'Too little dose - too early discontinuation?'-Effect of buprenorphine dose on short term treatment adherence in opioid dependence

Mobile Medication Adherence Platform for Buprenorphine (MAP4BUP): A Phase I feasibility, usability and efficacy pilot randomized clinical trial

BACKGROUND/AIM

Poor medication adherence is one of the main barriers to the long-term efficacy of buprenorphine/naloxone (BUP/NAL). The aims of this pilot investigation were to examine if a Bluetooth-enabled pill cap and mobile application is a feasible, usable tool for increasing BUP/NAL adherence among people with an opioid use disorder.

METHODS

This pilot randomized clinical trial (RCT; total n = 41) lasted 12 weeks and was conducted in two office-based BUP/NAL provider locations in Spokane, WA and Coeur d'Alene, ID from January 2020 to September of 2021 with an 11-month gap due to COVID-19. Patients receiving BUP/NAL who consented to participate were randomized to receive the pill cap device (PLY group; n = 19) or a service as usual (SAU group; n = 22) group that included an identical but inactive cap for their bottle. The PLY group received reminders via text and voice, and the support of a "helper" (e.g., friend) to monitor pill cap openings.

RESULTS

Most participants in PLY group found the device both feasible (92.86 %) and usable (78.57 %). Most participants liked using the device (92.86 %) and were satisfied with the device (85.71 %). While not statistically different from one another, medication adherence per the Medication Possession Ratio was 75 % in the SAU group and 84 % in the PLY group. Pill cap openings were significantly higher in the PLY group with an average of 91.8 openings versus the SAU group's average of 56.7 (p < 0.05).

CONCLUSION

The devices was feasible, usable, and patients had high levels of satisfaction. The device was associated with increased pill openings.

Administration and patient-incurred costs associated with opioid agonist treatment in Norway

OBJECTIVES

Opioid use disorder is associated with high rates of mortality and has become an escalating global health issue. Opioid agonist treatment (OAT) with oral methadone or daily sublingual buprenorphine hydrochloride, either administered separately or in combination with naloxone hydrochloride (SL-BPN, SL-BPN/NX), is supervised by a healthcare professional experienced in treating opioid use disorder to ensure proper dosing and prevent misuse. For that reason, there may be substantial direct and indirect costs associated with OAT. Recently, weekly and monthly subcutaneous depot formulations of buprenorphine (SC-BPN) have been approved. This study aimed to estimate management and patient-incurred costs associated with the most commonly used OATs compared to the cost of weekly and monthly SC-BPN.

METHODS

We conducted a cost-minimisation analysis comparing the monthly costs of OAT treatment with oral formulations, i.e. oral methadone, SL-BPN, SL-BPN/NX and SC-BPN. The analysis assessed treatment acquisition costs and costs associated with management, supervision and administration of therapy, patients' transportation costs and the indirect costs associated with patients' time-use. The model was set up to reflect the Norwegian medically assisted rehabilitation system and considered the costs of a stable maintenance OAT regimen given continuously to patients already initiated and titrated on the therapy.

RESULTS

OAT management with monthly formulation of SC-BPN was associated with a reduction in monthly costs of €605, €586, and €411 per month compared to SL-BPN, SL-BPN/NX and oral methadone, respectively. Similar results were estimated when comparing to the weekly formulation of SC-BPN.

CONCLUSION

The analysis showed that the monthly formulation of SC-BPN was the cost-minimising alternative, followed by the weekly formulation, when considering all cost components.

Do out-of-pocket costs influence retention and adherence to medications for opioid use disorder?

BACKGROUND

Availability of medications for opioid use disorder (MOUD) has increased during the past two decades but treatment retention and adherence remain low. This study aimed to measure the impact of out-of-pocket buprenorphine cost on treatment retention and adherence among US commercially insured patients.

METHODS

Medical payment records from IBM MarketScan were analyzed for 6,439 adults age 18-64 years with commercial insurance who initiated buprenorphine treatment during January 1, 2016 to June 30, 2017. Regression models analyzed the relationship between patients' average daily out-of-pocket buprenorphine cost and buprenorphine retention (at least 80 % days covered by buprenorphine) at three different thresholds (180, 360, and 540 days) and adherence (the number of days of buprenorphine coverage) within each retention threshold. Models controlled for patient demographic and clinical characteristics including age, sex, presence of other substance use disorders, psychiatric and pain diagnoses, and receipt of prescription medications.

RESULTS

A one dollar increase in daily out-of-pocket buprenorphine cost was associated with a 12-14 % decrease in the odds of retention and a 5-8 % increase in the number of days without buprenorphine coverage during each analyzed retention threshold.

CONCLUSION

Recent policies have attempted to address supply-side barriers to MOUD treatment. This study highlights patient cost-sharing as a demand-side barrier to MOUD. While the average out-of-pocket buprenorphine cost is lower than two decades ago, this study suggests even at current levels such costs decrease retention and adherence among commercially insured patients. Efforts to address demand-side barriers could help maximize the health and social benefits of buprenorphine-based MOUD.

MATERNAL AND FETAL BUPRENORPHINE PHARMACOKINETICS IN PREGNANT SHEEP DURING TRANSDERMAL PATCH DOSING: Buprenorphine pharmacokinetics in pregnant sheep

BACKGROUND

Buprenorphine is used in the opioid maintenance treatment for opioid dependent patients, including pregnant women. Despite the wide use, limited data exists on buprenorphine pharmacokinetics and fetal exposure during pregnancy. The aim of our study was to determine the buprenorphine pharmacokinetics during transdermal patch dosing to pregnant sheep and, to determine the extent of transplacental transfer of buprenorphine to the fetus.

METHODS

Pregnant sheep in late gestation (n=50) received 20, 25 or 40 µg/h of buprenorphine as a 7-day extended-release transdermal patch. Plasma samples were collected from the ewe and the fetus on days 1 - 6, and buprenorphine and norbuprenorphine concentrations were determined. During the exposure period the sheep had a surgical procedure on the second day, a recovery phase, and an experimental procedure on the sixth day. In the experiment, hypoxia was induced under anesthesia for 18 sheep to investigate if decreased fetal pH would cause ion-trapping of buprenorphine in the fetus. The fetal/maternal plasma concentration ratio was determined on the second and on the sixth exposure day at baseline and during hypoxia. Maternal pharmacokinetics were modelled with a population pharmacokinetic method using the data from this study and our previous intravenous administration study.

RESULTS

The transdermal patch provided an extended release of buprenorphine throughout the exposure period, but the release rate declined approximately 20 h after patch placement. The median fetal/maternal plasma concentration ratio was 13 - 27 % throughout the exposure period at baseline. A ratio over 100 % was observed for four sheep on the sixth exposure day (102 - 269 %). A minor increase was seen in the median fetal/maternal-ratios during maternal hypoxia. Norbuprenorphine was undetected in all plasma samples.

CONCLUSIONS

The low transplacental passage of less than one fourth of the ewe's exposure supports buprenorphine as an alternative to methadone in opioid maintenance therapy during pregnancy.

Sublingual buprenorphine-naloxone precipitated withdrawal-A case report with review of literature and clinical considerations

Buprenorphine- Naloxone Fixed Dose Combination (BNX) is widely used to manage opioid use disorders. Contrary to evidence based concepts about sublingual bio-availability of naloxone, a few small studies have reported non-negligible amounts absorbed sublingually. But the extent to which these amounts exert opioid antagonist effects is yet to be established. We hereby report the first case of opioid dependence who developed a rare phenomenon of moderate to severe opioid withdrawal symptoms on administration of sublingual BNX after several days of being stabilized on plain buprenorphine (BUP). The case demonstrates the need to consider using buprenorphine monotherapy whenever such adverse effects are encountered. We also discuss the possible pharmacological explanations behind this rare side effect.

Kann die Symptombelastung einen regulären oder irregulären Behandlungsabschluss bei Substanzkonsumstörungen vorhersagen?

Ziel der Studie Das Ziel der vorliegenden explorativen Studie war zu untersuchen, ob die subjektive Symptombelastung vor und während der Behandlung von PatientInnen mit einer Substanzkonsumstörung einen Einfluss darauf hat, ob die Behandlung regulär (d. h. in gegenseitigem Einverständnis zwischen Therapeut und Patient) oder irregulär (d. h. Therapeut oder Patient bricht ab) beendet wird.

Methodik In der vorliegenden, retrospektiven Untersuchung wurden 54 PatientInnen einer Drogenentzugs- und Entwöhnungsstation untersucht. Die Informationen zur Art des Behandlungsabschlusses wurden der Basisdokumentation und zur Symptombelastung der Brief-Symptom-Checkliste (BSCL) entnommen.

Ergebnisse Die Ergebnisse der binären logistischen Regressionsanalysen zeigten, dass eine allgemeine Reduktion der Symptombelastung während der Behandlung mit einem regulären statt einem irregulären Behandlungsabschluss einherging. Die Analysen der Subskalen der BSCL ergaben signifikante Effekte für eine Abnahme der Ängstlichkeit und des Paranoiden Denkens während der Therapie zugunsten eines regulären Behandlungsabschlusses. Des Weiteren sagten hohe Werte der Zwanghaftigkeit zu Behandlungsbeginn einen regulären Behandlungsabschluss vorher.

Schlussfolgerung Bei der Behandlung von PatientInnen mit Substanzkonsumstörungen erscheint es sinnvoll, die allgemeine subjektive Symptombelastung während der Behandlung zu erfragen, um Therapieabbrüche zu vermeiden. Insbesondere sollten die Ängstlichkeit und das Paranoide Denken in den Fokus der Behandlung rücken, da diese in der vorliegenden Studie einen regulären Behandlungsabschluss vorhersagten.