(18) Real-World Outcomes With MOUD in Uninsured Patients: Inpatient to Outpatient Transitions

Background: Linkage to outpatient care following inpatient or residential detoxification has been shown to promote recovery, reduce the likelihood of returning to use, and reduce overdose rates for individuals with opioid use disorder (1-3). However, real-world studies involving care transitions among patients from vulnerable communities remain limited. We evaluate outpatient outcomes in an uninsured population following initiation of medication for opioid use disorder (MOUD) during inpatient detoxification.

Methods: Forty-seven patients with opioid use disorder were included in this retrospective record review. Patients initiated treatment with sublingual buprenorphine-naloxone (BUP-NX) or intramuscular extended-release naltrexone (XR-NTX) while admitted to an inpatient detoxification facility in a Southeastern urban city between July 2018 – November 2020 and were transitioned to a co-located outpatient clinic. The primary outcome was retention in outpatient treatment at 30, 60, 90, and 180 days. Secondary outcomes were length of stay on the inpatient unit, return-to-use with illicit opioids, and confirmed overdose death.

Results: Among the 47 patients (66% male; mean age 34.7 years; 64% Caucasian; 96% uninsured), 35 initiated BUP-NX and 12 initiated XR-NTX. Patients on BUP-NX had higher rates of retention in outpatient treatment than patients on XR-NTX at 30 days (89% vs 58%, p=0.02), 60 days (77% vs 50%, p=0.08), 90 days (71% vs 50%, p=0.18), and 180 days (69% vs 25%, p=0.01). The proportion of patients who discharged from the detoxification unit within 7 days was 49% in the BUP-NX group vs. zero in the XR-NTX group. Rates of returning-to-use were similar (BUP-NX, 49%; XR-NTX, 58%). One overdose death occurred in the XR-NTX group.

Conclusion: We observed higher rates of retention in outpatient treatment at six months, different patterns of acute care utilization, and similar rates of returning to use among patients inducted onto BUP-NX during inpatient detoxification as compared with XR-NTX. Our findings contrast with prior randomized trials comparing BUP-NX and XR-NTX (4,5), which may reflect unique characteristics of our population. More research is needed to understand factors that may influence treatment outcomes over time as well as strategies to optimize implementation of evidence-based OUD treatment, particularly for vulnerable populations in resource-limited settings.

References: 1. Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev 2014; 2:CD002207
2. Nunes EV, Gordon M, Friedmann PD, et al. Relapse to opioid use disorder after inpatient treatment: protective effect of injection naltrexone. J Subst Abuse Treat 2018; 85: 49–55
3. Wakeman SE, Larochelle MR, Ameli O, et al. Comparative Effectiveness of Different Treatment Pathways for Opioid Use Disorder. JAMA Netw Open. 2020 Feb 5;3(2):e1920622.
4. Lee JD, Nunes EV Jr, Novo P, et al. Comparative effectiveness of extended-release naltrexone versus buprenorphine-naloxone for opioid relapse prevention (X:BOT): a multicentre, open-label, randomised controlled trial. Lancet. 2018 Jan 27;391(10118):309-318. doi: 10.1016/S0140-6736(17)32812-X. Epub 2017 Nov 14.
5. Tanum L, Solli KK, Latif ZE, et al. Effectiveness of Injectable Extended-Release Naltrexone vs Daily Buprenorphine-Naloxone for Opioid Dependence: A Randomized Clinical Noninferiority Trial. JAMA Psychiatry. 2017 Dec 1;74(12):1197-1205

Diversity, Equity, and Inclusion: Nearly all patients in our study population were uninsured (45/47, 96%), which reflects our practice setting in a non-Medicaid expansion state. In addition, 20/47 (43%) experienced homelessness in the past year. To ensure access to substance use treatment for our patients, we partnered with the local managed care organization (MCO) to establish a partnership allowing uninsured patients to be evaluated in our outpatient clinic at no charge. The MCO covered the expense of BUP-NX for uninsured patients, and a pharmaceutical manufacturer supplied XR-NTX to patients without insurance who met the financial eligibility requirements.