A retrospective cohort study of medication dispensing at pharmacies: Administration matters!

BACKGROUND

Opioid agonist treatment (OAT) for opioid use disorders may be delivered at treatment clinics or dispensed from pharmacies, however the type of delivery may be associated with different risks and benefits. The aim of the study was to investigate whether dispensing of methadone or buprenorphine at pharmacies during treatment for opioid use disorders was associated with adverse outcomes.

METHODS

Retrospective cohort study using a national, linked, population-level data set from Denmark. Patients included were between 18 and 75 years, living in Denmark, and admitted for treatment for opioid use disorders during 2000-2016 (n = 9299). Cox proportional hazards regression was estimated for convictions, non-fatal overdoses, and death, after the first dispensing of either methadone or buprenorphine from a pharmacy after starting treatment.

FINDINGS

Of all patients, 68 % had methadone and 31 % had buprenorphine dispensed at a pharmacy. Compared with the time prior to pharmacy dispension, the risk of criminal convictions increased after having methadone dispensed from a pharmacy (adjusted hazard ratio (aHR) = 1.22, 95 % confidence interval (CI) = 1.16-1.28), non-fatal overdoses (aHR = 1.55, CI 1.41-1.71), and all-cause mortality (aHR = 1.54, CI = 1.43-1.76). After having buprenorphine dispensed at a pharmacy, risk of criminal convictions increased (aHR = 1.08, CI = 1.01-1.16) and non-fatal overdoses (aHR = 1.31, CI = 1.18-1.45), but not all-cause mortality (aHR = 1.07, CI = 0.94-1.23).

CONCLUSIONS

For almost all outcomes investigated across medication type, the risk of adverse events increased following a switch from clinic dispension to pharmacy dispension of medications in OAT. Medically responsible and safe provision of OAT may often require more clinical follow-up than what is typically provided when medication is dispensed at pharmacies.

The effect of medications for opioid use disorder (MOUD) on residential treatment completion and retention in the US

BACKGROUND

This study examines whether MOUD increases treatment completion and retention in both short-term (ST) and long-term (LT) residential programs using a national dataset.

METHODS

Data were extracted from the 2015-2017 TEDS-D (Treatment Episode Dataset-Discharge) datasets for opioid using adults in ST (n = 87,296) and LT (n = 66,623) residential treatment. Primary outcome variables were treatment completion and retention (ST: length of stay >10 days; LT: >90 days). Logistic regression estimated the effects of MOUD on the probability of treatment completion and retention separately for ST and LT residential treatment, controlling for individual background characteristics.

RESULTS

Only 18% of clients in residential treatment programs had MOUD in their treatment plans. For ST residential treatment, MOUD was associated with a 40% increased likelihood of treatment completion (OR = 1.404) and 34% increased retention (OR = 1.337). For LT residential treatment, MOUD was associated with a 26% reduced likelihood of treatment completion (OR = 0.743) and no significant increase in retention. Post hoc analysis suggests insurance coverage may be influencing outcomes.

CONCLUSIONS

Despite MOUD being a standard of care for OUD, MOUD is particularly under-utilized in residential treatment. Further research should focus on how best to integrate MOUD within short-term residential treatment and to explore the potential viability of MOUD in long-term residential programs. Given the risk of overdose following residential treatment, for at least short-term residential programs, this setting may be advantageous for integrating psychosocial treatments with early MOUD engagement in a structured therapeutic environment as part of a long-term continuum of care recovery program.

Concomitant use of buprenorphine for medication-assisted treatment of opioid use disorder and benzodiazepines: Using the prescription behavior surveillance system

BACKGROUND

Despite clinical guidelines discouraging the practice, it is well-documented that the concomitant use of benzodiazepines and opioid analgesics occurs regularly. Information on concomitant use of buprenorphine for medication-assisted treatment (MAT) of opioid use disorder (OUD) and benzodiazepines, however, is limited. Thus, we aimed to describe real-world drug dispensing patterns for the concomitant use of buprenorphine products approved for MAT and benzodiazepines.

METHODS

We examined concomitant use of buprenorphine for MAT and benzodiazepines using the 2013 Prescription Behavior Surveillance System data from eight states. For prescription-level analysis, we estimated the proportion of concomitant buprenorphine and benzodiazepine prescriptions and the proportions of concomitant prescriptions prescribed by the same provider (co-prescribing) and dispensed by the same pharmacy (co-dispensing) for each state. For patient-level analysis, we calculated the proportion of patients with ≥1 buprenorphine therapy episode overlapping with a benzodiazepine episode, i.e., concomitant users, and the proportion of concomitant users who experienced co-prescribing or co-dispensing.

RESULTS

In 2013, 1,925,072 prescriptions of buprenorphine products for MAT were dispensed to 190,907 patients in eight states. Approximately 1 in 8 buprenorphine prescriptions was used concomitantly with ≥1 benzodiazepine prescription(s). Co-prescribing proportions ranged from 22.2 to 64.6% across states, while co-dispensing proportions ranged from 54.7 to 91.0%. Approximately 17.7% of patients had >1 buprenorphine episode overlapping a benzodiazepine episode for ≥7 cumulative days' supply. Among these patients, 33.1-65.2% experienced co-prescribing, and 65.1-93.3% experienced co-dispensing.

CONCLUSIONS

The concomitant use of buprenorphine for MAT and benzodiazepines occurs frequently, with variations by state in co-prescribing and co-dispensing.