RTI Study Validates Retention as a Quality Measure for Opioid Treatment Programs

Patients who remain in opioid treatment programs for at least 30 days are substantially less likely to die or require emergency care in the following five months, according to a nationwide study published September 14 in the Journal of Substance Use and Addiction Treatment. The findings, from researchers at RTI International, provide the first large-scale validation that retention rates can serve as reliable indicators of care quality across the country's medication-assisted treatment infrastructure.

The analysis drew on Medicaid claims from 1,218 opioid treatment programs in 48 states, covering 441,603 treatment episodes among 268,000 patients who initiated care between July 2022 and June 2023. Programs with higher casemix-adjusted retention rates consistently recorded lower rates of substance use disorder-related hospitalizations, emergency department visits, and deaths.

Linking retention to survival

The study examined three retention thresholds: 30 days, 90 days, and 180 days. At the program level, each incremental improvement in retention was associated with measurably better outcomes. For episodes lasting longer than 180 days, the odds of a patient experiencing a substance use disorder-related hospitalization or ER visit dropped significantly (adjusted odds ratio 0.718, 95% CI 0.621–0.830). A parallel analysis using 2020 data found that the same retention benchmark was tied to reduced substance use disorder-related mortality (adjusted odds ratio 0.675, 95% CI 0.471–0.968).

"Patients report that staying alive and not overdosing are key reasons why they seek opioid use disorder treatment. This study demonstrates the importance of retention in achieving these goals," said Tami L. Mark, Ph.D., a Distinguished Fellow in behavioral health financing and quality measurement at RTI and senior author of the paper. "Moreover, this study suggests that patients may want to seek out programs with higher retention rates."

The median 180-day retention rate across all programs in the study period was just 26%, with a wide spread between the 25th percentile (11%) and the 75th percentile (37%). That variation suggests considerable room for improvement, particularly at the lower-performing sites where patients are at greatest risk.

Why retention matters now

The study arrives at a moment when the United States is debating how to sustain recent gains against the opioid crisis. Overdose deaths have fallen for three consecutive years, but the decline remains fragile. Medications for opioid use disorder—methadone, buprenorphine, and naltrexone—reduce the risk of fatal overdose by roughly half, yet their protective effect depends on continuous use. Patients who leave treatment within the first six months face mortality rates comparable to those who never started.

Retention has historically been difficult to measure and compare across programs because patient populations differ in severity, co-occurring conditions, and social stability. The RTI team addressed that problem by developing casemix-adjusted metrics that account for demographic and clinical differences, allowing fairer comparisons between a rural clinic serving mostly unemployed patients and an urban program with a more stable clientele.

Implications for accreditation and payment

If retention is a valid quality indicator, it could eventually shape how opioid treatment programs are accredited, ranked, and reimbursed. Federal and state agencies currently lack a standardized, evidence-based metric for comparing program performance. The RTI measures, derived entirely from existing Medicaid claims, offer a low-burden option that does not require new data collection.

"Programs with higher retention had fewer negative outcomes after adjusting for patient casemix," the authors concluded. "Measuring OTP-level retention could support quality improvement efforts to increase retention in OTPs and reduce costly healthcare utilization."

Payers, including state Medicaid agencies and commercial insurers, could use the metrics to identify high-performing programs for network inclusion or value-based contracts. Conversely, low-performing programs could be targeted for technical assistance, staffing investments, or operational reforms.

Challenges to keeping patients engaged

The study does not explain why some programs retain patients at dramatically higher rates than others, but prior research points to several contributing factors. Transportation barriers, inflexible dosing schedules, stigma, inadequate mental health integration, and housing instability all predict early dropout. Programs that offer evening hours, telehealth check-ins, peer recovery support, and co-located psychiatric care tend to keep patients longer.

Workforce shortages are another constraint. The expansion of buprenorphine prescribing after the X-waiver elimination in 2023 increased the number of entry points into treatment, but many new prescribers lack the time or training to provide the intensive case management that supports long-term engagement. The result is a system that excels at initiating care but struggles to sustain it.

The research behind the findings

The study was funded by the National Institute on Drug Abuse under award number RM1DA059375. The research team included Kathryn N. Burke, William N. Dowd, David H. Barch, Brooke W. Montgomery, Cameron L. Katz, Drake DeLisle, and Gary A. Zarkin, all affiliated with RTI International, with Barch also holding an appointment at Tufts University.

Because the analysis relied on Medicaid claims, it captures the population most heavily affected by the opioid crisis: low-income Americans who qualify for public insurance. Medicaid finances more than half of all medication-assisted treatment in the United States, making program performance within the program a matter of national consequence.

For individuals seeking help for opioid addiction, understanding how to evaluate and choose a treatment program can be overwhelming. Resources that explain different levels of care and treatment approaches can help patients and families make informed decisions about where to begin.