Discontinuation Of Buprenorphine Research Articles

Are gaps in rates of retention on buprenorphine for treatment of opioid use disorder closing among veterans across different races and ethnicities? A retrospective cohort study

IntroductionThe U.S. Veterans Health Administration has undertaken several initiatives to improve veterans' access to and retention on buprenorphine because it prevents overdose and reduces drug-related morbidity. We aimed to determine whether improvements in retention duration over time was equitable across veterans of different races and ethnicities. MethodsThis retrospective cohort study was conducted among veterans who initiated buprenorphine from federal fiscal years (FY) 2006 to 2020 after diagnosis of opioid use disorder. Using an accelerated failure time model, we estimated the association between time to buprenorphine discontinuation and FY of initiation, race and ethnicity, and other control covariates. We followed veterans from buprenorphine initiation until they discontinued or had a censoring event. We then estimated the predicted median days retained on buprenorphine, the average marginal effect of initiating in a later FY, the same measure by race and ethnicity, the incremental effect of the various racial and ethnic identities in contrast to non-Hispanic White, and the total change in the size of the gap over the 15 years of the study between veterans with a minoritized racial or ethnic identity compared to non-Hispanic White veterans. ResultsMost of the 31,797 veterans in the sample were non-Hispanic White (74.5 %), from urban areas (83.5 %), male (92.0 %), and had significant comorbidities, most frequently anxiety disorders (51.0 %) and depression (63.0 %). Overall, 49.8 % of veterans were retained at least 180 days. The average marginal effect of FY was 7.0 days [95%CI:5.3, 8.8] but was significantly smaller among veterans identifying as Black or African American [3.2 days, 95%CI:2.4, 4.1] or Asian [3.6 days, 95%CI:1.6, 5.7] compared to veterans who identify as non-Hispanic White [7.9 days, 95%CI:5.9, 9.9]. Additional measures of change were significant for veterans identifying as Hispanic White or with two or more races. ConclusionAlthough buprenorphine retention in OUD treatment improved for all veterans over the 15-year study period, veterans from most minoritized racial and ethnic groups fell further behind as gains in duration on therapy accrued primarily to non-Hispanic White veterans. Targeted interventions addressing specific challenges experienced by veterans with minoritized identities are needed to close gaps in retention on buprenorphine.

An explainable machine learning framework for predicting the risk of buprenorphine treatment discontinuation for opioid use disorder among commercially insured individuals

ObjectivesBuprenorphine is an effective evidence-based medication for opioid use disorder (OUD). Yet premature discontinuation undermines treatment effectiveness, increasing the risk of mortality and overdose. We developed and evaluated a machine learning (ML) framework for predicting buprenorphine care discontinuity within 12 months following treatment initiation. MethodsThis retrospective study used United States (US) 2018–2021 MarketScan commercial claims data of insured individuals aged 18–64 who initiated buprenorphine between July 2018 and December 2020 with no buprenorphine prescriptions in the previous six months. We measured buprenorphine prescription discontinuation gaps of ≥30 days within 12 months of initiating treatment. We developed predictive models employing logistic regression, decision tree classifier, random forest, extreme gradient boosting, Adaboost, and random forest-extreme gradient boosting ensemble. We applied recursive feature elimination with cross-validation to reduce dimensionality and identify the most predictive features while maintaining model robustness. For model validation, we used several statistics to evaluate performance, such as C-statistics and precision-recall curves. We focused on two distinct treatment stages: at the time of treatment initiation and one and three months after treatment initiation. We employed SHapley Additive exPlanations (SHAP) analysis that helped us explain the contributions of different features in predicting buprenorphine discontinuation. We stratified patients into risk subgroups based on their predicted likelihood of treatment discontinuation, dividing them into decile subgroups. Additionally, we used a calibration plot to analyze the reliability of the models. ResultsA total of 30,373 patients initiated buprenorphine and 14.98% (4551) discontinued treatment. C-statistic varied between 0.56 and 0.76 for the first-stage models including patient-level demographic and clinical variables. Inclusion of proportion of days covered (PDC) measured after one month and three months following treatment initiation significantly increased the models’ discriminative power (C-statistics: 0.60 to 0.82). Random forest (C-statistics: 0.76, 0.79 and 0.82 with baseline predictors, one-month PDC and three-months PDC, respectively) outperformed other ML models in discriminative performance in all stages (C-statistics: 0.56 to 0.77). Most influential risk factors of discontinuation included early stage medication adherence, age, and initial days of supply. ConclusionML algorithms demonstrated a good discriminative power in identifying patients at higher risk of buprenorphine care discontinuity. The proposed framework may help healthcare providers optimize treatment strategies and deliver targeted interventions to improve buprenorphine care continuity.

Association of Receipt of Opioid Prescription for Acute Post-Delivery Pain Management with Buprenorphine Discontinuation among Postpartum People with Opioid Use Disorder

Buprenorphine is a safe and effective medication to treat opioid use disorder (OUD) in pregnant patients and is intended to be continued throughout pregnancy, delivery, and at least the one-year postpartum period. However, delivery often involves the need for acute pain management with opioid medications, such as after a cesarean section. For patients receiving buprenorphine, the provision of prescription opioids may negatively impact OUD treatment outcomes; however, not optimally managing acute pain may also impede OUD treatment benefit. Evidence is needed to disentangle the impacts of opioid prescription provision and methods of pain management in the immediate postpartum period on OUD treatment trajectories, ultimately to inform clinical guidelines tailored to the unique needs of pregnant and postpartum people receiving buprenorphine. Accordingly, this study took an initial step towards this goal to conduct a secondary analysis of a retrospective cohort of pregnant patients taking buprenorphine for OUD at the time of delivery (n = 142) to determine whether receipt of an opioid prescription at birth hospitalization discharge was associated with the time of buprenorphine discontinuation within the 12 months following delivery. Among the sample, 26% (n = 37) were prescribed an opioid at the time of birth hospitalization discharge. The number of weeks post-delivery until buprenorphine discontinuation occurred was shorter amongst patients who were prescribed an opioid (median 11 weeks) compared to patients who were not prescribed an opioid (median 39 weeks; p < 0.001 by Mann–Whitney U test). However, a Cox regression model reported that receipt of an opioid prescription following delivery did not significantly increase the hazard ratio for buprenorphine discontinuation. In other words, OUD patients not prescribed an opioid at birth hospitalization discharge continued their buprenorphine for a longer median duration after delivery compared to their counterparts who received prescription opioids; yet, this finding did not reach statistical significance when taking into account additional clinical variables. The findings indicate how further research is warranted to inform evidence-based post-delivery pain practices for postpartum OUD treatment patients.

Treatment setting and buprenorphine discontinuation: an analysis of multi-state insurance claims

BackgroundPotential differences in buprenorphine treatment outcomes across various treatment settings are poorly characterized in multi-state administrative data. We thus evaluated the association of opioid use disorder (OUD) treatment setting and insurance type with risk of buprenorphine discontinuation among commercial insurance and Medicaid enrollees initiated on buprenorphine.MethodsIn this observational, retrospective cohort study using the Merative MarketScan databases (2006–2016), we analyzed buprenorphine retention in 58,200 US adults with OUD. Predictor variables included insurance status (Medicaid vs commercial) and treatment setting, operationalized as substance use disorder (SUD) specialty treatment facility versus outpatient primary care physicians (PCPs) versus outpatient psychiatry, ascertained by linking physician visit codes to buprenorphine prescriptions. Treatment setting was inferred based on timing of prescriber visit claims preceding prescription fills. We estimated time to buprenorphine discontinuation using multivariable cox regression.ResultsAmong enrollees with OUD receiving buprenorphine, 26,168 (45.0%) had prescriptions from SUD facilities without outpatient buprenorphine treatment, with the remaining treated by outpatient PCPs (n = 23,899, 41.1%) and psychiatrists (n = 8133, 13.9%). Overall, 50.6% and 73.3% discontinued treatment at 180 and 365 days respectively. Buprenorphine discontinuation was higher among enrollees receiving prescriptions from SUD facilities (aHR = 1.03[1.01–1.06]) and PCPs (aHR = 1.07[1.05–1.10]). Medicaid enrollees had lower buprenorphine retention than those with commercial insurance, particularly those receiving buprenorphine from SUD facilities and PCPs (aHR = 1.24[1.20–1.29] and aHR = 1.39[1.34–1.45] respectively, relative to comparator group of commercial insurance enrollees receiving buprenorphine from outpatient psychiatry).ConclusionBuprenorphine discontinuation is high across outpatient PCP, psychiatry, and SUD treatment facility settings, with potentially lower treatment retention among Medicaid enrollees receiving care from SUD facilities and PCPs.

Co-occurring psychiatric disorders and disparities in buprenorphine utilization in opioid use disorder: An analysis of insurance claims

BackgroundAs the overdose crisis continues in the U.S. and Canada, opioid use disorder (OUD) treatment outcomes for people with co-occurring psychiatric disorders are not well characterized. Our objective was to examine the influence of co-occurring psychiatric disorders on buprenorphine initiation and discontinuation. MethodsThis retrospective cohort study used multi-state administrative claims data in the U.S. to evaluate rates of buprenorphine initiation (relative to psychosocial treatment without medication) in a cohort of 236,198 people with OUD entering treatment, both with and without co-occurring psychiatric disorders, grouping by psychiatric disorder subtype (mood, psychotic, and anxiety-and-related disorders). Among people initiating buprenorphine, we assessed the influence of co-occurring psychiatric disorders on buprenorphine retention. We used multivariable Poisson regression to estimate buprenorphine initiation and Cox regression to estimate time to discontinuation, adjusting for all 3 classes of co-occurring disorders simultaneously and adjusting for baseline demographic and clinical characteristics. ResultsBuprenorphine initiation occurred in 29.3 % of those with co-occurring anxiety-and-related disorders, compared to 25.9 % and 17.5 % in people with mood and psychotic disorders. Mood (adjusted-risk-ratio[aRR] = 0.82[95 % CI = 0.82–0.83]) and psychotic disorders (aRR = 0.95[0.94–0.96]) were associated with decreased initiation (versus psychosocial treatment), in contrast to greater initiation in the anxiety disorders cohort (aRR = 1.06[1.05–1.06]). We observed an increase in buprenorphine discontinuation associated with mood (adjusted-hazard-ratio[aHR] = 1.20[1.17–1.24]) and anxiety disorders (aHR = 1.12[1.09–1.14]), in contrast to no association between psychotic disorders and buprenorphine discontinuation. ConclusionsWe observed underutilization of buprenorphine among people with co-occurring mood and psychotic disorders, as well as high buprenorphine discontinuation across anxiety, mood, and psychotic disorders.

Prescription amphetamines in people with opioid use disorder and co-occurring psychostimulant use disorder initiating buprenorphine: an analysis of treatment retention and overdose risk

BackgroundAttention-deficit and hyperactivity disorder (ADHD) is frequently diagnosed in patients with substance use disorders (SUDs), including opioids. There remains concern about the safety and efficacy of prescription amphetamines (PAs) and...

Postoperative buprenorphine continuation in stabilized buprenorphine patients: A population cohort study.

Sudden discontinuation of buprenorphine in the treatment of opioid use disorder can increase the risk of subsequent relapse and overdose. Little is known about buprenorphine use in the perioperative period. The aim of this study was to determine the rate of buprenorphine continuation after hospital discharge following surgery and factors associated with continuation. A population-based retrospective cohort study was conducted using administrative data from Ontario, Canada, between 2012 and 2018. The cohort included individuals on continuous buprenorphine prior to surgery. Logistic regression modeling was used to estimate the association of buprenorphine continuation with demographic, opioid agonist treatment, surgical and health service use factors. Administrative databases from Institute for Clinical Evaluative Sciences (ICES) were used, which capture the Ontario, Canada, population. The data sets describe physician billing, monitoring of controlled substances and hospital discharges. Adults (≥ 18 years, n = 2176) had received a buprenorphine/naloxone product continuously for at least 60 days for the treatment of opioid use disorder and subsequently underwent a surgical procedure. Continuation (versus discontinuation) of buprenorphine prescriptions in the 14 days after surgical discharge was recommended. Exposures included demographic, comorbidity, opioid agonist treatment, surgical and health service use characteristics. About 176 (8.1%) of the 2176 patients discontinued buprenorphine after surgery. Inpatient surgery (versus ambulatory) was associated with reduced odds of continuation, with an unadjusted odds ratio (OR) of 0.17 [95% confidence interval (CI) = 0.12-0.25] and an adjusted OR of 0.16 (95% CI = 0.11-0.23) after accounting for age, sex, rural residence, neighborhood income quintile, Charlson comorbidity index, psychiatric hospitalizations in the past 5 years and recent dispensed supply of buprenorphine (number needed to harm of 6.6). In Ontario, Canada, from 2012 to 2018, most patients receiving continuous preoperative buprenorphine therapy continued buprenorphine use after surgery. Inpatient surgery was a strong predictor of discontinuation compared with ambulatory procedures.

Patients' experiences with continuation or discontinuation of buprenorphine before painful procedures: A brief report.

Patients with opioid use disorder may be asked by their clinicians to discontinue maintenance buprenorphine treatment before surgical operations due to concerns that buprenorphine will interfere with acute pain management. However, discontinuation of buprenorphine may not be well tolerated or safe for all patients. We, therefore, administered a survey to better understand the experiences of patients on buprenorphine treatment who had previously undergone painful procedures and had their buprenorphine maintenance treatment either continued or discontinued before the procedure. After this study received institutional review board approval, patients were invited to participate if they were being prescribed sublingual buprenorphine for treatment of opioid use disorder and had also previously undergone a painful procedure requiring treatment with full agonist opioids. Patients who were eligible and agreed to participate (n = 32) then completed a survey of basic demographics; medical, psychiatric, and substance use histories; and their experience and satisfaction with the treatment of pain and substance use in the perioperative period, including whether buprenorphine was continued or discontinued before their procedure. Compared with patients whose home dose of buprenorphine was continued (n = 15), patients whose buprenorphine was discontinued preoperatively (n = 17) reported less satisfaction with pain management and were more likely to be prescribed full agonist opioids upon discharge. Consistent with prior studies, these survey findings suggest that discontinuation of buprenorphine before painful surgeries may be associated with poorer clinical outcomes. This survey study adds patients' perspective to a growing body of scientific literature suggesting that discontinuation of maintenance buprenorphine treatment before painful procedures may decrease patient satisfaction and increase clinical risk.

Location of buprenorphine initiation and opioid use disorder treatment outcomes during pregnancy

Opioid use disorder (OUD) is a major contributor to maternal morbidity and mortality, largely during the one-year postpartum period. Medication treatment reduces overdose risk and improves perinatal outcomes. Our study aimed to assess the association of the location of buprenorphine initiation (inpatient versus outpatient) with buprenorphine continuation through one year postpartum among a cohort of pregnant people with OUD. We performed a retrospective cohort study comparing rates of buprenorphine continuation through 52 weeks postpartum among a cohort of pregnant people cared for at an academic medical center (2017 – 2020) where both inpatient and outpatient buprenorphine initiation is offered. Medical record abstractions were conducted in pregnancy through one year postpartum. Exposure of interest was location of buprenorphine initiation (inpatient versus outpatient). Primary outcome was postpartum week of buprenorphine discontinuation. Bivariate analyses, Kaplan Meier survival curves, and Cox Proportional Hazard models were used. Our cohort included 116 patients, 77 initiating buprenorphine inpatient and 39 initiating outpatient. Most were insured by Medicaid (73%), lacked college education (55%), and had comorbid mental health conditions (71%) and substance use disorder (69%). Median gestational age at delivery was 39 weeks (Table 1). Outpatient initiation of buprenorphine during pregnancy was negatively associated with buprenorphine discontinuation in the postpartum period, with HR 0.63 (95% CI 0.38-1.03) (Figure 1). In our cohort, postpartum buprenorphine continuation outcomes were similar across initiation clinical settings. Outpatient initiation was marginally associated with longer postpartum buprenorphine duration, likely due to selection bias. Our observational cohort was small; findings should be interpreted with caution. Nonetheless, results illustrate need for further investigation into how perinatal clinical systems can expand access to life-saving treatments for OUD, such as by providing flexibility in how patients can engage in treatment.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

A prospective, randomized trial of the effect of buprenorphine continuation versus dose reduction on pain control and post-operative opioid use.

An increasing number of individuals are taking buprenorphine for management of opioid use disorder (OUD). Pain control can be challenging when these patients develop acute pain requiring supplemental analgesia. Buprenorphine's pharmacokinetic profile can render supplemental opioid-based analgesia ineffective. There is limited guidance on the optimal management of buprenorphine when acute pain is anticipated. Although there is growing acceptance that the risk of OUD relapse with buprenorphine discontinuation overshadows the risks of increased opioid utilization and difficult pain control with buprenorphine continuation, perioperative courses comparing buprenorphine dose reduction and full dose buprenorphine continuation have yet to be investigated. Here, we describe the protocol for our randomized controlled, prospective trial investigating the effect of buprenorphine continuation compared to buprenorphine dose reduction on pain control, post-operative opioid use, and OUD symptom management in patients on buprenorphine scheduled for elective surgery. This is a single institution, randomized trial that aims to enroll 80 adults using 12 mg buprenorphine or greater for treatment of OUD, scheduled for elective surgery. Participants will be randomly assigned to receive 8mg of buprenorphine on the day of surgery onwards until postsurgical pain subsides or to have their buprenorphine formulation continued at full dose perioperatively. Primary outcome will be a clinically significant difference in pain scores 24 hours following surgery. Secondary outcomes will be opioid consumption at 24, 48, and 72 hours postoperatively, opioid dispensing up to 30 days following surgery, changes in mood and withdrawal symptoms, opioid cravings, relapse of opioid misuse, and continued use of buprenorphine treatment postoperatively.

Discontinuation of Buprenorphine Treatment for Opioid Use Disorder During the Coronavirus Disease-2019 Pandemic: A Multilevel Framework.

The coronavirus disease-2019 pandemic has been associated with large increases in opioid-related mortality, yet it is unclear whether specific subpopulations were especially likely to discontinue buprenorphine treatment for opioid use disorder as the pandemic ensued. The aim was to assess predictors of buprenorphine discontinuation in the early months of the coronavirus disease-2019 pandemic (April-July 2020) compared with a prepandemic period (April-July 2019). In each time period, we estimated a multilevel regression models to assess risk of discontinuation in April-July for people who started buprenorphine in January-February. Models included person-level, prescriber-level, and area-level covariates. Individuals age 18 years or older in the all-payer IQVIA Longitudinal Prescription Claims. The primary outcome was buprenorphine discontinuation (ie, no filled prescriptions during the follow-up periods). Overall, 13.98% of patients discontinued buprenorphine in April-July 2020, less than the 15.71% in 2019 (P<0.001). In 2020, patient-level factors associated with discontinuation included younger age, male sex, shorter baseline possession ratio, and payment by cash. Compared with patients with a primary care physician prescriber, specialties most associated with discontinuation were pain medicine and physician assistant/nurse practitioner. Compared with the South Atlantic region, discontinuation risk was lowest in New England and highest in the West South Central States. The association between patient, prescriber, and geographic variables to risk of discontinuation was very similar in 2019 and 2020. While clinical and policy interventions may have mitigated opioid use disorder treatment discontinuation following the pandemic, such discontinuation is nevertheless common and varies by identifiable patient, provider and geographic factors.

Psychiatric comorbidities and their treatment predict buprenorphine continuation among postpartum people with opioid use disorder

BackgroundOpioid use disorder (OUD) is a growing crisis among pregnant and postpartum people. Psychiatric comorbidities are common, yet how they impact OUD treatment outcomes is not well characterized. The aim of this study was to assess the association of psychiatric comorbidities and receipt of psychiatric treatment with buprenorphine continuation through one year postpartum among a sample of people with OUD. MethodsA subsample was identified from a larger retrospective cohort of patients receiving buprenorphine for OUD at the time of delivery from an academic medical center between 2017 and 2020. Medical record abstractions were conducted during pregnancy through one year postpartum. Independent variables included any psychiatric diagnosis and postpartum receipt of psychiatric treatment (medication or behavioral health). The primary outcome was week of buprenorphine discontinuation. Cox Proportional Hazard models were used. ResultsOf 138 patients, 71.8% had a psychiatric condition and 35.5% continued buprenorphine for a full year postpartum. Postpartum buprenorphine continuation was associated with (a) Psychiatric co-morbidity (buprenorphine discontinuation HR 0.49; 95% CI 0.29, 0.82), (b) Receipt of psychiatric medications in weeks 39–52 postpartum (buprenorphine discontinuation HR 0.21; 95% CI 0.06, 0.83), and (c) Receipt of behavioral health therapy in weeks 9–38 postpartum (buprenorphine discontinuation HR 0.40; 95% CI 0.18, 0.90). ConclusionOur work suggests a dynamic relationship between OUD treatment outcomes, psychiatric comorbidities and receipt of psychiatric treatments through the highly vulnerable postpartum period. Clinicians and researchers alike should work to advance patient-centered engagement in integrated care models tailored for this unique population.

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?

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.

Postoperative respiratory depression in patients on sublingual buprenorphine: a retrospective cohort study for comparison between postoperative continuation and discontinuation of buprenorphine

BackgroundWe tested the hypothesis that patients who continued buprenorphine postoperatively experience postoperative respiratory depression less frequently than those who discontinued buprenorphine.MethodsThis is a retrospective cohort study of patients who were on buprenorphine preoperatively. The primary outcome was postoperative respiratory depression as defined by respiratory rate < 10/minute, oxygen saturation (SpO2) < 90%, or requirement of naloxone for 48 h postoperatively. The secondary outcome was the composite of postoperative respiratory complications. The associations between postoperative buprenorphine continuation and respiratory depression and respiratory complications were estimated using separate multivariable logistic regression models, including demographic, intraoperative characteristics, and preoperative buprenorphine dose as covariates.ResultsPostoperative buprenorphine continuation was not associated with postoperative respiratory depression (adjusted odds ratio (OR), 1.11, 95% confidence interval (CI), 0.61 to 1.99, P=0.72). In subanalysis stratified by the preoperative buprenorphine dose, buprenorphine continuation was not associated with postoperative respiratory depression either when preoperative buprenorphine dose was high (≥16 mg daily) or low (<16 mg daily). Postoperative buprenorphine continuation was associated with lower incidence of postoperative respiratory complications (adjusted OR, 0.43, 95% CI, 0.21 to 0.86, P=0.02).ConclusionsContinuing buprenorphine was not associated with respiratory depression, but it was associated with a lower incidence of respiratory complications.

Association Between Receipt of Antidepressants and Retention in Buprenorphine Treatment for Opioid Use Disorder: A Population-Based Retrospective Cohort Study.

Objective: Clinical interventions targeting co-occurring psychiatric disorders may represent a tangible target for improving retention in buprenorphine treatment for opioid use disorder. The aims of this study are to characterize receipt of antidepressants among patients receiving buprenorphine treatment and to examine the association between receiving antidepressants and retention in treatment.Methods: A retrospective cohort design was used. Using data from a large national commercially insured population, the cohort was selected as adults aged 18 to 64 years who initiated buprenorphine treatment in outpatient settings between January 1, 2016, and June 30, 2017. Receiving antidepressants was identified as prescription fills in the period between 6 months prior to buprenorphine initiation and during buprenorphine treatment. Buprenorphine discontinuation was defined as no buprenorphine prescription supply for at least 60 days following the end of the last buprenorphine prescription.Results: The cohort consisted of 11,619 individuals who initiated buprenorphine treatment and met our inclusion criteria. The cohort had a mean age of 36.3 years, 63% were male, and 55.7% received at least 1 antidepressant prescription at any time between 6 months prior to buprenorphine initiation and during treatment. Compared with those receiving no antidepressants at all, individuals starting antidepressants during buprenorphine treatment had an adjusted hazard ratio (HR) for treatment discontinuation of 0.72 (95% CI = 0.67-0.77), while receiving antidepressants only prior to buprenorphine initiation was associated with an increased risk of treatment discontinuation (HR = 1.40, 95% CI = 1.28-1.53).Conclusions: Findings suggest that receiving antidepressants during buprenorphine treatment is associated with improved retention. This highlights the critical importance of screening for and treating mental disorders concomitantly with treatment of opioid use disorder.

Psychosocial and behavioral therapy in conjunction with medication for opioid use disorder: Patterns, predictors, and association with buprenorphine treatment outcomes

IntroductionCurrent evidence indicates that buprenorphine is a highly effective treatment for opioid use disorder (OUD), though premature medication discontinuation is common. Research on concurrent psychosocial and behavioral therapy services and related outcomes is limited.The goal of this study was to define patterns of OUD-related psychosocial and behavioral therapy services received in the first 6 months after buprenorphine initiation, identify patients' characteristics associated with service patterns, and examine the course of buprenorphine treatment, including the association of therapy with medication treatment duration. MethodsWe analyzed 2013–2018 MarketScan Multi-State Medicaid claims data. The sample included adults aged 18–64 years at buprenorphine initiation with treatment episodes of at least 7 days (n = 61,976). We used group-based trajectory models to define therapy service patterns and multinomial logistic regression to identify pre-treatment patient characteristics associated with therapy trajectories. Multinomial propensity-score weighted Cox proportional hazards regression estimated time to buprenorphine discontinuation and unweighted Cox proportional hazards models estimated risk of adverse health care events during buprenorphine treatment (all-cause and opioid-related inpatient and emergency department services, overdose treatment). ResultsWe identified three trajectories of psychosocial and behavioral therapy services: none (73.8%), low-intensity (17.2%), and high-intensity (9.0%). Compared to those without therapy, low-intensity and high-intensity service patterns were associated with behavioral health diagnoses and medical treatment for opioid overdose in the baseline period prior to buprenorphine initiation. The hazard of buprenorphine discontinuation was significantly lower for low-intensity (HR = 0.55; 95% CI, 0.54–0.57) and high-intensity (HR = 0.71; 95% CI, 0.67–0.74) therapy groups compared to those without therapy services. Yet patients in the high-intensity therapy group had increased risk of opioid-related health care events during buprenorphine treatment, including medical treatment for opioid overdose (HR = 1.29; 95% CI, 1.01–1.64). ConclusionMost patients received little or no OUD-related psychosocial and behavioral therapy after initiating buprenorphine treatment. Patients who received therapy had characteristics indicating greater treatment needs as well as more complex treatment courses. Concurrent therapy services may help to address premature buprenorphine discontinuation, particularly for patients with high-risk clinical profiles; however, future prospective research should determine whether therapy is effective for extending buprenorphine retention.

Opioid prescribing and prescription monitoring program use after buprenorphine discontinuation

AbstractIntroductionPrescription opioid use is not recommended in individuals with a history of opioid use disorder. Still, patients often experience pain or craving after buprenorphine discontinuation leading to opioid use. As complete, accessible, patient level records of controlled substance use, prescription monitoring programs (PMPs) may offer a useful tool to recognize recent treatment with buprenorphine and prevent new opioid use.ObjectiveThe objective of this study was to estimate the incidence of new opioid use after buprenorphine discontinuation and to measure the rate of provider and pharmacist PMP query prior to dispensing opioid analgesics to individuals with a recent history of buprenorphine treatment.MethodsA cohort of patients who initiated and discontinued a buprenorphine product between June 30, 2016 and July 4, 2018 was identified from the Texas PMP. Eligible participants were then followed for an additional 180 days to determine if they filled a prescription for an opioid medication after discontinuation. Records of PMP query were then used to measure the frequency with which prescribers and pharmacists queried the PMP prior to dispensing an opioid prescription after buprenorphine discontinuation.ResultsOf the 7081 eligible participants, 16.5% filled an opioid prescription after treatment discontinuation. Pharmacists or prescribers checked the PMP prior to prescribing or dispensing in only 116 of these 1169 instances (9.9%). Of those who filled an opioid prescription after discontinuation, 36.8% did so at a pharmacy where they previously filled a buprenorphine prescription.ConclusionsA considerable number of patients filled an opioid prescription after buprenorphine discontinuation. Despite the availability of the PMP, prescribers and pharmacists rarely use it when deciding whether to dispense an opioid prescription to an individual who recently discontinued buprenorphine. Reform focused on PMP workflow integration and usability may be a useful tool to reduce opioid use after buprenorphine discontinuation.

Retention in care for persons with opioid use disorder transitioning from sublingual to injectable buprenorphine

IntroductionIn the current overdose epidemic, effective treatments for opioid use disorders (OUD), including innovations in medication delivery such as extended-release formulations, have the potential to improve treatment access and reduce treatment discontinuation. This study assessed treatment retention in a primary care–based, extended-release buprenorphine program. MethodsThe study recruited individuals (n = 92) who transitioned from sublingual buprenorphine to extended-release buprenorphine (BUP-XR) in 2018–2019. The study defined the primary outcome, treatment retention, as three or more consecutive, monthly BUP-XR injections following the transition to BUP-XR in this retrospective chart review. ResultsParticipants' mean age was 38 years old and 67% were male. The average duration of sublingual buprenorphine prior to transition was 17.1 (±28.1) months. Three months after transition, 48% of extended-release buprenorphine patients had discontinued BUP-XR treatment. Persons with chronic pain were more likely, and those who had used heroin in the past month less likely to continue BUP-XR. Mean months on sublingual buprenorphine prior to BUP-XR initiation was 24.3 (±32.5) months for people who received 3+ post-induction injections compared to only 8.9 (±19.5) months for those who did not (p = .009). ConclusionsExtended-release buprenorphine discontinuation was high in a real-world setting. Retention continues to represent a major obstacle to treatment effectiveness, and programs need interventions with even newer MOUD formulations.

Postoperative Pain and Opioid Dose Requirements in Patients on Sublingual Buprenorphine: A Retrospective Cohort Study for Comparison Between Postoperative Continuation and Discontinuation of Buprenorphine.

To test the hypothesis that patients who continued buprenorphine postoperatively experience less severe pain and require a smaller dose of opioids than those who discontinued buprenorphine. This is a retrospective cohort study of surgical patients who were on buprenorphine preoperatively. Using our previous study's data as pilot data, we selected the covariates to be included in 2 regression models with postoperative time-weighted average pain score and opioid dose requirements in morphine milligram equivalents during 48 hours after surgery as the outcomes. Both contained preoperative daily buprenorphine dose, whether buprenorphine was continued postoperatively, and the preoperative daily dose-by-postoperative continuation interaction as predictors. Precision variables were identified by exhaustive search of perioperative parameters with the exposure variables (preoperative daily dose, postoperative continuation, and their interaction) included in the regression model. The model selected by using the pilot data was estimated again using the new data extracted for this study to make inference about the effect of the 2 exposures (postoperative buprenorphine continuation and preoperative daily buprenorphine dose) and their interaction on the outcomes. Continuing buprenorphine was associated with a 1.3-point lower time-weighted average pain score than discontinuing (95% confidence interval, 0.39-2.21; P=0.005) but was not associated with a difference in opioid dose requirements (P=0.48). Continuing buprenorphine was associated with lower postoperative pain levels than discontinuing. Our results were primarily driven by patients on lower buprenorphine dose as only 22% of patients were on daily doses of 24 mg or above.

Telehealth Utilization Is Associated with Lower Risk of Discontinuation of Buprenorphine: a Retrospective Cohort Study of US Veterans.

ObjectiveTreatment for opioid use disorder (OUD) may include a combination of pharmacotherapies (such as buprenorphine) with counseling services if clinically indicated. Medication management or engagement with in-person counseling services may be hindered by logistical and financial barriers. Telehealth may provide an alternative mechanism for continued engagement. This study aimed to evaluate the association between telehealth encounters and time to discontinuation of buprenorphine treatment when compared to traditional in-person visits and to evaluate potential effect modification by rural-urban designation and in-person and telehealth combination treatment.MethodsA retrospective cohort study of Veterans diagnosed with OUD and treated with buprenorphine across all facilities within the Veterans Health Administration (VHA) between 2008 and 2017. Exposures were telehealth and in-person encounters for substance use disorder (SUD) and mental health, treated as time-varying covariates. The primary outcome was treatment discontinuation, evaluated as 14 days of absence of medication from initiation through 1 year.ResultsCompared to in-person encounters, treatment discontinuation was lower for telehealth for SUD (aHR: 0.69; 95%CI: 0.60, 0.78) and mental health (aHR: 0.69; 95%CI: 0.62, 0.76). There was no evidence of effect modification by rural-urban designation. Risk of treatment discontinuation appeared to be lower among those with telehealth only compared to in-person only for both SUD (aHR: 0.48, 95%CI: 0.37, 0.62) and for mental health (aHR: 0.46; 95%CI: 0.33, 0.65).ConclusionsAs telehealth demonstrated improved treatment retention compared to in-person visits, it may be a suitable option for engagement for patients in OUD management. Efforts to expand services may improve treatment retention and health outcomes for VHA and other health care systems.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-021-06969-1.