Treatment for Opioid Use Disorder: Population Estimates — United States, 2022

Discussion

Among adults needing OUD treatment in 2022, only 25% received medications for OUD; 30% received OUD treatment not including these medications. These findings underscore disparities in treatment and a need to increase use of medications for OUD. Lower percentages of Black and Hispanic adults, who have been particularly affected by increasing overdose deaths (3), received any OUD treatment compared with White adults. Among adults who received OUD treatment, lower percentages of women and younger and older adults received medication. Higher proportions of persons with other drug use or misuse or who had ever been arrested and booked received medications for OUD; these findings might reflect greater awareness of treatment need or contact with systems linking persons to OUD treatment. Higher percentages receiving medication among adults with severe OUD might reflect perception or more clinician recognition of treatment need among adults with six or more OUD symptoms. Still, among adults with severe OUD, fewer than one half (80.7% of the 53.0% who received any OUD treatment) received medications for OUD, underscoring the large gap in receipt of evidence-based treatment, even for this highly affected group.

Approximately 43% of adults needing OUD treatment did not perceive that they needed it, consistent with previous findings that large proportions of persons with SUDs did not feel that they needed treatment.^¶¶ Patients taking opioids only as prescribed (who constitute a majority of persons meeting OUD criteria***) might be particularly unlikely to perceive a need for OUD treatment, even if they experience OUD symptoms. If clinicians suspect that patients prescribed opioids for pain have OUD on the basis of patient concerns or behaviors, or if patients experience harm from opioids or choose to but are unable to taper opioids, clinicians should discuss their concern with the patient, provide an opportunity for the patient to disclose related concerns or problems, and assess for OUD using DSM-5 criteria (4). Nonjudgmental support and harm reduction approaches can establish rapport, build trust, and reduce overdoses and other harms among persons not ready for treatment.^†††

Several factors limit access to medications for OUD despite strong recommendations for their use (4,5). Some clinicians prefer an approach that does not include medications, and some hold beliefs equating medications for OUD with illegal substance use (6). Methadone for OUD can only be dispensed from a Substance Abuse and Mental Health Services Administration–certified opioid treatment program (OTP); many U.S. counties have no OTP.^§§§ Buprenorphine or naltrexone can be prescribed in any setting, but several barriers exist. Many facilities treating OUD do not offer these medications; some do not accept clients using medications for OUD.^¶¶¶ In addition, large proportions of pharmacies do not stock buprenorphine.**** Payors, including many state Medicaid programs, have restrictions (such as prior authorization) that can delay dispensing of some buprenorphine formulations (7). Fewer than 10% of physicians^†††† obtained the waiver that, until 2023, was required to prescribe buprenorphine for OUD. Primary care physicians have reported barriers to obtaining the waiver and prescribing buprenorphine, including too little experience treating OUD, concern about being inundated with requests for buprenorphine, lack of access to addiction or behavioral health specialists, and acquiring the training required to obtain a waiver (8).

Limitations

The findings in this report are subject to at least five limitations. First, the number of persons needing OUD treatment presented in this report are likely underestimates; NSDUH is a household survey, includes persons experiencing homelessness only if they use shelters, and does not include residents of institutional group quarters such as jails. Second, NSDUH response rates in 2021 and 2022 were lower than in previous years, which might increase the potential for nonresponse bias resulting in over- or underestimates. Third, sample size limited some comparisons of OUD treatment across racial and ethnic groups, prohibited comparisons across health insurance coverage, and precluded treatment estimates specific to persons with mild OUD or with moderate OUD. Medications for OUD are strongly recommended, particularly for moderate or severe OUD (4,5). However, Food and Drug Administration approvals for medications for OUD were based on data for patients with opioid dependence as defined by Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; application to DSM-5–defined mild OUD is less clear (5). Understanding specific treatment needs for patients with mild OUD merits further study. Fourth, cross-sectional survey responses were insufficient to ascertain the presence of OUD symptoms before the preceding year. Finally, OUD was a proxy diagnosis based on respondents’ answers to questions corresponding to diagnostic criteria; respondents were not asked whether they had ever received a clinical diagnosis of OUD.

Implications for Public Health Practice

The shift from use of heroin to illegally manufactured fentanyl has increased the likelihood that overdoses are fatal (9), adding urgency to the need to provide effective care for persons with OUD (2). This need is particularly acute for Black and Hispanic adults (3,10), women, and younger and older adults. Population-level interventions across a variety of settings are needed to link persons to care,^{§§§§,¶¶¶¶} initiate medications for OUD,***** and support sustained treatment and recovery.

Expanded communication about effectiveness of medications for OUD is needed to reduce nonfatal and fatal overdoses. Increasing awareness among persons who use drugs and their families, friends, and other contacts that medications for OUD are effective is critical.^{†††††} Clinicians and treatment providers should offer or arrange evidence-based treatment, including medications for OUD (4). As of 2023, a waiver is no longer required to prescribe buprenorphine. All clinicians with a current Drug Enforcement Administration registration including Schedule III authority may prescribe buprenorphine for OUD if permitted by applicable state law.^§§§§§ Guidance (4,5) and mentoring^¶¶¶¶¶ are available for diagnosis and management of opioid use disorder. Pharmacists and payors can work to make these life-saving medications available without delays.