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Effects of Medication-Assisted Treatment (MAT) on Functional Outcomes Among Patients with Opioid Use Disorder (OUD)

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Effects of Medication-Assisted Treatment (MAT) on Functional Outcomes Among Patients with Opioid Use Disorder (OUD) NATIONAL DEFENSE RESEARCH INSTITUTE Effects of Medication- Assisted Treatment (MAT) for Opioid Use Disorder on Functional Outcomes A Systematic Review Margaret A. Maglione, Laura Raaen, Christine Chen, Gulrez Shah Azhar, Nima Shahidinia, Mimi Shen, Ervant J. Maksabedian Hernandez, Roberta M. Shanman, Susanne Hempel Prepared for the Office of the Secretary of Defense Approved for public release; distribution unlimited For more information on this publication, visit www.rand.org/t/RR2108 Published by the RAND Corporation, Santa Monica, Calif. © Copyright 2018 RAND Corporation R® is a registered trademark. Limited Print and Electronic Distribution Rights This document and trademark(s) contained herein are protected by law. This representation of RAND intellectual property is provided for noncommercial use only. Unauthorized posting of this publication online is prohibited. Permission is given to duplicate this document for personal use only, as long as it is unaltered and complete. Permission is required from RAND to reproduce, or reuse in another form, any of its research documents for commercial use. For information on reprint and linking permissions, please visit www.rand.org/pubs/permissions. The RAND Corporation is a research organization that develops solutions to public policy challenges to help make communities throughout the world safer and more secure, healthier and more prosperous. RAND is nonprofit, nonpartisan, and committed to the public interest. RAND’s publications do not necessarily reflect the opinions of its research clients and sponsors. Support RAND Make a tax-deductible charitable contribution at www.rand.org/giving/contribute www.rand.org Preface Over the past two decades, the U.S. Department of Defense (DoD) has invested unparalleled resources into developing effective treatments for military-related psychological health conditions. Systematic reviews are a key component in the knowledge translation process and function to translate the available research into evidence-based health care guidelines that promote optimal clinical care. Although a few government agencies, including the U.S. Department of Veterans Affairs and the Agency for Healthcare Research and Quality, have established evidence synthesis centers, there is no similar center within DoD that focuses exclusively on psychological health issues. Thus, the Southern California Evidence-based Practice Center, housed at the RAND Corporation, has been awarded a three-year contract to synthesize research on psychological health interventions important to military populations. This document is a systematic review performed during year two of this three-year project. The review will be of interest to military health policymakers and practitioners who oversee or implement Medication Assisted Treatment for opioid use disorder. None of the authors has any conflict of interest to declare. This research is sponsored by the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury and conducted within the Forces and Resources Policy Center of the RAND National Defense Research Institute, a federally funded research and development center sponsored by the Office of the Secretary of Defense, the Joint Staff, the Unified Combatant Commands, the Navy, the Marine Corps, the defense agencies, and the defense Intelligence Community. For more information on the RAND Forces and Resources Policy Center, see www.rand.org/nsrd/ndri/centers/frp.html or contact the director (contact information is provided on the webpage). iii Abstract At the request of the Defense Centers of Excellence (DCoE) for Psychological Health and Traumatic Brain Injury, this systematic review (PROSPERO 2017: CRD 42017058608) synthesizes evidence on the effects of medication-assisted treatment (MAT) on functional outcomes among patients with opioid use disorder (OUD). Functional outcomes included cognitive (e.g., memory), occupational (e.g., return to work), physical (e.g., fatigue), behavioral/social (e.g., family function), and neurological (e.g., balance) function. We searched five databases from inception to January 2017 and bibliographies of systematic reviews to identify English-language controlled trials, case control studies, and cohort comparisons of one or more groups; cross-sectional studies were excluded. Two independent reviewers screened identified literature, abstracted study-level information, and assessed the quality of included studies. Meta-analyses used the Hartung-Knapp method for random-effects models. The quality of evidence (QoE) was assessed using the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach. A comprehensive search and 1,327 full-text publication screenings yielded 27 randomized controlled trials (RCTs) and ten observational studies meeting inclusion criteria. The studies reported highly diverse functional outcome measures. No RCT was rated as having low risk of bias, but several methodologically sound observational studies were identified. The statistical power to detect differences in functional outcomes was unclear in the majority of studies. Regarding cognitive outcomes, a large observational study found that MAT users had twice the risk of injurious traffic accidents as nonusers (low QoE). Two studies reported that MAT users performed significantly worse in working memory and cognitive speed than matched controls with no history of substance use disorder (SUD) or opioid use (very low QoE). Regarding occupational outcomes, patients with OUD on MAT showed no differences from those treated without MAT. One cohort study found that fewer persons with OUD who were treated with buprenorphine reported fatigue than did persons with OUD who were untreated; other physical function outcomes either showed mixed evidence or no difference. One study showed patients taking buprenorphine or methadone scored worse in aggressive responding than did controls with no history of SUD (very low QoE); studies of other behavioral/social function outcomes either showed mixed evidence or no statistically significant difference. iv Contents Preface ...................................................................................................................................... iii Abstract ..................................................................................................................................... iv Figures and Tables .................................................................................................................... vii Summary ................................................................................................................................. viii Acknowledgments .................................................................................................................... xv Abbreviations .......................................................................................................................... xvi 1. Introduction ............................................................................................................................ 1 2. Methods .................................................................................................................................. 4 Literature Search ................................................................................................................................. 4 Eligibility Criteria ............................................................................................................................... 4 Inclusion Screening ............................................................................................................................. 5 Data Extraction ................................................................................................................................... 5 Risk of Bias ........................................................................................................................................ 6 Data Synthesis .................................................................................................................................... 7 Quality of Evidence ............................................................................................................................ 8 3. Results .................................................................................................................................... 9 Search Results .................................................................................................................................... 9 Description of Included Studies......................................................................................................... 10 Risk of Bias for Individual Included Studies ...................................................................................... 12 Key Question 1: What Are the Effects of MAT (Using Buprenorphine, Buprenorphine Plus Naloxone, Methadone, or Naltrexone) for OUD on Functional Outcomes Compared to Wait-List, Placebo, Treatment Without Medication, Any Other Comparator, or Each Other (e.g., Buprenorphine Versus Naltrexone)? ................................................................................... 19 Key Question 1a: Does the Effect Vary by Type of Medication? ....................................................... 31 Key Question 1b: Does the Effect Vary by Route of Administration? ................................................ 37 Key Question 1c: Does the Effect Vary by Length of Treatment, Follow-Up Time,
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