What About Methadone? Triangulation of Choice and Usage Patterns for Medications for Opioid Use Disorder

While the rates of buprenorphine initiation for the treatment of opioid use disorder (OUD) have increased in US EDs, the rise in fentanyl, fear of precipitated withdrawal, and negative personal experiences with buprenorphine have emerged as barriers to treatment. In response, some EDs have started to offer methadone, an alternative opioid agonist therapy (OAT) that allows for symptom relief without risk of precipitating withdrawal (OAT= methadone and buprenorphine). Our objective was to explore usage and initiation trends of both types of OAT for ED patients with OUD.

We used two sources of data to understand both current OAT usage and OAT initiation: 1) retrospective EHR-derived data from 4 EDs in a single healthcare system in western MA from 10/23-9/24 and 2) prospective observational data of choice of OAT in the ED. For group 1, we reviewed EHR data of ED patients with a discharge diagnosis of opioid overdose, withdrawal, or OUD and report current OAT use and OAT initiation (10% of charts were manually reviewed). Prospective data (2) was obtained from patients enrolled in an observational study which included only ED patients with OUD not currently on OAT. We analyzed the primary outcome, the initiation of methadone versus buprenorphine, using tests of proportions.

The EHR cohort included 1976 visits. Using both EHR-extracted data and manual chart review methods, 284(14%) were currently on or initiated buprenorphine, 819(41%) were currently on or initiated methadone, and 873(44%) had no OAT (ongoing or new). There were 47 patients prospectively enrolled from 6/24-11/25: 18(38%) patients reported starting methadone in the ED, 3(6%) reported starting buprenorphine, and 26(55%) were either not offered OAT or chose not to start. Test of proportions yielded p<0.001 for both comparisons.

In our healthcare system, more ED patients with OUD are currently on or initiate methadone compared to buprenorphine, at a ratio that ranged from 3:1 to 6:1. This difference may reflect patient choice, fear of precipitated withdrawal, access, or other factors that may be personal, local, or systemic. While generalizability may be limited by differences in access to methadone, our findings may denote why EDs that offer only buprenorphine may have difficulty increasing OAT initiation rates.