Prescribed safer opioid supply (SOS) and methadone both lead to better health outcomes among patients who use opioids, reducing overdoses, decreasing healthcare utilization, and reducing costs. The two approaches are effective and complementary, according to a population-based cohort study from Ontario.
Opioid-related deaths in Canada increased from 3007 in 2019 to 6222 in 2021. Aside from providing naloxone to reverse the effects of overdoses and encouraging supervised consumption services, current responses to the crisis include providing better access to opioid agonist treatment (OAT). Many patients choose not to access or remain with OAT, however, so additional measures aimed at preventing overdoses must be established.
“Most studies have either focused on looking at treatments like methadone or looking at treatments or harm reduction approaches like safer supply,” lead study author Tara Gomes, PhD, principal investigator of the Ontario Drug Policy Research Network in Toronto, told Medscape Medical News. “We wanted to try and bring those together to get a better sense of how they are positioned within the options that are available for people who use drugs.”
The researchers identified 856 patients who started SOS between January 2016 and December 2021 and matched them with 856 patients taking methadone during the same period. The matches were based on age within 3 years, sex, residence, prior heath diagnoses, and encounters with the healthcare system.
Among the most striking findings were the differences in healthcare attributes of people who started SOS vs methadone, according to Gomes. “We had about 1000 people who were starting safer supply and about 25,000 people starting methadone,” she said. “Obviously, there are very large differences in general, in terms of the accessibility of these two options.” But when the researchers examined prior healthcare encounters for overdoses, infected endocarditis, skin and soft tissue infections, HIV, hepatitis C, and recent emergency department (ED) visits, they found that these outcomes were all much more common among patients who were prescribed SOS than among those starting methadone. “It really showed a difference in the characteristics of patients who tend to be engaged within safer supply, compared with these more traditional treatment options,” said Gomes.
Inpatient hospitalizations also declined, but not as much for the SOS group: 2.08 per 100 patients vs 2.35 per 100 patients in the methadone group. Incident infections declined by 0.68 per 100 patients in the SOS group and 0.38 in the methadone group. Healthcare costs (excluding primary care and medications) fell by $91,699 per 100 patients for SOS and $103,875 for methadone.
Although SOS recipients had higher rates of opioid toxicity, all-cause ED visits, and all-cause inpatient admissions, they were less likely to discontinue treatment. “Improvements tended to be larger and faster among people getting methadone, compared to safer supply, while they were on treatment,” Gomes said. “However, people tended to stop methadone faster. When you take that into account and just look at any outcomes over the following year among people starting these two different options, the benefits were really similar between the two groups, and I think that was a really important finding.”
One limitation of the study was related to how SOS dispensing was identified. There was no specific code or label for SOS in the records, and patients taking lower doses may have been missed. In addition, there was a lack of information about some confounders, and the researchers did not have access to costs of primary care provided by community health centers or of medications obtained outside of the provincial drug program. As a result, the end costs would likely be higher than calculated. The researchers also had no data regarding dose changes for both groups during the study.
Commenting on the study for Medscape Medical News, Kimberly Sue, MD, PhD, assistant professor of medicine with the Program in Addiction Medicine (Division of General Internal Medicine) at Yale University School of Medicine in New Haven, Connecticut, said, “This study is a valuable asset to the literature in North America on novel forms of engagement for people with opioid use disorder who do not engage in formal treatment systems such as methadone or buprenorphine.
“This is a very promising finding because it suggests that new approaches such as SOS might be able to engage a different and high-risk group of patients in healthcare systems and improve the health of people who use drugs.”