Department of Pharmacy Practice, College of Pharmacy (Drs. Posen, Keller, Elmes, and Jarrett) and Department of Academic Internal Medicine (Dr. Messmer) and Department of Family and Community Medicine (Drs. Gastala and Neeb), College of Medicine, University of Illinois Chicago jarrett8@uic.edu
Drs. Posen, Keller, Elmes, Messmer, Gastala, and Neeb reported no potential conflict of interest relevant to this article. Dr. Jarrett is a consultant to Trevena, developer of an investigative agent, TRV734, for medication-assisted treatment of opioid use disorder. She receives research funding from the US Health Resources and Services Administration; the Illinois Department of Human Services; the Substance Abuse and Mental Health Services Administration of the US Department of Health and Human Services; the Gordon and Betty Moore Foundation; and the Coleman Foundation.
Overall, the cost-effectiveness of intramuscular naltrexone is unclear. State-administered insurance programs vary in their requirements for coverage of naltrexone treatment.31
Comprehensive medication reconciliation is vital
Overall fragmentation of care within OTPs places patients at risk for adverse events, such as drug interactions.32 Under Title 42 of the US Code,33 patients must provide written consent for an OTP provider to disclose their history of a substance use disorder. Allowing the patient to decide which medical providers can access their treatment records for an OUD benefits patient confidentiality but poses numerous issues worth exploring.
All prescribed controlled substances are recorded in the prescription drug monitoring program, or PDMP, a state-level electronic database accessible to health care professionals to inform prescribing decisions and identify drug interactions. The PDMP has substantially reduced opioid overprescribing and improved identification of patients at risk for overdose or misuse of opioids.
Buprenorphine, available for office-based treatment, has a so-called ceiling effect that reduces the adverse effect profile, including respiratory depression and euphoria.
Unlike all other controlled substances, however, prescriptions ordered by an OTP are not recorded in the PDMP (although there are recent exceptions to this scenario). Without such information, a physician might not have important information about the patient when making medical decisions—placing the patient at risk for harmful outcomes, such as drug–drug and drug–disease interactions.
For example: Methadone is associated with a prolonged QT interval,34 increasing the risk for a fatal arrhythmia. Concurrent QT-prolonging medications, such as azithromycin and citalopram, further increase this risk.35 Because methadone dispensing is isolated from the patient’s medical record, the clinician who prescribes MOUD has an incomplete patient history and could make a potentially fatal treatment decision.
