Gary Young, director of Northeastern University’s Center for Health Policy and Healthcare Research, is doing his part to tackle a question that’s been plaguing the country for years: How do we treat people suffering from opioid use disorder? In 2020, roughly 2.7 million people in the United States struggled with it. And while pursuit of treatment varies across geography, one study suggested a 50-60% discontinuation rate during the first 12 months.
While public health experts debate the most effective treatment, Young takes a different tack. He wants to understand how to keep people in treatment, regardless of the method.
“When they do discontinue they are at high risk of relapsing, overdosing or ending up in hospital,” says Young.
Many researchers have tried to understand this issue from the viewpoint of the prescribers. But Young argues that with treatment varying between prescribers, studying the issue is like comparing apples to oranges. Each provider can only speak to their own practice. So he decided to go directly to the source: the patients themselves.
Roadblocks to staying in treatment
One of the many treatments someone with opioid use disorder (OUD) can pursue is a Food and Drug Administration-approved drug that blocks the effects of opioids and/or suppresses cravings: either buprenorphine, methadone or naltrexone. These drugs are highly effective at preventing relapses, but their success depends on a few things. Getting a prescription in the first place depends on whether a patient is willing to fulfill the prescribers’ requirements, which could include a commitment to a specific treatment timeline, opioid abstinence, weekly counseling and/or in-person medication pick-ups.
Young feels that some of these requirements are important. In his study published in The American Journal of Drug and Alcohol Abuse in 2022, he found that people who stay in treatment for at least twelve months are less likely to overdose or be hospitalized. But on the flipside, time commitment is also a barrier.
“Many patients right from the beginning tell their prescribers they only want to be in treatment for a few months,” says Young. “And [if] prescribers pushback, they won’t move forward with treatment at all. So, prescribers have a real challenge there, because they lose patients from the beginning.”
“[These drugs] offer so much hope,” he says, “if patients can stay in treatment.”
In February of 2023, Young and his team — which included Muhammad Noor E Alam, associate professor of mechanical and industrial engineering, as well as two PhD students — were of the first to publish a study in which patients were asked directly about their experience with opioid treatment. The 43 participants were recruited from one of three clinical settings: a community health center, an academically-based treatment site and an independent substance abuse treatment facility. Through interviews with these patients, he sought to understand what makes it so hard to continue treatment.
“We’re trying to understand that from the patients themselves,” says Young. “What impedes you from staying in treatment? And what are the factors that might help you remain in treatment?”
The majority of study participants said they would have continued if their prescribers had reached out to them and had a personal interest in their well-being. The following participant quotes are pulled directly from the study published in Substance Use and Misuse.
One study participant said, “I just sort of disappeared and not even a call to why I did not pick up my meds. I know I could have been the one to reach out, but when you are feeling that low, it is hard to sort out what to do next.”
Another participant explained their disappointment about the lack of connection between them and their prescriber. “A few times I am not even sure she [the prescriber] was sure of my name. Turned me off a bit.”
Young echoes: “When a patient doesn’t pick up the medication or doesn’t come in for their refill, they just sort of get lost in the shuffle. Patients need more active support.” He thinks the culprit behind this is prescriber bandwidth. Prescribers can only take on so many patients and more often than not, they don’t have the resources they need to create a genuine connection with each patient, he says.
Young is working on tackling this issue using technology — not as a replacement for in-person connection, but to help with follow-up. He thinks an alert system that informs prescribers when a patient has not returned for their refill appointment or picked up their medication could encourage prescribers to stay up to date with them.
The details are yet to be worked out, but Young has a sense of how the alert system could work. “The alert would be implemented through the state’s prescription monitoring program, in which all physicians who prescribe controlled substances in the state are required to be enrolled.”
What’s next for Young?
Young is on to his next study to look at the effect of counseling as additional clinical value to medication treatment. It may seem like an obvious good, but Young says there is a movement away from requiring it because “people see it as a barrier, and prescribers are really trying just to get people access to buprenorphine.” If it is going to be a requirement, he feels there should be some scientific backing to it.
“Most prescribers will tell you that counseling might have some value [for OUD],” says Young. “[But] there’s not currently a lot of science to support it.”
Ultimately, Young feels that best practices aren’t about one universally effective treatment, but rather the approach that prescribers take toward offering it. He hopes his findings and the success stories of fully-engaged prescribers can serve as a guide to helping people stick with it.
“If we could sort of bottle up what some prescribers are doing, and give it to other prescribers, we could save a lot of lives,” says Young.
Story from the Science Media Lab.
Last Updated on October 12, 2023