Commentary on Glanz et al.: Longer buprenorphine treatment duration is associated with lower rates of opioid overdose, but can we address barriers to staying in treatment?

Abstract

Glanz et al. examine the association between treatment duration and outcomes including all-cause mortality and overdose, demonstrating that treatment of at least 12 months is associated with lower opioid overdose rates. We now need to understand why people leave treatment after shorter periods of time, and what can be done to improve treatment retention. Opioid dependence, and particularly untreated opioid dependence, places an enormous health and economic burden on individuals and society. As opioid-related deaths in North America have continued to increase, and increase more steeply [1], the provision of evidence-based treatments such as buprenorphine has been increasingly critical. The study by Glanz et al. [2] addresses one key aspect of providing buprenorphine treatment for which there is currently limited information—optimal treatment duration. The study examines buprenorphine discontinuation with different treatment durations in relation to the critical outcomes of all-cause mortality and overdose. The study provides evidence that risk of opioid overdose may be greater following discontinuation of treatment episodes of shorter duration relative to treatment of 12 months duration or longer, with the authors concluding that their findings did not support limitations on treatment duration. It is well established that short-term treatments are ineffective for most and that longer-term treatments such as opioid agonist treatment are critical in reducing mortality [3]. This new study represents an addition to the limited evidence on how long opioid agonist treatment should continue. Clinical guidelines vary, but often propose that there should not be a hard limit on how long treatment continues. The World Health Organization guidelines state that opioid agonists treatments can be continued indefinitely, and for some patients this may be optimal [4]. For patients who may seek advice regarding ‘how long is long enough?’, providing a clear answer based on the existing evidence is currently challenging, but the work by Glanz and others helps to address this evidence gap. Questions regarding how long treatment should be continued become particularly important where access to treatment is restricted to arbitrary periods of time due to limitations placed by national or jurisdictional policies, health insurers or treatment providers. Despite the evidence that longer treatment with opioid agonists produces better outcomes, philosophical debates continue to arise regarding whether staying on opioid treatment for extended periods of time represents a poor outcome [5]. There is also a range of critical factors that can influence treatment cessation, which often centre on barriers to remaining in treatment. These include cost, attendance requirements, requirements to disclose treatment to employers and lack of family support. Glanz et al. speculate that treatment contracts and requirements for frequent and expensive urine drug screening, psychotherapy and follow-up visits may influence treatment discontinuation. Other studies examining the perspectives of people who receive treatment have identified cost to patients and the inconvenience of travelling for regular supervised dosing as critical factors in treatment discontinuation [6, 7]. Experiences of stigma and discrimination that are commonplace when receiving opioid agonist treatment can also contribute to decisions to leave treatment or perhaps shift to treatment modalities that are less ‘observable’ [8, 9]. Individually and combined, these factors can often influence treatment duration despite evidence suggesting that treatment cessation will increase overdose and other risk. Importantly, the majority of these factors are not inherent to the treatment itself but pertain to how treatment is delivered, and represent modifiable factors that could be addressed to improve treatment retention. Future research may be able to further unpack these individual circumstances and complexities and determine how we might increase treatment retention. Ultimately, it is critical that our treatment systems are set up so that people are able to remain in treatment for as long as they need, which would be determined by the patient and their treatment provider. These decisions should not be driven by arbitrary policies or due to treatment systems that make remaining in treatment too difficult. Open access publishing facilitated by Monash University, as part of the Wiley - Monash University agreement via the Council of Australian University Librarians. S.N. is a named investigator on an implementation trial of depot buprenorphine funded by Indivior. S.L. has received untied educational grant funding from Indivior. Suzanne Nielsen: Conceptualization. Sarah Larney: Conceptualization.