drug users
• Former drug users
• Pregnant women
• Minorities
• Patients with co-morbid mental health diagnoses
• Adolescents and young adults
• Rural populations (transportation costs, etc associated with distance from treatment center)

Specific technologies, devices, drugs, or interventions to be compared: Maintenance, detoxification, and tapering treatments Frequency of dosage (e.g., daily vs. alternate-day dosing) Duration of dosage/tapering Inpatient vs. Outpatient Pharmacologic choice Tools and strategies to stratify patients into different treatment options

The nominator is not interested in investigating behavioral, counseling, or psychosocial approaches to the treatment of opioid dependence

Potential benefits:

• Long-term/permanent abstinence from opiates
• Decreased relapses and repeat treatments
• Improved overall health
• Improved self-image and confidence
• Decreased health burden
• Social benefits (restore family relationships, employability, avoid incarceration)

Potential harms:

• Relapse to opiate use
• Non-adherence
• Increased depression, mental health burden
• Severe opiate withdrawal
• Dependence on treatment drugs
• Overdose potential
• Polypharmacy
• Risk of relapse or other treatment failure due to inappropriate selection of treatment for a specific patient

EHC priority conditions: XDepression and other mental health disorders XFunctional limitations and disability XPregnancy, including preterm birth XSubstance abuse

EHC priority populations: XLow income groups

XMinority groups

XWomen

XChildren

XIndividuals with special health care needs, including individuals with disabilities or who need chronic care or end-of-life health care

Federal Health Care Program: XMedicaid XMedicare

This topic is important because of the rise in opioid use and dependence in recent years and the need for interventions that get patients off of replacement drugs. Non-prescription opiate use (including heroin) and prescription opioid use (hydrocodone and OxyContin) is widespread with both adults and adolescents abusing these drugs in increasing numbers. Roughly 1 in 9 youth abused prescription drugs in the past year. Young people are abusing prescription drugs at alarming rates. These drugs act on the same brain systems as illegal drugs and pose similar risks for dangerous health consequences, including later addiction. After marijuana, prescription and over-the-counter medications account for most of the past-year use of commonly abused drugs among high school seniors. Additionally, legal use of opioids can also lead to addiction. buprenorphine and methadone treatment, in particular, are two effective methods for treating opioid dependence, but it is not clear as to how to get patients to stop using these replacement drugs and to prevent future relapse.

See:

Veilleux JC, Colvin PJ, Anderson J, York C, Heinz A. A review of opioid dependence treatment: Pharmacological and psychosocial interventions to treat opioid addiction. Clinical Psychology Review. 2010;30(2):155-66. National Institute on Drug Abuse. Prescription Drug Abuse: Young People at Risk. http://www.drugabuse.gov/related-topics/trends-statistics/infographics/prescription-drug-abuse-young-people-risk.

Substance Abuse and Mental Health Services Administration. http://www.samhsa.gov

This question was prioritized by stakeholders engaged in the Topic Identification project conducted by the Oregon Evidence-based Practice Center for the Medicaid Medical Directors Learning Network.

The question represents uncertainty for clinicians and/or policy-makers. While it is clear that medication assisted treatments are useful for treating opiate addiction, there is uncertainty regarding the best methods for treating, tapering, and weaning patients off of these drugs.

An answer to this question will help provide the best methods for treating addiction and dependence on replacement drug treatment (i.e., methadone and buprenorphine). This will help clinicians provide high quality care to patients with opioid addiction by guiding patients away from long-term addiction to these drugs by using the most effective methods.

There is no specifc timeframe being requested for responding to the nominated question.

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

Public Policy-Maker/Legislator, Health Care Payer/Purchaser (Employer, Federal Government, or State Government), Researcher

If you are you making a suggestion on behalf of an organization, please state the name of the organization

Medicaid Medical Directors Learning Network

Please tell us how you heard about the Effective Health Care Program