Receipt of Pharmacotherapy and Association with Healthcare Utilization among US Adults with Alcohol or Opioid Use Disorder, 2022-2023

Abstract

Background:

Every year, millions of US adults with substance use disorders (SUDs) interface with the health care system, with high rates of emergency department (ED) visits and hospitalizations. FDA-approved medications for alcohol (AUD) and opioid use disorder (OUD), have been shown to decrease acute care utilization for addiction-related issues. However, the characteristics of adults who receive these medications and how receipt is associated with healthcare utilization is not well understood. The objective of this study was to characterize US adults with AUD or OUD who received addiction pharmacotherapy and to examine the association between pharmacotherapy receipt and healthcare utilization in a nationally representative cross-sectional sample.

Methods:

Using data from the National Survey of Drug Use and Health 2022-2023, we included US adults with AUD or OUD and tested the association between self-reported receipt of pharmacotherapy for SUD and health care utilization (ED visits, nights hospitalized, and outpatient visits) using negative binomial regression models adjusted for socio-demographic covariates and medical comorbidities.

Outcomes:

Among US adults with AUD and/or OUD, only 4.8% reported use of medication for addiction treatment in the past 12 months. In adjusted models, receiving pharmacotherapy for substance use was associated with increased number of times treated in the ED (IRR 1.57; 95% CI 1.16, 2.14) increased number of nights hospitalized (IRR 2.79; 95% CI 1.10, 4.87) and increased number of outpatient visits (IRR 1.28; 95% CI 1.02, 1.60).

Conclusion:

In this nationally representative sample of adults with substance use disorder, few reported receipt of pharmacotherapy for SUD in the past year. Individuals receiving MAUD or MOUD reported higher rates of healthcare utilization. The findings underscore the need to identify best practices in outpatient settings to screen and initiate treatment for individuals with substance use disorders, ideally prior to decompensation requiring a higher level of care.

INTRODUCTION

Substance use disorders (SUDs), defined as problematic patterns of substance use leading to impairment or distress[1], are a significant public health concern. National estimates report the prevalence of any SUD among US adults to be approximately 10.6%[2]. Worldwide, SUDs are highly prevalent and are among the leading causes of global morbidity and mortality [3], with an increasing trend from 1990 to 2021[4]. SUDs are associated with increased risk for infectious diseases[5], psychiatric comorbidity[6], suicidality[7-9], and significant impairment in social and occupational functioning with increased rates of homelessness, incarceration, and social instability[6, 10]. The societal costs for SUDs are significant. In the employer-sponsored insurance population, the annual direct medical cost attributable to SUDs was $35.3 billion in 2018, with per-person costs averaging $15,640. Alcohol and opioid use disorders were the costliest subset of SUDs [11]. The excess health care utilization associated with opioid use disorder costs the U.S. health care system approximately $90 billion each year[12] while the annual attributable medical cost for alcohol-related disorders in US hospitals was $7.6 billion[13].

Among the wide range of evidence-based treatments available for alcohol, opioid, and other SUDs, evidence supporting the effectiveness of pharmacotherapy is strongest for alcohol and opioid use disorder[14-16]. Guidelines recommend standard use of these treatments for patients with AUD[17] and OUD [18]. MOUD reduce the risk of mortality, improve quality of life and retention in care, among other benefits; while medications for MAUD can reduce heavy drinking days and improve rates of abstinence [19]. A 2024 cohort study found that initiation of AUD pharmacotherapy at hospital discharge was associated with 18% decrease in return to hospitalization or death within 30 days compared with no initiation[20]. Similarly, medications for opioid use disorder have been linked to lower health care costs, primarily due to fewer emergency department visits and hospitalizations, even when the cost of the treatments themselves is included[21, 22] Despite the substantial burden of substance use disorders (SUDs) in healthcare settings, pharmacologic treatment remains markedly underutilized. Among the estimated 27.1 million U.S. adults with AUD in 2024, only 2.4% received medication-assisted treatment while only 25.1% of U.S. adults with OUD received medication-based treatment in the prior 12 months[23, 24]. Patient-level barriers include internalized stigma and limited awareness of available pharmacologic treatment options.[25, 26].

Although initiation of substance use pharmacotherapy may serve as a factor to help reduce acute care utilization while improving outpatient engagement, there is a paucity of generalizable data exploring characteristics of which adults with AUD or OUD are likely to receive such treatment. Similarly, little is known about the relationship between addiction pharmacotherapy and health service utilization. To address these gaps, we analyzed a nationally representative sample of adults with AUD or OUD to characterize pharmacotherapy receipt according to demographic and socioeconomic characteristics, self-reported medical comorbidities, and disorder severity. We also examined the relationship between receipt of addiction pharmacotherapy and healthcare utilization, including emergency department (ED) visits, nights hospitalized, and outpatient visits.

METHODS

This study utilized data from the 2022 and 2023 National Survey on Drug Use and Health (NSDUH) [27]. NSDUH is the Substance Abuse and Mental Health Service Administration’s (SAMHSA) nationally representative survey conducted on an annual basis that provides comprehensive data on substance use, mental health conditions, and other health-related issues in the United States. The overall survey response rate ranged from 47-50% during the study years included[28]. The survey data excludes respondents currently living in institutionalized settings, including those who are in long-term care facilities or incarcerated in prison or detention centers. The Medical College of Wisconsin’s Institutional Review Board considers this study as exempt due to its reliance on publicly available deidentified data.

Population

The study sample included adult respondents (aged ≥18 years) who met criteria for alcohol or opioid use disorder in the past year using DSM-V criteria as measured by the survey responses [1].

Measures

Primary Independent Variable -

The independent variable was self-reported receipt of addiction pharmacotherapy. Receipt of addiction pharmacotherapy was defined as a positive response to one of the following questions: 1) “During the past 12 months, did you use medication prescribed to you to help cut back or stop your drug use?” Examples provided as possible medications included methadone, buprenorphine, and naltrexone. 2) “During the past 12 months, did you use medication prescribed to you to help cut back or stop your alcohol use?” Examples provided as possible medications included acamprosate, disulfiram and naltrexone[27].

Outcomes Variables –

The outcomes included the following self-reported healthcare utilization variables: 1) number of ED visits 2) number of nights spent hospitalized and 3) number of outpatient visits in the past 12 months.

Covariates:

Demographic and socioeconomic covariates included age (18-25, 26-34, 35-49, 50+); self-identified sex (male, female); educational attainment (less than high school, high school graduate, some college, college graduate); self-identified race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, other) ; marital status (married, widowed/divorced/separated, never married); employment status (full-time, part-time, unemployed, other); income level (<100% federal poverty level, 100-200%, >200%); county size classification (large metropolitan, small metropolitan, non-metropolitan); health insurance coverage (Medicare, Medicaid, VA Healthcare, private insurance, uninsured). Clinical covariates were considered by a count of all self-reported medical comorbidities listed in the NSUDH (COPD, cirrhosis, asthma, HIV, cancer, serious mental illness, heart condition, diabetes, hepatitis B or C, kidney disease or high blood pressure). For sensitivity analyses, we included a variable of substance use disorder severity (mild, moderate, or severe) provided by NSDUH guidance per DSM V criteria[29].

Statistical Analysis

Descriptive statistics reported baseline characteristics summarized using cross-tabulations to compare covariates by receipt of addiction pharmacotherapy. Weighted proportions were reported for categorical variables and means along with standard deviations were reported for continuous variables. Negative binomial regression models were used to assess the association between medication-assisted treatment and healthcare utilization. Unadjusted models examined the bivariate association between medication-assisted treatment and each healthcare utilization outcome. Adjusted models included all demographic, socioeconomic, and medical covariates to control for potential confounders. We then stratified the descriptive tables and regression models by alcohol versus opioid use disorder to assess for differences between these clinically distinct populations. Finally, in sensitivity analyses, we tested for an interaction between receipt of addiction pharmacotherapy and substance use disorder severity among the entire study sample (adults with either AUD or OUD).

Statistical significance was set at p < 0.05. Analyses were conducted using R incorporating NSDUH-specific weighting procedures to ensure appropriate variance estimation. All analyses applied NSDUH survey weights to account for the complex sampling design and to ensure nationally representative estimates.

RESULTS

Table 1 displays descriptive characteristics for U.S. adults with alcohol and/or opioid use disorder from 2022 – 2023 with statistical comparisons by use of prescribed pharmacotherapy. The weighted sample represented 60,402,501 participants, of whom 2,898,742 (4.8%) had received pharmacotherapy for their addiction. Among those with AUD, 2.1% received addiction pharmacotherapy in the last year; among those with OUD, 29.9% received addiction pharmacotherapy in the past year. Those who received pharmacotherapy for OUD or AUD were more likely to be in the 35–49-year age range compared to those who did not (43% vs 28%, p<0.001), less likely to be currently married (22% vs 37%, p<0.001), and be of lower socioeconomic status. There were no differences in receipt of addiction pharmacotherapy by self-identified race. Finally, respondents who had received pharmacotherapy had a higher comorbidity count than those who did not (mean number 1.38 versus 0.80; p<0.001) and were more likely to have severe use disorder (74% versus 23%, p<0.001). Descriptive tables stratified by AUD and OUD are provided as supplemental tables.

Table 1:

Descriptive statistics by use addiction pharmacotherapy among adults with alcohol or opioid use disorder, weighted, United States, 2022 - 2023

	Received addiction pharmacotherapy
	No N = 57,503,759	Yes N = 2,898,742	P-value
	95.2%	4.8%
SUD Category
Alcohol Use Disorder	55,783,896 (97.9%)	1,175,496 (2.1%)
Opioid Use Disorder	3,401,932 (70.1%)	1,452,683 (29.9%)
Age Category			<0.001
18-25	10,691,085 (19%)	191,838 (6.6%)
26-34	13,413,118 (23%)	593,374 (20%)
35-49	16,152,240 (28%)	1,251,230 (43%)
50+	17,247,316 (30%)	862,299 (30%)
Sex			0.8
Male	33,905,341 (59%)	1,729,485 (60%)
Female	23,598,419 (41%)	1,169,256 (40%)
Educational Status			<0.001
Less than High School/High School	18,860,948 (33%)	1,493,132 (52%)
Some College/College Graduate	38,642,811 (67%)	1,405,610 (48%)
Race/Ethnicity			0.11
Non-Hispanic White	36,565,119 (64%)	2,091,939 (72%)
Non-Hispanic Black	7,075,765 (12%)	258,826 (8.9%)
Other race*	13,862,875 (24%)	547,977 (19%)
Employment Status			<0.001
Employed full time/part time	40,378,006 (70%)	1,509,982 (52%)
Unemployed/Other (not in labor force)	17,125,753 (30%)	1,388,760 (48%)
Marital Status			<0.001
Married	21,337,930 (37%)	648,446 (22%)
Widowed/Divorced/Separated	10,702,739 (19%)	915,885 (32%)
Never Married	25,463,090 (44%)	1,334,410 (46%)
Income (Poverty Level)		<0.001
Living in Poverty	8,739,923 (15%)	893,693 (31%)
Income up to 2X Federal Poverty Threshold	10,128,695 (18%)	717,606 (25%)
Income More than 2X Federal Poverty Threshold	38,629,591 (67%)	1,287,443 (44%)
Insurance Status			<0.001
Public Insurance **	15,698,174 (27%)	1,637,579 (56%)
Covered by private insurance	35,524,914 (62%)	1,004,951 (35%)
Uninsured	6,280,671 (11%)	256,211 (8.8%)
County Type			0.3
Large Metropolitan	32,626,127 (57%)	1,506,794 (52%)
Small/non-metropolitan	24,877,632 (43%)	1,391,948 (48%)
Comorbidity Count ***			<0.001
Mean (SD)	0.80 (1.01)	1.38 (1.27)
Median (IQR)	1.00 (0.00, 1.00)	1.00 (1.00, 2.00)
Range	0.00 - 8.00	0.00 - 7.00
SUD Severity			<0.001
Mild	30,695,484 (53%)	288,697 (10.0%)
Moderate	13,516,109 (24%)	461,112 (16%)
Severe	13,292,166 (23%)	2,148,933 (74%)

^*Other race includes: Hispanic/Other/Native American/ Native Hawaiian/Other Pacific Islander/Asian/more than one race

^**Covered by Medicaid /Medicare/ VA Health / Other

^***Comorbidity count includes: COPD, cirrhosis, asthma, HIV, cancer, serious mental illness, heart condition, diabetes, hepatitis B or C, kidney disease or high blood pressure

Table 2 displays mean healthcare utilization measures with corresponding standard deviations for U.S. adults with substance use disorders from 2022 – 2023 by use of prescribed pharmacotherapy. On average, patients who received addiction pharmacotherapy reported higher numbers of healthcare utilization including times been treated in emergency room (mean = 1.24, SD = 2.35), nights stayed in hospital (mean = 2.18, SD = 5.84), and number of outpatient visits (mean = 5.6, SD = 7.8).

Table 2.

Mean healthcare utilization by receipt of MOUD or MAUD among US adults with AUD or OUD, United States, 2022-2023.

	Did not receive addiction pharmacotherapy	Received addiction pharmacotherapy	p-value
				Emergency Room Visits in Past 12 months
Mean (SD)	0.50 (1.28)	1.24 (2.35)	<0.001
Nights Hospitalized in Past 12 months
Mean (SD)	0.44 (2.44)	2.18 (5.84)	<0.001
Number of Outpatient Visits in Past 12 months
Mean (SD)	3.3 (5.1)	5.6 (7.8)	0.008

Table 3 displays results for the unadjusted and adjusted negative binomial regression models associated between the kinds of healthcare utilization (ED visits, hospital stays, outpatient visits) by receipt of addiction pharmacotherapy. In unadjusted analyses, pharmacotherapy use in the past year among U.S. adults with substance use disorder was associated with higher incidence rates of ED visits (IRR 2.49; 95% CI: 1.87, 3.32), nights hospitalized (IRR 4.98; 95% CI: 2.84, 8.72), and outpatient visits (IRR 1.69; 95% CI: 1.29, 2.21). These associations remained statistically significant after multivariable adjustment, with pharmacotherapy use associated with increased incidence rates of ED visits (IRR 1.50; 95% CI: 1.11, 2.02), hospital nights (IRR = 2.61; 95% CI: 1.39, 4.88), and outpatient visits (IRR = 1.26; 95% CI: 1.00, 1.57), compared with no pharmacotherapy use.

Table 3:

Negative binomial regression models testing the association between receipt of addiction pharmacotherapy and healthcare utilization among US adults with AUD or OUD, United States, 2022-2023.

	ED visits in the past 12 months		Nights hospitalized in the past 12 months		Outpatient visits in the past 12 months
	Unadjusted Model	Adjusted Model*	Unadjusted Model	Adjusted Model*	Unadjusted Model	Adjusted Model*
Received addiction pharmacotherapy
No	REF	REF	REF	REF	REF	REF
Yes	2.49 (1.87, 3.32)	1.50 (1.11, 2.02)	4.98 (2.84, 8.72)	2.61 (1.39, 4.88)	1.69 (1.29, 2.21)	1.26 (1.00, 1.57)
	p < 0.001	p = 0.01	p < 0.001	p = 0.004	p = 0.0004	p = 0.048

^*Included covariates: age, sex, education, race/ethnicity (self-identified), employment, marital, income, insurance, county, and comorbidity county reflecting all described comorbid medical and mental health conditions

Table 4 displays the unadjusted and adjusted negative binomial regression models stratified by AUD status and by OUD status. Among U.S. adults with AUD, unadjusted analyses showed that past-year pharmacotherapy use was associated with higher rates of ED visits (IRR = 3.10; 95% CI: 1.98, 4.83), hospital nights (IRR = 4.10; 95% CI 2.17, 7.75), and outpatient visits (IRR = 1.76; 95% CI: 1.18, 2.62). After adjustment for covariates, these associations remained significant for ED visits (IRR = 1.91; 95% CI: 1.19, 3.06) and hospital nights (IRR = 2.03; 95% CI: 1.09, 3.79), whereas the association with outpatient visits was no longer statistically significant. Among U.S. adults with OUD, past-year pharmacotherapy use was not significantly associated with healthcare utilization in unadjusted analyses. However, after multivariable adjustment, pharmacotherapy use was associated with a higher rate of hospital nights (IRR = 2.08; 95% CI: 1.22, 3.55).

Table 4:

Negative binomial regression models testing the association between receipt of pharmacotherapy and healthcare utilization stratified by US adults with AUD and OUD, United States, 2022-2023.

	ED visits in the past 12 months		Nights hospitalized in the past 12 months		Outpatient visits in the past 12 months
	Unadjusted Model	Adjusted Model*	Unadjusted Model	Adjusted Model*	Unadjusted Model	Adjusted Model*
Among adults with AUD
Received addiction pharmacotherapy
No	REF	REF	REF	REF	REF	REF
Yes	3.10 (1.98, 4.83)	1.91 (1.19, 3.06)	4.10 (2.17, 7.75)	2.03 (1.09, 3.79)	1.76 (1.18, 2.62)	1.22 (0.91, 1.63)
	p < 0.001	p = 0.01	p < 0.001	p = 0.03	p = 0.01	p = 0.18
Among adults with OUD
Received addiction pharmacotherapy
No	REF	REF	REF	REF	REF	REF
Yes	0.96 (0.68, 1.34)	0.99 (0.72, 1.35)	2.12 (0.86, 5.26)	2.08 (1.22, 3.55)	0.98 (0.71, 1.35)	1.01 (0.78, 1.31)
	p = 0.80	p = 0.95	p = 0.11	p = 0.01	p = 0.90	p = 0.95

^*Included covariates: age, sex, education, race/ethnicity (self-identified), employment, marital, income, insurance, county, and comorbidity county reflecting all described comorbid medical and mental health conditions

The sensitivity analyses show that in fully adjusted models the association between receipt of pharmacotherapy for addiction treatment and ED use was significant (IRR 1.87, 95% CI 1.17, 2.98) as was the association between severe SUD and ED use (IRR 1.71, 95% CI 1.41, 2.06). However, the interaction term shows that the association between addiction pharmacotherapy and ED use does not differ significantly by SUD severity (IRR 1.10, 95% CI 0.59, 2.04). Similar findings held for the inpatient outcome. There was a significant association between receipt of addiction pharmacotherapy and nights hospitalized (IRR 5.52, 95% CI 1.69; 18.03) and between severe SUD and nights hospitalized (IRR 3.12; 95% CI 1.78, 5.45). However, their interaction term was not significant (0.46, 95% CI 0.11, 1.97). The association between receipt of pharmacotherapy and outpatient use was not significant in adjusted models, thus an interaction analysis was not performed.

DISCUSSION

In this nationally representative sample of US adults with alcohol or opioid use disorder, only one in twenty respondents reported use of evidence-based pharmacotherapy for their addiction in the past 12 months, underscoring the persistent underutilization of effective medications for SUDs. Overall, respondents who reported receipt of pharmacotherapy for SUD tended to be greater than 35 years old, had greater substance use disorder severity and medical comorbidity, and were more likely to experience socioeconomic disadvantage, including lower educational attainment and income, unemployment, being unmarried, and covered by a public insurance. Among respondents with AUD, pharmacotherapy recipients were additionally more likely to reside in small or nonmetropolitan areas, whereas among those with OUD, pharmacotherapy receipt was primarily associated with older age and greater disorder severity. Having used addiction pharmacotherapy was associated with increased use of healthcare, in particular acute healthcare utilization including ED visits and nights hospitalized, findings which persisted after controlling sociodemographic and social risk factors, although did differ after stratification, with the relationship persisting among those AUD, but less so for those with OUD.

A notable finding was the substantially lower receipt of pharmacotherapy among respondents with AUD compared with those with OUD. This aligns with prior literature demonstrating a substantial disparity in pharmacotherapy use between AUD and OUD[30], with fewer than 2% of US adults with AUD receiving medications to treat it in 2019[31] compared with one in five US adults with OUD receiving medication in 2021[32]. Although the design of our study does not allow us to elucidate the reasons for this, plausible explanations may relate to public health priorities and public messaging. The opioid epidemic prompted substantial public attention[33, 34], policy reform, and financial investment to expand access to medications for OUD, including eliminating prior authorization requirements in some Medicaid programs[35], repealing the federal buprenorphine X-waiver requirement[36], and directing opioid settlement funds toward opioid-specific treatment initiatives including expansion of pharmacotherapy [37, 38]. No comparable national effort has been undertaken to promote MAUD. Additionally, the legal status and greater social acceptability of alcohol, compared with illicit opioid use, may reduce the perceived public urgency for MAUD.

We note some unexpected findings in the characteristics of adults with substance use disorder who reported past year receipt of pharmacotherapy for addiction treatment. There were no differences by racial identity in our study among those who did and did not receive addiction pharmacotherapy. Other studies, many using claims data, have found disparities by race and socioeconomic status among those prescribed pharmacotherapy for addiction treatment. People who identified as Black or Hispanic were less likely to receive MOUD or MAUD despite frequent contact with providers. [39, 40], Moreover, in our sample, individuals with lower educational attainment, lower income, and unemployment were more likely to have used these medications. The reasons for this discrepancy from prior literature are unclear.

Finally, receipt of pharmacotherapy was associated with greater acute healthcare utilization. This association persisted after stratification by disorder for those with for AUD. However, receipt of addiction pharmacotherapy was only associated with increased hospitalizations after adjusting for confounders for those with OUD. Rather than suggesting that pharmacotherapy increases healthcare utilization, these findings likely reflect that individuals receiving medications for SUD have greater disease severity and comorbidities and that emergency departments and hospitals are frequently serving as important points of care for them[41, 42]. The findings suggest that researchers who aim to improve health outcomes for individuals with SUD should consider strategies for expanding access outside of acute care settings, such as implementing early screening tools in the outpatient setting and reducing barriers to prescribing addiction pharmacotherapy. Such efforts could capture people early in their SUD course and prior to acute decompensation and developing medical sequela, making them prone to more frequent ED visits and hospitalization.

This study has several important limitations. First, the cross-sectional design precludes causal inference and limits the analysis to observed associations between variables. In addition, the dataset does not permit determination of the temporal sequence between pharmacotherapy initiation and healthcare utilization. As a result, it is unclear whether healthcare encounters occurred before, during, or after initiation of MOUD or MAUD. Furthermore, the dataset does not identify the specific reasons for healthcare encounters, including whether they were related to substance use. These limitations restrict interpretation of the observed associations and prevent conclusions regarding the directionality of relationships or the potential impact of pharmacotherapy on healthcare utilization. Second, the NSDUH relies on self-reported information, which is subject to recall bias; use of pharmacotherapy and healthcare utilization may be underreported, particularly among individuals with limited contact with healthcare providers. However, this design may capture a construct that claims and EHR data cannot – that respondents are reporting the purpose of the medications as specific to reducing or stopping substance use as opposed to management of pain or other conditions. Third, our categorization of self-reported racial identity is imperfect, with multiple identities combined into the “other” race category because of small sample sizes. Despite these limitations, the study’s large, nationally representative sample offers valuable insight into the clinical needs of U.S. adults with substance use disorders.

CONCLUSION

Adults in the U.S. with alcohol and opioid use disorders represent a large population with substantial health needs and high healthcare utilization. However, only a small proportion receive evidence-based pharmacotherapy. Among those who received addiction pharmacotherapy, healthcare utilization is significantly higher. Future research should focus on understanding how pharmacotherapy is accessed and delivered for those with alcohol and opioid use disorders. Further, investigators should develop and test targeted interventions that expand access and reduce barriers in outpatient addiction medicine treatment.