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Receipt of Timely Addiction Treatment and Association of Early Medication Treatment With Retention in Care Among Youths With Opioid Use Disorder

Educational Objective
To understand the relationship between the timing of initiation of opioid addiction therapy and retention in treatment programs.
1 Credit CME
Key Points

Question  What percentage of youths receive medications for opioid use disorder shortly after diagnosis, and are those who receive medications early after diagnosis more likely to remain in care compared with those who receive behavioral treatment only?

Findings  In this multistate cohort of 4837 youths with opioid use disorder, 1 of 21 adolescents younger than 18 years and 1 of 4 young adults aged 18 to 22 years received medication for opioid use disorder within 3 months of diagnosis. Youths who received buprenorphine were 42% less likely to discontinue treatment, those who received naltrexone were 46% less likely to discontinue treatment, and those who received methadone were 68% less likely to discontinue treatment compared with youths who received behavioral treatment only.

Meaning  Pharmacotherapy, a critical evidence-based intervention to address opioid use disorder, may be underused in youths with this disorder; those who receive medications shortly after diagnosis may be more likely to remain in care than youths who receive behavioral health services only.

Abstract

Importance  Retention in addiction treatment is associated with reduced mortality for individuals with opioid use disorder (OUD). Although clinical trials support use of OUD medications among youths (adolescents and young adults), data on timely receipt of buprenorphine hydrochloride, naltrexone hydrochloride, and methadone hydrochloride and its association with retention in care in real-world treatment settings are lacking.

Objectives  To identify the proportion of youths who received treatment for addiction after diagnosis and to determine whether timely receipt of OUD medications is associated with retention in care.

Design, Setting, and Participants  This retrospective cohort study used enrollment data and complete health insurance claims of 2.4 million youths aged 13 to 22 years from 11 states enrolled in Medicaid from January 1, 2014, to December 31, 2015. Data analysis was performed from August 1, 2017, to March 15, 2018.

Exposures  Receipt of OUD medication (buprenorphine, naltrexone, or methadone) within 3 months of diagnosis of OUD compared with receipt of behavioral health services alone.

Main Outcomes and Measures  Retention in care, with attrition defined as 60 days or more without any treatment-related claims.

Results  Among 4837 youths diagnosed with OUD, 2752 (56.9%) were female and 3677 (76.0%) were non-Hispanic white. Median age was 20 years (interquartile range [IQR], 19-21 years). Overall, 3654 youths (75.5%) received any treatment within 3 months of diagnosis of OUD. Most youths received only behavioral health services (2515 [52.0%]), with fewer receiving OUD medications (1139 [23.5%]). Only 34 of 728 adolescents younger than 18 years (4.7%; 95% CI, 3.1%-6.2%) and 1105 of 4109 young adults age 18 years or older (26.9%; 95% CI, 25.5%-28.2%) received timely OUD medications. Median retention in care among youths who received timely buprenorphine was 123 days (IQR, 33-434 days); naltrexone, 150 days (IQR, 50-670 days); and methadone, 324 days (IQR, 115-670 days) compared with 67 days (IQR, 14-206 days) among youths who received only behavioral health services. Timely receipt of buprenorphine (adjusted hazard ratio, 0.58; 95% CI, 0.52-0.64), naltrexone (adjusted hazard ratio, 0.54; 95% CI, 0.43-0.69), and methadone (adjusted hazard ratio, 0.32; 95% CI, 0.22-0.47) were each independently associated with lower attrition from treatment compared with receipt of behavioral health services alone.

Conclusions and Relevance  Timely receipt of buprenorphine, naltrexone, or methadone was associated with greater retention in care among youths with OUD compared with behavioral treatment only. Strategies to address the underuse of evidence-based medications for youths with OUD are urgently needed.

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Article Information

Accepted for Publication: May 30, 2018.

Corresponding Author: Scott E. Hadland, MD, MPH, MS, Grayken Center for Addiction and Department of Pediatrics, Boston Medical Center, 88 E Newton St, Vose Hall, Room 322, Boston, MA 02118 (scott.hadland@bmc.org).

Published Online: September 10, 2018. doi:10.1001/jamapediatrics.2018.2143

Author Contributions: Dr Hadland and Mr Rodean had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Hadland, Bagley, Rodean, Larochelle, Zima.

Acquisition, analysis, or interpretation of data: Hadland, Bagley, Rodean, Silverstein, Levy, Samet, Zima.

Drafting of the manuscript: Hadland, Zima.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Hadland, Rodean, Zima.

Obtained funding: Hadland.

Administrative, technical, or material support: Rodean, Silverstein, Larochelle, Zima.

Supervision: Hadland, Levy, Zima.

Conflict of Interest Disclosures: None reported.

Funding/Support: Dr Hadland was supported by the Thrasher Research Fund Early Career Award, the Academic Pediatric Association Young Investigator Award, and grant L40 DA042434 from the National Institutes of Health/National Institute on Drug Abuse (NIH/NIDA). Dr Bagley was supported by grant K23 DA044324 from the NIH/NIDA. Dr Silverstein was supported by grant K24 HD081057 from the NIH/Eunice Kennedy Shriver National Institute of Child Health and Human Development. Dr Larochelle was supported by grant K23 DA042168 from the NIH/NIDA. Dr Samet was supported by grant R25 DA13582 from the NIH/NIDA.

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: Jason Vassy, MD, MPH, SM, Veterans Affairs Boston Healthcare System and Harvard Medical School, reviewed the manuscript. He was not compensated for his contribution.

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