Residential Treatment Compared With Outpatient Treatment Coupled With MOUD

"Residential treatment is often considered the highest intensity of treatment for individuals with OUD [40], and may by particularly important for those with unstable housing, co-morbid mental health conditions, or high medical need [41]. However, evidence supporting this assumption is mixed and has primarily focused on treatment completion, retention, and abstinence outcomes [9, 13]. Few studies have directly compared residential treatment with outpatient treatment for clinical outcomes such as overdose [20,21,22]. In this analysis, we used a linked Medicaid dataset to compare outcomes for individuals with OUD who received residential or outpatient treatment. After adjustment for a variety of physical, mental, and addiction-related comorbidities, we found that rates of overdose, opioid-related, and all-cause ED or hospitalizations were not reduced for individuals receiving residential treatment compared to those treated as an outpatient. While residential treatment was associated with higher retention at 6-months, this difference was not significant at 12-months. In stratified analyses, the benefits of residential treatment on retention appeared to be confined to those not receiving MOUD.

"Historically, public perception has assumed residential treatment to be the gold standard, a view often endorsed by the addiction treatment community despite its greater cost and limited evidence [8, 13]. Efforts to further refine selection of patients most likely to benefit from residential treatment are likely to be eclipsed by increasing the use of MOUD in, and following, residential treatment. Opioid agonist treatment for OUD improves a variety of addiction-related outcomes and markedly reduces the risk of overdose and all-cause mortality [7, 42]. In our study, MOUD was associated with a 55% reduction in the risk of opioid overdose independent of treatment setting. About one-third of individuals receiving treatment were prescribed MOUD which is comparable to other reports and suggests missed opportunities for improving OUD treatment outcomes [1, 24].

"This study adds to a mixed literature demonstrating the potential benefits of residential treatment for individuals with OUD with respect to treatment retention [13, 21, 22, 43]. Studies using SAMHSA TEDS data exclusively have generally shown that individuals entering residential facilities have higher treatment completion rates [43, 44]. Consistent with this literature, we found that residential treatment was associated with enhanced retention. While treatment completion is associated with improved some clinical and social outcomes, it is a surrogate indicator of improved addiction-related health outcomes. Moreover, OUD is now universally recognized as a chronic condition requiring long-term outpatient management. Although residential care was associated with improved retention in our study, it was not associated with improvements in overdose or other opioid-related outcomes. This largely comports with recent claims-based analyses that suggest outpatient treatment may be clinically superior to inpatient or residential treatment, especially when coupled with MOUD [21, 22].

"Our subgroup analyses found that among individuals receiving MOUD, outpatient treatment was associated with improved opioid-related ED or hospitalizations compared to residential treatment. Using a similar retrospective cohort design, Morgan et al. found outpatient-based MOUD to be associated with improved rates of opioid overdose and all-cause admissions compared to inpatient treatment initiation [21]. Additional research is required to identify whether other subgroups of patients might benefit from residential treatment in the fentanyl era, such as those with a history of previous unsuccessful attempts at outpatient treatment, housing instability, and adolescents."