The opioid epidemic has become a national public health problem. Although, the opioid epidemic is being addressed nationally and drug overdose deaths decreased by 4% from 2017 to 2018, still more than 67,000 people died from drug overdoses in 2018, and almost 70% involved a prescription or illicit opioidi. According to the most recent estimates in 2018, over 2.0 million US persons, 12 years of age and older, have an opioid use disorder (OUD)ii. OUD is defined in the DSM-5 as a problematic pattern of opioid use leading to clinically significant impairment or distressiii. Misuse may involve prescribed opioid medications, use of diverted opioids, or use of illicit heroin.
Methadone, buprenorphine and naltrexone are the medication treatment options for opioid use disorder. Methadone is offered only in opioid treatment facilities where daily supervised dosing is given, whereas buprenorphine may be given at these treatment facilities or as office-based opioid treatment on a weekly or monthly basis by specialized clinicians. Naltrexone may be prescribed in any setting by any clinician; however, it is an opioid antagonist unlike the other two opioid agonists, which makes adherence an issue due to severe withdrawal symptoms upon opioid relapse. Methadone is recommended for OUD by guidelines when buprenorphine has been unsuccessful or daily surveillance may be beneficialiv. With buprenorphine being widely available in different settings, it has become the standard of treatment of OUD.
Opioid misuse is associated with an increased risk of HIV transmission through shared needles or increase in risky sexual behavior. Furthermore, in people living with HIV, substance use can accelerate disease progression, impede adherence to antiretroviral therapy, and worsen the overall consequences of HIVv.
A study presented at the Conference on Retroviruses and Opportunistic Infections held March of 2020, by Jongyeon Kim, PhD, demonstrated additional benefit in buprenorphine treatment for opioid use disorder in patients living with HIV. The study included 207 people, mostly men (69%), black (88%), with a median age of 49 years. After the BUP treatment, approximately 74% of viral loads were below 1500 copies/mL, compared to 69% before treatmentvi. Viral loads below that threshold are significant, because it lowers the risk of transmitting HIV.
Although the mechanism of action for buprenorphine’s effect on the HIV viral load is yet to be determined, it may be that treatment of OUD leads to better adherence of antiretroviral therapy. If the patients are regularly taking their HIV medications, then their viral loads will decrease. In another study, both methadone and buprenorphine were found to aid in the suppression of HIV viral load, increase adherence to antiretroviral therapy, and improve overall mortality for people with OUDvii. Buprenorphine also presents with fewer drug interactions with antiretroviral therapy than methadone, has a lower overdose risk and is more administratively feasible. Given the chronic relapsing nature of OUD and HIV, long-term treatment of both diseases is essential for improved outcomes.
What does this mean to the claims professional?
- Overall use of antiviral medications that may be used to treat compensable HIV cases is only 1.83%. However, as referenced in our recent research paper on Specialty Drugs, that small percentage can drive a disproportionate amount of drug spend.
- Although the exact number is unknown, the number of HIV claims that must also be treated for OUD would be less than 0.95%. However, when encountered, this small study of 207 patients, primarily black males, indicates buprenorphine may be beneficial in lowering the viral loads for HIV patients being treated for opioid use disorder. Mechanism of action is yet to be determined. If viral loads are below 1500 copies/mL, then there is a lower chance of transmitting HIV.
- No action necessary from adjusters, this blog is meant to be educational about our understanding of other potential benefits of buprenorphine.
- This is a preliminary small study, further research is required.
- i. Center for Disease Control and Prevention. “Opioid Overdose” (2020) Retrieved from: https://www.cdc.gov/drugoverdose/index.html
- ii. Center for Behavioral Health Statistics and Quality. Results from the 2018 National Survey on Drug Use and Health: Detailed Tables. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2020.
- iii. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington, VA 2013.
- iv. The ASAM National Practice Guideline. “For the Use of Medications in the Treatment of Addiction Involving Opioid Use” Retrieved from: https://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-docs/asam-national-practice-guideline-supplement.pdf
- v. Centers for Disease Control and Prevention. “HIV and Substance Use in the United States” (2018). Retrieved from: https://www.cdc.gov/hiv/risk/substanceuse.html
- vi. Kim J, Chander G, Lesko CR, Fojo AT, Moore RD, Lau B. Buprenorphine treatment is related to decreased HIV RNA levels among people with HIV. Poster presented at: CROI 2020; March 8–11, 2020; http://www.croiconference.org/sites/default/files/uploads/croi2020-boston-abstract-ebook.pdf. Accessed April 14, 2020.
- vii. Fanucchi, L., Springer, S. A., & Korthuis, P. T. (2019). Medications for Treatment of Opioid Use Disorder among Persons Living with HIV. Current HIV/AIDS reports, 16(1), 1–6. https://doi.org/10.1007/s11904-019-00436-7