Opioid Agonist Therapy: Are We Missing Out on a Viable Treatment Option?

Do you know that few patients with opioid toxicity receive opioid agonist therapy (OAT), data suggest?

Yes, it is true! In a retrospective study that examined about 21,000 hospital visits related to opioid use disorder (OUD) in Ontario, Canada, 4.1% resulted in community-based initiation of OAT within 7 days of discharge.

Tina Hu, MD

“From what I have seen as a physician, I suspected that OAT initiation rates would be low. However, I did not think that it would be so low,” study author Tina Hu, MD, family physician and assistant professor of family and community medicine at the University of Toronto, told Medscape Medical News. “OAT is a proven and effective treatment for OUD, reducing both morbidity and mortality. In the midst of a public health crisis…. [I]t is inconceivable to me that we are not using every healthcare encounter as an opportunity to discuss OAT with patients with OUD and initiate life-saving treatment.” 

The findings were published on December 18, 2023, in CMAJ. 

‘Critical Missed Opportunities’ 

The researchers conducted a retrospective, population-based, serial cross-sectional study to examine community-based OAT initiation in Ontario. They drew data from ICES, the Canadian Institute for Health Information Discharge Abstract Database, and other sources to examine emergency department or hospital visits for opioid toxicity between January 1, 2013, and March 31, 2020. The researchers defined community-based OAT initiation as a new prescription filled for methadone, buprenorphine–naloxone, or slow-release oral morphine from a community-based pharmacy. 

“To exclude patients who received slow-release oral morphine for pain rather than for OAT, we included only those who were initiated on daily dispensed therapy,” wrote the authors, explaining that a 2018 Canadian clinical practice guideline recommends buprenorphine-naloxone “as first-line treatment to reduce the risk of toxicity and facilitate safer take-home dosing.” Methadone and slow-release oral morphine are recommended as second- and third-line options, respectively.

Among 47,910 emergency department visits or hospital admissions for opioid toxicity in Ontario during the study period, 20,702 (43.2%) events among 14,053 patients (median age, 35 years) met inclusion criteria. The primary reasons for exclusion were previous claims for OAT within 30 days of the index visit (17.9%) and no documented OUD diagnosis in the preceding 5 years (24.8%).

The 20,702 OUD events included 5219 hospital admissions and 15,483 emergency department visits. In all, 215 hospital admissions and 636 emergency department visits led to OAT initiation within 7 days of discharge. A secondary analysis showed that the rate of readmission or return outpatient or emergency department visits within 7 days of initial discharge following an OUD event was 22.1%. 

“This is the timeframe associated with very high mortality risk after an overdose,” said Hu. “Despite this connection to healthcare services, these patients did not receive OAT, which highlights the critical missed opportunities to engage patients in treatment to prevent future mortality and morbidity related to opioid use.”

Of the 379 OAT prescribers whom the researchers identified,

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