Prior buprenorphine experience is associated with office-based buprenorphine treatment outcomes

96-week retention in treatment with extended-release subcutaneous buprenorphine depot injections among people with opioid dependence: Extended follow-up after a single-arm trial

BACKGROUND

The most recent formulation of buprenorphine treatment is extended-release depot injections (BUP-XR) that are administered subcutaneously by health care professionals. This study aimed to observe treatment outcomes of BUP-XR delivered in standard practice during a 96-week follow-up period in a community setting.

METHODS

This study is an extension of the CoLAB study, a prospective single-arm, multicentre, open label trial (N=100, 7 sites in Australia) among people with opioid dependence who received monthly injections of BUP-XR to evaluate the retention in treatment. Participants were followed for 96 weeks, comprising 48 weeks of the CoLAB study followed by a 48-week extension.

RESULTS

Of 100 participants at baseline, 47 were retained on BUP-XR at 96 weeks. The median time retained on monthly depot was 90 weeks. Heroin use (adjusted OR=0.19, P=0.012) in the month prior to baseline was associated with lower odds of retention on BUP-XR. Older age at first opioid use (adjusted OR= 1.08, P=0.009) and longer duration in OAT at baseline (adjusted OR= 1.12, P=0.001) were associated with increased retention. Prevalence of past four-weeks opioid use was estimated at 4% at 96 weeks of treatment (prevalence 0.04, 95%CI: 0.00-0.11) compared to 15% at baseline. Quality of life and medication treatment satisfaction improved over time for those retained in treatment.

CONCLUSION

This is one of the few studies to describe long term (96 week) retention in treatment with BUP-XR in a community setting. It displayed retention rates with 47% of participants completing 96 weeks of treatment with BUP-XR. Patient reported outcomes suggest improvements in client wellbeing.

FUNDING

Indivior.

Low-dose buprenorphine initiation and treatment continuation among hospitalized patients with opioid dependence: A retrospective cohort study

BACKGROUND

Buprenorphine is an effective treatment for both opioid use disorder (OUD) and chronic pain, but buprenorphine's pharmacology complicates treatment initiation for some patients. Low-dose buprenorphine initiation is a novel strategy that may reduce precipitated withdrawal. Few studies describe what patient populations benefit most from low-dose initiations and the clinical parameters that impact treatment continuation. This study aimed to 1) describe experiences with low-dose buprenorphine initiation, including both successes and failures among hospitalized patients in an urban underserved community; 2) identify patient- and treatment-related characteristics associated with unsuccessful initiation and treatment discontinuation; and 3) assess buprenorphine treatment continuation after discharge.

METHODS

This is a retrospective cohort study with opioid-dependent (meaning OUD or receiving long-term opioid therapy for chronic pain) patients who underwent low-dose buprenorphine initiation during hospital admission from October 2021 through April 2022. The primary outcome was successful completion of low-dose initiation. Bivariate analysis identified patient- and treatment-related factors associated with unsuccessful initiation. Secondary outcomes were buprenorphine treatment discontinuation at post-discharge follow-up, 30- and 90-days.

RESULTS

Of 28 patients who underwent low-dose buprenorphine initiation, 68 % successfully completed initiation. Unsuccessful initiation was associated with receipt of methadone during admission and higher morphine milligram equivalents (MME) of supplemental opioids. Of 22 patients with OUD, the percent receiving a buprenorphine prescription at a follow-up visit, 30 days, and 90 days, respectively, was 46 %, 36 %, and 36 %. Of 6 patients with chronic pain, the percent receiving a buprenorphine prescription at a follow-up visit, 30 days, and 90 days, respectively, was 100 %, 100 %, and 83 %.

CONCLUSION

Low-dose buprenorphine initiation can be successful in opioid-dependent hospitalized patients. Patients taking methadone or requiring higher MME of supplemental opioids may have more difficulty with the low-dose buprenorphine initiation approach, but these findings should be replicated in larger studies. This study suggests patient- and treatment-related factors that clinicians could consider when determining the optimal treatment strategy for patients wishing to transition to buprenorphine.

Trajectories of non-prescribed buprenorphine and other opioid use: A multi-trajectory latent class growth analysis

INTRODUCTION

With the increasing use of non-prescribed buprenorphine (NPB), we need more data to identify the longitudinal patterns of NPB use. The goal of this natural history study is to characterize heterogeneity in trajectories of NPB, other opioid use, and participation in medication for opioid disorder (MOUD) treatment among a community-recruited sample of individuals with current opioid use disorder (OUD).

METHODS

The study recruited a community-based sample of 357 individuals with OUD who used NPB in the past 6 months in Ohio, United States, for baseline and follow-up assessments (every 6 months for 2 years) of drug use, treatment participation, and other health and psychosocial characteristics. The study used multiple imputation to handle missing data. We used a multi-trajectory latent class growth analysis (MT-LCGA) to find salient groupings of participants based on the trajectories of NPB, other opioid use, and treatment participation.

RESULTS

Over time, NPB use frequency declined from a mean of 14.6 % of days at baseline to 3.6 % of days at 24-month follow-up along with declines in heroin/fentanyl (56.4 % to 23.6 % of days) and non-prescribed pharmaceutical opioid (NPPO) use (11.6 % to 1.5 % of days). Participation in MOUD treatment increased from a mean of 17.0 % of days at baseline to 52.4 % of days at 24 months. MT-LCGA identified a 6-class model. All six classes showed declines in NPB use. Class 1 (28 %) was characterized by high and increasing MOUD treatment utilization. Class 2 (21 %) showed sustained high levels of heroin/fentanyl use and had the lowest levels of NPB use (2.2 % of days) at baseline. Class 3 (3 %) was characterized as the primary NPPO use group. Class 4 (5 %) transitioned from high levels of NPB use to increased MOUD treatment utilization. It had the highest levels of NPB use at baseline (average of 80.7 % of days) that decreased to an average of 12.9 % of days at 24 months. Class 5 (16 %) showed transition from high levels of heroin/fentanyl use to increased MOUD treatment utilization. Class 6 (27 %) showed decreased heroin/fentanyl use over time and low MOUD treatment utilization. Classes showed varying levels of improvement in psychosocial functioning, polydrug use, and overdose risks.

CONCLUSION

Overall, our findings suggest that NPB use was generally self-limiting with individuals reducing their use over time as some engage in greater utilization of MOUD treatment. A need exists for continuing improvements in MOUD treatment access and retention.

Higher buprenorphine dose associated with increased treatment retention at low threshold buprenorphine clinic: A retrospective cohort study

INTRODUCTION

Controversy exists regarding effective sublingual buprenorphine dosing for treatment of opioid use disorder (OUD), leading to dose caps of 16 mg per day. The Project Connections at Re-Entry (PCARE) program is a low-threshold buprenorphine clinic that provides medication for OUD to vulnerable populations in Baltimore City.

OBJECTIVES

To compare retention in care based on treatment dose of buprenorphine, and to examine associated population characteristics.

METHODS

This analysis includes clinical patients who received buprenorphine treatment at PCARE between January and July 2021. The study categorized patients into two dosing groups (16 mg or >16 mg). We conducted chi-square tests of independence for categorical variables and independent sample t-tests for continuous variables to evaluate any significant differences in demographic and clinical characteristics by dosing category. To examine differences in 30- and 90-day retention, we conducted multivariable logistic regression analyses with the outcome variable defined as successful retention (at 30 and 90 days, respectively) controlling for demographic and clinical characteristics.

RESULTS

In the study period, 566 patients received buprenorphine treatment at the PCARE van. Patients were primarily male (70.9 %), Black (89.4 %), had a mean age of 46.3 years (SD = 11.5), and a mean opioid use of 22.1 years (SD = 13.5). The majority had previous criminal justice involvement (73.9 %), Medicaid insurance coverage (75.4 %), and were unemployed (69.6 %). Nearly half of the sample had reported a previous overdose event (48.4 %). The study found no significant demographic differences between patients receiving 16 mg of buprenorphine per day compared to patients receiving >16 mg. Patients receiving >16 mg had significantly higher rates of treatment retention at 30 and 90 days: 95.4 % vs 86.7 % (p = 0.001), and 82.7 % vs. 67.6 % (p < 0.001) than those receiving 16 mg, respectively. In a multivariable logistic regression controlling for demographic and drug use characteristics, odds of 30-day (Adjusted Odds Ratio [AOR] = 3.98, 95 % Confidence Interval [CI] = 1.92, 8.74, p < 0.001) and 90-day retention (AOR = 2.56, 95 % CI = 1.55, 4.22, p < 0.001) were greater among patients receiving >16 mg daily compared to 16 mg.

CONCLUSIONS

In this study examining patients with OUD in a low-threshold buprenorphine clinic, we observed higher rates of treatment retention with buprenorphine doses >16 mg.

Scope of, Motivations for, and Outcomes Associated with Buprenorphine Diversion in the United States: A Scoping Review

BACKGROUND

Expanding access to medications to treat opioid use disorder (OUD), such as buprenorphine, is an evidence-based response to the mounting drug overdose crisis. However, concerns about buprenorphine diversion persist and contribute to limited access.

METHODS

To inform decisions about expanding access, a scoping review was conducted on publications describing the scope of, motivations for, and outcomes associated with diverted buprenorphine in the U.S.

RESULTS

In the 57 included studies, definitions for diversion were inconsistent. Most studied use of illicitly-obtained buprenorphine. Across studies, the scope of buprenorphine diversion ranged from 0% to 100%, varying by sample type and recall period. Among samples of people receiving buprenorphine for OUD treatment, diversion peaked at 4.8%. Motivations for using diverted buprenorphine were self-treatment, management of drug use, to get high, and when drug of choice was unavailable. Associated outcomes examined trended toward positive or neutral, including improved attitudes toward and retention in MOUD.

CONCLUSIONS

Despite inconsistent definitions of diversion, studies reported a low scope of diversion among people receiving MOUD, with inability to access treatment as a motivating factor for using diverted buprenorphine, and increased retention in MOUD as an outcome associated with use of diverted buprenorphine. Future research should explore reasons for diverted buprenorphine use in the context of expanded treatment availability to address persistent barriers to evidence-based treatment for OUD.

Precipitated opioid withdrawal after buprenorphine administration in patients presenting to the emergency department: A case series

Objectives

Buprenorphine is a highly effective medication for the treatment of opioid use disorder, but it can cause precipitated withdrawal (PW) from opioids. Incidence, risk factors, and best approaches to management of PW are not well understood. Our objective was to describe adverse outcomes after buprenorphine administration among emergency department (ED) patients and assess whether they met the criteria for PW.

Methods

This study is a case series using retrospective chart review in a convenience sample of patients from 3 hospitals in an urban academic health system. This study included patients who were reported by clinicians as potential cases of PW. Relevant clinical data were abstracted from the electronic health record using a structured retrospective chart review instrument.

Results

A total of 13 cases were included and classified into the following 3 categories: (1) PW after buprenorphine administration consistent with guidelines (n = 5), (2) PW after deviating from guidelines (n = 4), and (3) protracted opioid withdrawal with no increase in Clinical Opiate Withdrawal Scale score (n = 4). A total of 11 patients had urine drug testing positive for fentanyl, and 11 patients received additional doses of buprenorphine for symptom management. Of the patients, 5 had self-directed hospital discharges, and 6 were ultimately discharged with prescriptions for buprenorphine.

Conclusions

Cases of adverse outcomes after buprenorphine administration in the ED and hospital meet criteria for PW, although some cases may have represented protracted opioid withdrawal. Further investigation into the incidence, risk factors, management of PW as well as patient perspectives is needed to expand and sustain the use of buprenorphine in EDs and hospitals.

Assessing Motivations for Nonprescribed Buprenorphine Use Among Rural Appalachian Substance Users

OBJECTIVE

Buprenorphine (Suboxone) is an effective treatment for opioid use disorder (OUD). However, there have been widespread reports of diversion and misuse. This study examined motivations for nonprescribed buprenorphine use among rural residents.

METHODS

Eligible participants (N = 200) were at least 18 years old, had used any illegal or prescription drugs to get high, and had ever used nonprescribed buprenorphine. A questionnaire administered by a trained interviewer assessed demographic characteristics, substance use, and motivations for use.

RESULTS

Primary motivations for first nonprescribed buprenorphine use included avoiding withdrawal and getting high, while at most recent nonprescribed use, motivations shifted toward maintaining abstinence from other drugs. In adjusted logistic regression analyses, past month use of stimulants decreased odds of nonprescribed buprenorphine use for the purposes of self-treatment by 68% (adjusted odds ratio, 0.26; 95% confidence interval, 0.11-0.61), whereas history of treatment for OUD more than doubled odds of use for self-treatment (adjusted odds ratio, 2.71; 95% confidence interval, 1.11-6.63).

CONCLUSIONS

Results indicate that many individuals used buprenorphine without a prescription, motivated largely by behaviors consistent with self-treatment, and diversion of buprenorphine may be driven by these motivations more than desire to get high. While many participants attempted to access treatment, many were still using nonprescribed buprenorphine for self-treatment, and many were dissatisfied with care they had received as part of a treatment program. Thus, increasing quantity of providers may not be adequate to address the opioid epidemic, but particular attention should be paid to providing care targeted to the needs of those with OUD in rural areas.

Low barrier medication for opioid use disorder at a federally qualified health center: a retrospective cohort study

Background

Medication for opioid use disorder (MOUD) reduces mortality, but few patients access MOUD. At a Federally Qualified Health Center (FQHC), we implemented a low barrier model of MOUD, including same-day MOUD initiation and a harm reduction philosophy.

Objective

To investigate whether low barrier MOUD improved retention in care compared to traditional treatment.

Design and participants

Retrospective cohort study of patients with at least one visit seeking MOUD at the FQHC during a historical control period (3/1/2018—3/31/2019) and a low barrier intervention period (11/1/2019—7/31/2020).

Main measures

Primary outcomes were any MOUD prescription within 6 months of the index visit and 3- and 6-month retention in treatment without care gap, with care gap defined as 60 consecutive days without a visit or prescription. Secondary outcomes were all-cause hospitalization and emergency department visit within 6 months of the index visit.

Key results

Baseline characteristics were similar between the intervention (n = 113) and control (n = 90) groups, except the intervention group had higher rates of uninsured, public insurance and diabetes. Any MOUD prescription within 6 months of index visit was higher in the intervention group (97.3% vs 70%), with higher adjusted odds of MOUD prescription (OR = 4.01, 95% CI 2.08–7.71). Retention in care was similar between groups at 3 months (61.9% vs 60%, aOR = 1.06, 95% CI 0.78–1.44). At 6 months, a higher proportion of the intervention group was retained in care, but the difference was not statistically significant (53.1% vs 45.6%, aOR 1.27, 95% CI 0.93–1.73). There was no significant difference in adjusted odds of 6-month hospitalization or ED visit between groups.

Conclusions

Low barrier MOUD engaged a higher risk population and did not result in any statistically significant difference in retention in care compared with a historical control. Future research should determine what interventions improve retention of patients engaged through low barrier care. Primary care clinics can implement low barrier treatment to make MOUD accessible to a broader population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13722-022-00342-1.

Non-prescribed buprenorphine preceding treatment intake and clinical outcomes for opioid use disorder

OBJECTIVE

Successful retention on buprenorphine improves outcomes for opioid use disorder (OUD); however, we know little about associations between use of non-prescribed buprenorphine (NPB) preceding treatment intake and clinical outcomes.

METHODS

The study conducted observational retrospective analysis of abstracted electronic health record (EHR) data from a multi-state nationwide office-based opioid treatment program. The study observed a random sample of 1000 newly admitted patients with OUD for buprenorphine maintenance (2015-2018) for up to 12 months following intake. We measured use of NPB by mandatory intake drug testing and manual EHR coding. Outcomes included hazards of treatment discontinuation and rates of opioid use.

RESULTS

Compared to patients testing negative for buprenorphine at intake, those testing positive (59.6%) had lower hazards of treatment discontinuation (HR = 0.52, 95% CI: 0.44, 0.60, p < 0.01). Results were little changed following adjustment for baseline opioid use and other patient characteristics (aHR: 0.60, 95% CI: 0.51, 0.70, p < 0.01). Risk of discontinuation did not significantly differ between patients by buprenorphine source: prescribed v. NPB (reference) at admission (HR = 1.15, 95% CI: 0.90, 1.46). Opioid use was lower in the buprenorphine positive group at admission (25.0% vs. 53.1%, p < 0.0001) and throughout early months of treatment but converged after 7 months for those remaining in care (17.1% vs. 16.5%, p = 0.89).

CONCLUSION

NPB preceding treatment intake was associated with decreased hazards of treatment discontinuation and lower opioid use. These findings suggest use of NPB may be a marker of treatment readiness and that buprenorphine testing at intake may have predictive value for clinical assessments regarding risk of early treatment discontinuation.

Safety of induction at standard doses of buprenorphine for inpatients with opioid use disorder

Patients with opioid use disorder (OUD) are commonly admitted to various inpatient services where treatment can be started. The typical initiation of buprenorphine involves delay of treatment until withdrawal symptoms occur, however, those symptoms may interfere with other medical therapy. The purpose of this study was to evaluate the safety and efficacy of initiation of buprenorphine for inpatients with OUD.

We reviewed the charts of 99 patients for whom the inpatient addiction medicine consult service was contacted over a 15-month period from January 2020 to identify those patients started on buprenorphine. We abstracted data on toxicology results, prior use of buprenorphine, and Clinical Opioid Withdrawal Scale (COWS) and pain scores before and after the administration of buprenorphine.

There was no significant difference in COWS classification post treatment based on ancillary or non use of full agonist therapy. There was no significant change in COWS scores based on prior buprenorphine or methadone use. 5% of patients developed moderate withdrawal (COWS score 12-24) after the initiation of buprenorphine. Twenty of the study patients (20%) developed a 2-point increase in pain scores after the initiation of buprenorphine.

SUMMARY

The initiation of buprenorphine for inpatients rarely results in a significant increase in withdrawal symptoms. A larger percent of patients may have an increase in pain scores which would need to be managed. Further prospective work on this subject is warranted.

Descriptive Analysis of Inpatient and Outpatient Cohorts Seeking Treatment After Prescription Opioid Misuse and Medical Toxicology Evaluation

INTRODUCTION

Medical toxicology expertise has expanded into the addiction medicine realm including outpatient medication for opioid use disorder (MOUD) and addiction treatment. Concomitantly, the emergency department (ED) and hospital are increasingly seen as important sites for the screening, prevention, and treatment of patients with substance use disorders and addiction. This analysis seeks to characterize patients seen by medical toxicologists for opioid use and opioid use disorder (OUD) in the ED and inpatient consultation setting (inpatient) versus in the OUD clinic (outpatient) setting.

METHODS

We searched the American College of Medical Toxicology's Toxicology Investigators Consortium Case Registry, a prospective, de-identified, national dataset that includes patients receiving medical toxicology consultation following prescription opioid misuse. The dataset also includes patients seen in outpatient MOUD clinics during the same period between June 2013 and November 2015. Intentional self-harm patients were excluded. We analyzed medical history, drug use patterns, and other factors with odds ratios and confidence intervals.

RESULTS

Of 110 patients identified, 60 (54.5%) were inpatients and 50 (45.5%) outpatients. Mean age (39 years), gender (68% male), and race breakdown (60% white/non-Hispanic) were similar. The outpatient group was more likely to have Medicare/Medicaid coverage (p<0.0001). By history, the outpatient group was more likely to have past alcohol misuse, intravenous drug use, prescription drug misuse, and prescription opioid misuse. Most inpatient group members sought a recreational high compared to avoiding withdrawal or treating dependence in the outpatient group.

CONCLUSION

Patients treated in the outpatient compared to inpatient setting were more likely to report adverse sequelae from their drug use including long-term drug use, depression, previous rehabilitation attempts, and seeking to avoid withdrawal.

"It's Crazy What Meth Can Help You Do": Lay Beliefs, Practices, and Experiences of Using Methamphetamine to Self-Treat Symptoms of Opioid Withdrawal

BACKGROUND

Across the U.S., methamphetamine use is expanding among people who use illicit opioids (PWUIO). Motives for methamphetamine use must be contextualized within the experiences of PWUIO, who may use methamphetamine not only to achieve euphoria, but also as a tactic of self-management. The overall aim of this study is to contextualize lay beliefs, practices, and experiences of methamphetamine use as a form of self-treatment of symptoms related to chronic opioid use among PWUIO in the Dayton Metro Area of Southwest Ohio, an epicenter of the ongoing opioid crisis.

METHODS

This paper draws on two phases of interviews conducted with 38 individuals who use both heroin/fentanyl and methamphetamine. This paper primarily analyzes qualitative data but includes supplementary information from the structured interview component. Qualitative interview sections were transcribed in their entirety and thematically analyzed.

RESULTS

Participants described learning about methamphetamine as a tactic to treat opioid withdrawal symptoms through social networks and through personal experimentation. Many participants suggested that methamphetamine was helpful in relieving exhaustion, alleviating some acute physical symptoms of opioid withdrawal, and providing a psychological distraction, although some admitted that methamphetamine use could incur additional health risks. To effectively use methamphetamine as a tactic of self-treatment, participants emphasized the importance of timing and dosing.

DISCUSSION

Among PWUIO in the Dayton area, methamphetamine use as a tactic to self-manage opioid withdrawal must be studied in relation to historical and evolving patterns of illicit opioid use and associated risks. More research is needed to understand the long-term health impacts of this emergent practice of polydrug use.

"The Doctor Says You Cannot Have [Buprenorphine]" Autonomy and Use of Prescribed or Non-Prescribed Buprenorphine

BACKGROUND

People may overcome barriers to professional buprenorphine treatment by using non-prescribed buprenorphine (NPB) to manage opioid use disorder (OUD). Little is known about how people perceive NPB differently than formal treatment. This qualitative study investigated how and why people use NPB as an alternative to formal treatment.

METHODS

In-depth, semi-structured interviews were conducted with participants of harm reduction agencies (N = 22) who had used buprenorphine. Investigators independently coded transcribed interviews, generating themes through iterative reading and analysis of transcripts.

RESULTS

Three main factors drove decisions about prescribed and non-prescribed buprenorphine use: 1) autonomy; 2) treatment goals; and 3) negative early experiences with NPB. An overarching theme from our analysis was that participants valued autonomy in seeking to control their substance use. NPB was a valuable tool toward this goal and professional OUD treatment could impede autonomy. Participants mostly used NPB to "self-manage" OUD symptoms. Many participants had concerns about long-term buprenorphine treatment and instead used NPB over short periods of time. Several participants also reported negative experiences with NPB, including symptoms of withdrawal, which then deterred them from seeking out professional treatment.

CONCLUSIONS

These results support prior studies showing that people use NPB to self-manage withdrawal symptoms and to reduce use of illicit opioids. Despite these benefits, participants focused on short-term goals and negative consequences were common. Increasing buprenorphine treatment engagement may require attention to patients' sense of autonomy, and also assurance that long-term treatment is safe, effective, and reliably accessible.

Impact of Fentanyl Use on Buprenorphine Treatment Retention and Opioid Abstinence

OBJECTIVES

There has been a rapid increase in the presence of illicitly manufactured fentanyl in the heroin drug supply. Buprenorphine is an effective treatment for heroin and prescription opioid use disorder; however, little is known about treatment outcomes among people using fentanyl. We compared 6-month treatment retention and opioid abstinence among people initiating buprenorphine treatment who had toxicology positive for heroin compared to fentanyl at baseline.

METHODS

Retrospective cohort study of 251 adult patients initiating office-based buprenorphine treatment who had available toxicology testing across an academic health system between August 2016 and July 2017. Exposure was assessed at baseline before initiating buprenorphine and was categorized as negative toxicology (n = 184) versus fentanyl positive toxicology (n = 48) versus heroin positive toxicology (n = 19).

RESULTS

Six-month treatment retention rates were not different between the fentanyl positive and heroin positive groups [38% (n = 18) vs 47% (n = 9); P = 0.58], or between the fentanyl positive and the negative toxicology group [38% (n = 18) vs 51% (n = 93); P = 0.14]. Opioid abstinence at 6 months among those who had testing did not differ between the fentanyl positive and the heroin positive group [55% (n = 6) vs 60% (n = 6); P = 0.99]. The fentanyl positive group had a lower abstinence rate at 6 months compared to those with negative toxicology at baseline [55% (n = 6) vs 93% (n = 63); P = 0.004]. Mean initial buprenophine dosage did not differ between groups.

CONCLUSIONS

Buprenorphine treatment retention and abstinence among those retained in treatment is not worse between people using fentanyl compared to heroin at treatment initiation. Both groups have lower abstinence rates at 6 months compared to individuals with negative toxicology at baseline. These findings suggest that people exposed to fentanyl still benefit from buprenorphine treatment.

Retention of patients in opioid substitution treatment: A systematic review

Background

Retention in opioid substitution (OST) treatment is associated with substantial reductions in all cause and overdose mortality. This systematic review aims to identify both protective factors supporting retention in OST, and risk factors for treatment dropout.

Methods

A systematic search was performed using MEDLINE, Embase, PsycInfo, CINAHL and Web of Science (January 2001 to October 2019). Randomised controlled trials (RCTs) and observational cohort studies reporting on retention rates and factors associated with retention in OST were included. Factors associated with treatment retention and dropout were explored according to the Maudsley Addiction Profile. A narrative synthesis is provided.

Results

67 studies were included in this review (4 RCTs and 63 observational cohort studies; N = 294,592), all assessing factors associated with retention in OST or treatment dropout. The median retention rate across observational studies was approximately 57% at 12 months, which fell to 38.4% at three years. Studies included were heterogeneous in nature with respect to treatment setting, type of OST, risk factor assessment, ascertainment of outcome and duration of follow-up. While the presence of such methodological heterogeneity makes it difficult to synthesise results, there is limited evidence to support the influence of a number of factors on retention, including age, substance use, OST drug dose, legal issues, and attitudes to OST.

Conclusions

Younger age, substance use particularly cocaine and heroin use, lower doses of methadone, criminal activity/incarceration, and negative attitudes to MMT appear to be associated with reduced retention in OST. A consensus definition of retention is required to allow for comparability across future studies.

"Everything is not right anymore": Buprenorphine experiences in an era of illicit fentanyl

BACKGROUND

Conducted in the Dayton Metropolitan area of Southwestern Ohio, this qualitative study explores the self-treatment practices of people who use illicit opioids (PWUIO) amidst the new risk environment produced by illicit, non-pharmaceutical fentanyl (NPF). We explore local perceptions of the presence of NPF in the Dayton area, and how this has both positively and negatively impacted practices of non-prescribed buprenorphine use among PWUIO.

METHODS

This study analyzes qualitative data from 63 interviews conducted between October 2018 and June 2019. Participants were selected from a larger longitudinal study on non-prescribed buprenorphine use among individuals with opioid use disorder. Qualitative interviews were transcribed in their entirety, and their transcriptions were analyzed using NVivo software, drawing on a mix of thematic and inductive coding.

RESULTS

Interview respondents ranged from 19 to 70 years old, with a mean age of 38.9 years. 54% of them were male, and 85.7% identified as non-Hispanic White. 98.4% of the sample had used heroin, and 93.7% of the sample reported use of NPF. Participants agreed NPF dominated the illicit opioids market in the area, and was perceived as both dangerous and desirable. The domination of NPF and associated overdose experiences prompted some to seek positive change and initiate self-treatment with non-prescribed buprenorphine. For others, NPF sabotaged established practices of harm reduction, as unanticipated experiences of precipitated withdrawals prompted some participants to give up non-prescribed buprenorphine use as a tactic of self-treatment.

DISCUSSION

The changing nature of heroin/NPF necessarily gives rise to new beliefs surrounding self-treatment attempts, treatment seeking behaviors, and harm reduction practices. While buprenorphine treatment continues to offer promising results for treating opioid use disorders, it is urgent to reconsider how the unpredictable biochemical mixture of NPFs circulating on the streets today may impact the initiation and success of treatment.

Patterns of non-prescribed buprenorphine and other opioid use among individuals with opioid use disorder: A latent class analysis

AIM

Non-prescribed buprenorphine (NPB) use increased in the US. This study aims to characterize heterogeneity in patterns of NPB and other opioid use among individuals with current opioid use disorder.

METHODS

The study recruited 356 participants in Dayton (Montgomery County), Ohio, area in 2017-2018 using targeted and Respondent Driven Sampling. Participants met the following criteria: 1) 18 years or older, 2) current moderate/severe opioid use disorder (DSM-5), 3) past 6-month NPB use. Latent class analysis (LCA) was conducted to identify subgroups based on past 6-month (days of NPB and heroin/fentanyl use; use of NPB to get high; use of non-prescribed and prescribed pharmaceutical opioids; participation in formal treatment) and lifetime (years since first NPB and other illicit opioid use) characteristics. Selected auxiliary variables were compared across classes using Asparouhov and Muthén's 3-step approach.

RESULTS

49.7% were female, and 88.8% were non-Hispanic whites. 89% used NPB to self-treat withdrawal. LCA resulted in three classes: "Heavy Heroin/Fentanyl Use" (61%), "More Formal Treatment Use" (29%) and "Intense NPB Use" (10%). After adjusting for multiple testing, the following past 6-month variables differed significantly between classes: injection as a primary route of heroin/fentanyl administration (p < 0.001), cocaine use (p = 0.044), unintentional drug overdose (p = 0.023), and homelessness (p = 0.044), with the "Intense NPB Use" class having the lowest prevalences.

CONCLUSION

Predominance of self-treatment goals and the association between more intense NPB use and lower risks of adverse consequences suggest potential harm minimization benefits of NPB use. More research is needed to understand consequences of NPB use over time.

Engaging an unstably housed population with low-barrier buprenorphine treatment at a syringe services program: Lessons learned from Seattle, Washington

Background: Clinic-imposed barriers can impede access to medication for opioid use disorder (MOUD). We evaluated a low-barrier buprenorphine program that is co-located with a syringe services program (SSP) in Seattle, Washington, USA. Methods: We analyzed medical record data corresponding to patients who enrolled into the buprenorphine program in its first year of operation. We used descriptive statistics and tests of association to longitudinally evaluate retention, cumulative number of days buprenorphine was prescribed, and toxicology results. Results: Demand for buprenorphine among SSP clients initially surpassed programmatic capacity. Of the 146 enrolled patients, the majority (82%) were unstably housed. Patients were prescribed buprenorphine for a median of 47 days (interquartile range [IQR] = 8-147) in the 180 days following enrollment. Between the first and sixth visits, the percentage of toxicology tests that was positive for buprenorphine significantly increased (33% to 96%, P < .0001) and other opioids significantly decreased (90% to 41%, P < .0001) and plateaued thereafter. Toxicology test results for stimulants, benzodiazepines, and barbiturates did not significantly change. Conclusions: SSP served as an effective point of entry for a low-barrier MOUD program. A large proportion of enrolled patients demonstrated sustained retention and reductions in opioid use, despite housing instability and polysubstance use.

Implementation and evaluation of Missouri's Medication First treatment approach for opioid use disorder in publicly-funded substance use treatment programs

BACKGROUND

Leaders of Missouri's State Targeted Response to the opioid crisis (STR) grant have prioritized increasing access to treatment medications for opioid use disorder (MOUD) through a "Medication First" approach. This conceptual framework prioritizes rapid, sustained, low-barrier access to MOUD for optimal impact on decreased illicit drug use and mortality. Medication First principles and practices were facilitated through state-level structural changes and disseminated to participating community treatment programs via a multi-pronged, multi-disciplinary approach. In the first nine months of STR, 14 state-contracted treatment agencies operating 38 sites used STR funding to implement the Medication First model.

METHODS

We utilized state billing and service data to make comparisons before and during STR on the following outcomes: MOUD utilization, timely access to MOUD, amount of psychosocial services delivered, treatment retention at 1, 3, and 6 months, and monthly price of treatment. We conducted follow-up analyses examining differences across MOUD types (no medication, methadone, buprenorphine, oral naltrexone, mixed antagonist + agonist, and extended release naltrexone).

RESULTS

During STR, MOUD utilization increased (44.8% to 85.3%), timeliness of MOUD receipt improved (Median of 8 days vs. 0 days), there were fewer psychosocial services delivered, treatment retention improved at one, three, and six month timeframes, and the median cost per month was 21% lower than in the year prior to STR. All differences were driven by increased utilization of buprenorphine.

CONCLUSIONS

Findings suggest Medication First implementation through STR was successful in all targeted domains. Though much more work is needed to further reduce logistical, financial, and cultural barriers to improved access to maintenance MOUD, the steps taken through Missouri's STR grant show significant promise at making swift and drastic transformations to a system of care in response to a growing public health emergency.

Demystifying buprenorphine misuse: Has fear of diversion gotten in the way of addressing the opioid crisis?

Buprenorphine is considered one of the most effective treatments for opioid use disorder and significantly reduces risk of overdose death. However, concerns about its diversion and misuse have often taken center stage in public discourse and in the design of practices and policies regarding its use. This has been to the detriment of many vulnerable patient populations, especially those involved in the criminal justice system. Policies that restrict access to buprenorphine in criminal justice and other settings due to concerns of diversion do not accurately reflect the relative risks and safety profile associated with it, creating unnecessary barriers that drive an illicit market of this much-needed medication. Although proper regulation of all controlled medications should be a priority, in most instances the benefits of buprenorphine highly outweigh its risks. In the midst of a national crisis, efforts should be focused on expanding, and not restricting, access to this lifesaving treatment.

Readiness and recovery: Transferring between methadone and buprenorphine/naloxone for the treatment of opioid use disorder

Long-acting opioids are prescribed as part of treatment for opioid use disorders; methadone and buprenorphine are well researched and commonly prescribed for the treatment of opioid use disorder. Meta-analysis suggests that buprenorphine has a slightly poorer retention rate in treatment as compared to methadone. Benefits of buprenorphine/naloxone include greater ease in ceasing treatment and less use of illicit opioids while in treatment as compared to methadone. There are a number of qualitative and mixed-method studies that ask patients about their experiences of methadone maintenance and buprenorphine maintenance treatment. This research aimed to understand perspectives of receiving buprenorphine/naloxone for the treatment of opioid use disorder. A qualitative descriptive approach was used. Seven participants with a current diagnosis of opioid use disorder treated with buprenorphine/naloxone were interviewed. Thematic analysis extracted four themes: drivers for opioid substitution treatment change; readiness for buprenorphine/naloxone substitution treatment; absence of effect from buprenorphine/naloxone; and an increased sense of citizenship on buprenorphine/naloxone. This study identified a number of factors influencing participants' decision-making in transferring between methadone and buprenorphine/naloxone for the treatment of their opioid use disorder. Methadone was preferred by those seeking sedation and wishing to continue using other opioids, and buprenorphine/naloxone was most effective for participants no longer wishing to experience sedation and seeing opioid abstinence as an end point in their recovery. Changing treatment expectations are important to consider when determining medication selection and highlight the importance of quality information when determining the most suitable medication for the treatment of opioid use disorder.

Buprenorphine treatment formulations: Preferences among persons in opioid withdrawal management

BACKGROUND

In the current study, we examined factors predicting willingness to receive buprenorphine treatment and preferences for various buprenorphine formulations (oral, injection, implant) among persons in opioid withdrawal management.

METHODS

Participants were three hundred thirty-eight persons entering brief inpatient opioid withdrawal management programs at two sites. We used t-tests and Pearson χ2 - tests of independence to compare participants willing and unwilling to be prescribed buprenorphine in the future. Among persons willing to receive buprenorphine, we used multinomial logistic regression to estimate the adjusted effects of potential correlates of type of buprenorphine formulation preferred.

RESULTS

Participants averaged 33.9 (±9.5) years of age, 70.4% were male, 82.8% were White, and 11.0% were Latino/a. In all, 55.6% of participants had been prescribed buprenorphine in the past, and 54.7% were willing to use prescribed buprenorphine in the future. Those reporting past month illicit buprenorphine use and prior overdose were more willing to use prescribed buprenorphine. Of these (n = 180), most preferred daily buprenorphine formulations (tablet or film) (48.6%) over a weekly or monthly injection (23.1%) or bi-annual implant (28.3%).

CONCLUSIONS

Past buprenorphine prescription does not predict future willingness to restart. Among those willing to use buprenorphine, newer formulations of buprenorphine appealed to more than half of the participants.

Very early disengagement and subsequent re-engagement in primary care Office Based Opioid Treatment (OBOT) with buprenorphine

INTRODUCTION

Patients with opioid use disorder often require multiple treatment attempts before achieving stable recovery. Rates of disengagement from buprenorphine are highest in the first month of treatment and termination of buprenorphine therapy results in return to use rates as high as 90%. To better characterize these at-risk patients, this study aims to describe: 1) the frequency and characteristics of patients with very early disengagement (≤1month) from Office Based Opioid Treatment (OBOT) with buprenorphine and 2) the frequency and characteristics of patients who re-engage in care at this same OBOT clinic within 2years, among the subset of very early disengagers.

METHODS

This is a retrospective cohort study of adult patients enrolled in a large urban OBOT program. Descriptive statistics were used to characterize the sample and the proportion of patients with very early (≤1month) disengagement and their re-engagement. Multivariable logistic regression models were used to identify patient characteristics associated with the outcomes of very early disengagement and re-engagement. Potential predictors included: sex, age, race/ethnicity, education, employment, opioid use history, prior substance use treatments, urine drug testing, and psychiatric diagnoses.

RESULTS

Overall, very early disengagement was unusual, with only 8.4% (104/1234) of patients disengaging within the first month. Among the subset of very early disengagers with 2years of follow-up, the proportion who re-engaged with this OBOT program in the subsequent 2years was 11.9% (10/84). Urine drug test positive for opiates within the first month (AOR: 2.01, 95% CI: 1.02-3.93) was associated with increased odds of very early disengagement. Transferring from another buprenorphine prescriber (AOR: 0.09, 95% CI: 0.01-0.70) was associated with decreased odds of very early disengagement. No characteristics were significantly associated with re-engagement.

CONCLUSIONS

Early disengagement is uncommon; however, continued opioid use appeared to be associated with higher odds of treatment disengagement and these patients may warrant additional support. Re-engagement was uncommon, suggesting the need for a more formal explicit system to encourage and facilitate re-engagement among patients who disengage.

Public sector low threshold office-based buprenorphine treatment: outcomes at year 7

Background

Buprenorphine maintenance for opioid dependence remains of limited availability among underserved populations, despite increases in US opioid misuse and overdose deaths. Low threshold primary care treatment models including the use of unobserved, “home,” buprenorphine induction may simplify initiation of care and improve access. Unobserved induction and long-term treatment outcomes have not been reported recently among large, naturalistic cohorts treated in low threshold safety net primary care settings.

Methods

This prospective clinical registry cohort design estimated rates of induction-related adverse events, treatment retention, and urine opioid results for opioid dependent adults offered buprenorphine maintenance in a New York City public hospital primary care office-based practice from 2006 to 2013. This clinic relied on typical ambulatory care individual provider-patient visits, prescribed unobserved induction exclusively, saw patients no more than weekly, and did not require additional psychosocial treatment. Unobserved induction consisted of an in-person screening and diagnostic visit followed by a 1-week buprenorphine written prescription, with pamphlet, and telephone support. Primary outcomes analyzed were rates of induction-related adverse events (AE), week 1 drop-out, and long-term treatment retention. Factors associated with treatment retention were examined using a Cox proportional hazard model among inductions and all patients. Secondary outcomes included overall clinic retention, buprenorphine dosages, and urine sample results.

Results

Of the 485 total patients in our registry, 306 were inducted, and 179 were transfers already on buprenorphine. Post-induction (n = 306), week 1 drop-out was 17%. Rates of any induction-related AE were 12%; serious adverse events, 0%; precipitated withdrawal, 3%; prolonged withdrawal, 4%. Treatment retention was a median 38 weeks (range 0–320) for inductions, compared to 110 (0–354) weeks for transfers and 57 for the entire clinic population. Older age, later years of first clinic visit (vs. 2006–2007), and baseline heroin abstinence were associated with increased treatment retention overall.

Conclusions

Unobserved “home” buprenorphine induction in a public sector primary care setting appeared a feasible and safe clinical practice. Post-induction treatment retention of a median 38 weeks was in line with previous naturalistic studies of real-world office-based opioid treatment. Low threshold treatment protocols, as compared to national guidelines, may compliment recently increased prescriber patient limits and expand access to buprenorphine among public sector opioid use disorder patients.

Psychoactive medications and disengagement from office based opioid treatment (obot) with buprenorphine

BACKGROUND

The prevalence of psychoactive medications (PAMs) use in patients enrolled in Office Based Opioid Treatment (OBOT) and its association with engagement in this care is largely unknown.

OBJECTIVE

To describe the use of PAMs, including those medications with emerging evidence of misuse ("emerging PAMs" - gabapentin, clonidine and promethazine) among patients on buprenorphine, and its association with disengagement from OBOT.

METHODS

This is a retrospective cohort study of adults on buprenorphine from January 2002 to February 2014. The association between use of PAMs and 6-month disengagement from OBOT was examined using multivariable logistic regression models. A secondary analysis exploring time-to-disengagement was conducted using Cox regression models.

RESULTS

At OBOT entry, 43% of patients (562/1308) were prescribed any PAM; including 17% (223/1308) on an emerging PAM. In separate adjusted analyses, neither the presence of any PAM (adjusted odds ratio [AOR] 1.07, 95% CI [0.78, 1.46]) nor an emerging PAM (AOR 1.28 [0.95, 1.74]) was significantly associated with 6-month disengagement. The results were similar for the Cox model (any PAM (adjusted hazard ratio [AHR] 1.16, 95% CI [1.00, 1.36]), emerging PAM (AHR 1.18 [0.98, 1.41])). Exploratory analyses suggested gabapentin (AHR 1.30 [1.05-1.62]) and clonidine (AHR 1.33 [1.01-1.73]) specifically, may be associated with an overall shorter time to disengagement.

CONCLUSIONS

Psychoactive medication use is common among patients in buprenorphine treatment. No significant association was found between the presence of any psychoactive medications, including medications with emerging evidence of misuse, and 6-month disengagement from buprenorphine treatment.

Long-term retention in Office Based Opioid Treatment with buprenorphine

BACKGROUND

Guidelines recommend long-term treatment for opioid use disorder with buprenorphine; however, little is known about patients in long-term treatment. The aim of this study is to examine the prevalence and patient characteristics of long-term treatment retention (≥1year) in an Office Based Opioid Treatment (OBOT) program with buprenorphine.

METHODS

This is a retrospective cohort study of adults on buprenorphine from January 2002 to February 2014 in a large urban safety-net primary care OBOT program. The primary outcome was retention in OBOT for at least one continuous year. Potential predictors included age, race, psychiatric diagnoses, hepatitis C, employment, prior buprenorphine, ever heroin use, current cocaine, benzodiazepine and alcohol use on enrollment. Factors associated with ≥1year OBOT retention were identified using generalized estimating equation logistic regression models. Patients who re-enrolled in the program contributed repeated observations.

RESULTS

There were 1605 OBOT treatment periods among 1237 patients in this study. Almost half, 45% (717/1605), of all treatment periods were ≥1year and a majority, 53.7% (664/1237), of patients had at least one ≥1year period. In adjusted analyses, female gender (Adjusted Odds Ratio [AOR] 1.55, 95% CI [1.20, 2.00]) psychiatric diagnosis (AOR 1.75 [1.35, 2.27]) and age (AOR 1.19 per 10year increase [1.05, 1.34]) were associated with greater odds of ≥1year retention. Unemployment (AOR 0.72 [0.56, 0.92]), Hepatitis C (AOR 0.59 [0.45, 0.76]), black race/ethnicity (AOR 0.53 [0.36, 0.78]) and Hispanic race/ethnicity (AOR 0.66 [0.48, 0.92]) were associated with lower odds of ≥1year retention.

CONCLUSIONS

Over half of patients who presented to Office Based Opioid Treatment with buprenorphine were ultimately successfully retained for ≥1year. However, significant disparities in one-year treatment retention were observed, including poorer retention for patients who were younger, black, Hispanic, unemployed, or with hepatitis C.

Prior Experience with Non-Prescribed Buprenorphine: Role in Treatment Entry and Retention

Buprenorphine availability continues to expand as an effective treatment for opioid dependence, but increases in availability have also been accompanied by increases in non-prescribed use of the medication. Utilizing data from a randomized clinical trial, this mixed-method study examines associations between use of non-prescribed buprenorphine and subsequent treatment entry and retention. Quantitative analyses (N = 300 African American buprenorphine patients) found that patients with prior use of non-prescribed buprenorphine had significantly higher odds of remaining in treatment through 6 months than patients who were naïve to the medication upon treatment entry. Qualitative data, collected from a subsample of participants (n = 20), identified three thematic explanations for this phenomenon: 1) perceived effectiveness of the medication; 2) cost of obtaining prescription buprenorphine compared to purchasing non-prescribed medication; and 3) convenience of obtaining the medication via daily-dosing or by prescription compared to non-prescribed buprenorphine. These findings suggest a dynamic relationship between non-prescribed buprenorphine use and treatment that indicates potential directions for future research into positive and negative consequences of buprenorphine diversion.

Illicit buprenorphine use, interest in and access to buprenorphine treatment among syringe exchange participants

Poor access to buprenorphine maintenance treatment (BMT) may contribute to illicit buprenorphine use. This study investigated illicit buprenorphine use and barriers to BMT among syringe exchange participants. Computer-based interviews conducted at a New York City harm reduction agency determined: prior buprenorphine use; barriers to BMT; and interest in BMT. Of 102 opioid users, 57 had used illicit buprenorphine and 32 had used prescribed buprenorphine. When illicit buprenorphine users were compared to non-users: barriers to BMT ("did not know where to get treatment") were more common (64 vs. 36%, p<0.01); mean levels of interest in BMT were greater (3.37 ± 1.29 vs. 2.80 ± 1.34, p=0.03); and more participants reported themselves likely to initiate treatment (82 vs. 50%, p<0.01). Illicit buprenorphine users were interested in BMT but did not know where to go for treatment. Addressing barriers to BMT could reduce illicit buprenorphine use.