Risk Factors for Relapse & Higher Costs among Medicaid Members with Opioid Dependence or Abuse: Opioid Agonists, Comorbidities & Treatment History

Clinical trials show that opioid agonist therapy (OAT) with methadone or buprenorphine is more effective than behavioral treatments, but state policymakers remain ambivalent about covering OAT for long periods. 

We used Medicaid claims for 52,278 Massachusetts Medicaid beneficiaries with a diagnosis of opioid abuse or dependence between 2004 and 2010 to study associations between use of methadone, buprenorphine or other behavioral health treatment without OAT, and time to relapse and total healthcare expenditures. 

Cox Proportional Hazards ratios for patients treated with either methadone or buprenorphine showed approximately 50% lower risk of relapse than behavioral treatment without OAT. Expenditures per month were from $153 to $233 lower for OAT episodes compared to other behavioral treatment. 

Co-occurring alcohol abuse/dependence quadrupled the risk of relapse, other non-opioid abuse/dependence doubled the relapse risk and severe mental illness added 80% greater risk compared to those without each of those disorders. 

Longer current treatment episodes were associated with lower risk of relapse. Relapse risk increased as prior treatment exposure increased but prior treatment was associated with slightly lower total healthcare expenditures. 

These findings suggest that the effectiveness of OAT that has been demonstrated in clinical trials persists at the population level in a less controlled setting and that OAT is associated with lower total healthcare expenditures compared to other forms of behavioral treatment for patients with opioid addiction. 

Co-occurring other substance use and mental illness exert strong influences on cost and risk of relapse, suggesting that individuals with these conditions need more comprehensive treatment

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By:  Clark RE1, Baxter JD2, Aweh G3, O'Connell E3, Fisher WH4, Barton BA5.

• 1Department of Family Medicine and Community Health, University of Massachusetts Medical School; Department of Quantitative Health Sciences, University of Massachusetts Medical School. Electronic address: robin.clark@umassmed.edu.
• 2Department of Family Medicine and Community Health, University of Massachusetts Medical School; Center for Health Policy and Research, University of Massachusetts Medical School.
• 3Center for Health Policy and Research, University of Massachusetts Medical School.
• 4School of Criminology and Justice Studies, University of Massachusetts Lowell.
• 5Department of Quantitative Health Sciences, University of Massachusetts Medical School; Center for Health Policy and Research, University of Massachusetts Medical School.
• J Subst Abuse Treat. 2015 Oct;57:75-80. doi: 10.1016/j.jsat.2015.05.001. Epub 2015 May 7. 

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Measuring Outcome in the Treatment of Cocaine Dependence

Below:  Patterns of Cocaine Use from Baseline to Month 18 Among Patients Identified as “Continued Users” (N=215) During Months 1 to 4 of Active Treatment. Note: The proportion of patients who used cocaine at each assessment is evaluated on a compositive cocaine use measure that combined information from self-report, urines, and the Addiction Severity Index cocaine use item.

Below:  Patterns of Cocaine Use from Baseline to Month 18 Among Patients Identified as “Slower Improvers” (N=90) During Months 1 to 4 of Active Treatment

Below: Patterns of Cocaine Use from Baseline to Month 18 Among Patients Identified as “Immediate Abstainers” (N=125) During Months 1 to 4 of Active Treatment

Measures of during-treatment reduction in use were moderately correlated with drug and cocaine use measures 12 months, but showed non-significant or small correlations with measures of functioning at 12 months. Highest correlations were evident for abstinence measures (maximum consecutive days abstinence and completely abstinent) during treatment in relation to sustained (3 month) abstinence at 12 months. Latent class analysis of patterns of change over time revealed that most patients initially (months 1 to 4 of treatment) either became abstinent immediately or continued to use every month. Over the couse of follow-up, patients either maintained abstinence or used regularly – intermittent use was less common.

There were generally small associations between various measures of cocaine use and longer-term clinical benefits, other than abstinence was associated with continued abstinence. No one method of measuring outcome of treatment of cocaine dependence appears superior to others.

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By: Paul Crits-Christoph,a Robert Gallop,b Mary Beth Connolly Gibbons,a Jaclyn S. Sadicario,a and George Woodya

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aDepartment of Psychiatry, University of Pennsylvania, 3535 Market Street, Philadelphia, PA 19104, USA
bApplied Statistics Program, Department of Mathematics, West Chester University, 25 University Avenue, West Chester, PA 19383, USA

aDepartment of Psychiatry, University of Pennsylvania, 3535 Market Street, Philadelphia, PA 19104, USA

aDepartment of Psychiatry, University of Pennsylvania, 3535 Market Street, Philadelphia, PA 19104, USA