A comparison of buprenorphine treatment in clinic and primary care settings: a randomised trial

Abstract

Objective: To compare outcomes, costs and incremental cost‐effectiveness of heroin detoxification performed in a specialist clinic and in general practice. Design and setting: Randomised controlled trial set in a specialist outpatient drug treatment centre and six office‐based general practices in inner city Sydney, Australia. Participants: 115 people seeking treatment for heroin dependence, of whom 97 (84%) were reinterviewed at Day 8, and 78 (68%) at Day 91. Interventions: Participants were randomly allocated to primary care or a specialist clinic, and received buprenorphine for 5 days for detoxification, then were offered either maintenance therapy with methadone or buprenorphine, relapse prevention with naltrexone, or counselling alone. Main outcome measures: Completion of detoxification, engagement in post‐detoxification treatment, and heroin use assessed at Days 8 and 91. Costs relevant to providing treatment, including staff time, medication use and diagnostic procedures, with abstinence from heroin use on Day 8 as the primary outcome measure. Results: There were no significant differences in the proportions completing detoxification (40/56 [71%] primary care v 46/59 [78%] clinic), participating in postwithdrawal treatment (28/56 [50%] primary care v 36/59 [61%] clinic), reporting no opiate use during the withdrawal period (13/56 [23%] primary care v 13/59 [22%] clinic), and in duration of postwithdrawal treatment by survival analysis. Most participants in both groups entered postwithdrawal buprenorphine maintenance. On an intention‐to‐treat basis, self‐reported heroin use in the month before the Day 91 interview was significantly lower than at baseline (27 days/month at baseline, 14 days/month at Day 91; P < 0.001) and did not differ between groups. Buprenorphine detoxification in primary care was estimated to be $24 more expensive per patient than treatment at the clinic. The incremental cost‐effectiveness ratio reveals that, in this context, it costs $20 to achieve a 1% improvement in outcome in primary care. Conclusions: Buprenorphine‐assisted detoxification from heroin in specialist clinic and primary care settings had similar efficacy and cost‐effectiveness. Buprenorphine treatment can be initiated safely in primary care settings by trained GPs.

The association between outpatient buprenorphine detoxification duration and clinical treatment outcomes: A review

“…Overall, the above search terms resulted in 16 randomized trials (Amass et al, 1988; Bickel et al, 1988b; Blondell et al, 2010, Breen et al, 2003; Cameron et al, 2001; Gandhi et al, 2003; Gibson et al, 2003; Ling et al, 2005; Ling et al, 2009; Lintzeris et al, 2002; Marsch et al, 2005; O’Connor et al, 1997; Raistrick et al, 2005; Resnick et al, 1992; Woody et al, 2008; Wright et al, 2007), 10 unrandomized evaluations (Becker et al, 2001; Diamont et al, 1998; Galanter et al, 2003; Katz et al, 2009; Lintzeris, 2002; Quigley et al, 1987; Resnick et al, 2001; Sigmon et al, 2009; Summers and Stone, 2002; Williams et al, 2002) and 2 retrospective comparisons with other treatment medications (Fingerhood et al, 2001; White et al, 2001). …”

Factors affecting willingness to provide buprenorphine treatment

“…Buprenorphine, which reduces cravings, blocks the effects of opioids, and has limited overdose potential, can be prescribed in office-based settings for the treatment of opioid dependence by physicians who meet the requirements of the Drug Addiction Treatment Act (DATA 2000), including completion of an 8-hour training or certification in addiction medicine and registration with the Drug Enforcement Administration (DEA). Despite evidence of its efficacy and safety (Fiellin & O’Connor, 2002; Fiellin et al, 2002; Gibson et al, 2003; O’Connor et al, 1998; O’Connor & Samet, 1996), initially, office-based buprenorphine treatment was not as quickly adopted by U.S. physicians as anticipated (Knudsen et al, 2006a, 2006b; National Consensus Development Panel, 2003; Join Together, 2003; Stanton et al, 2006). …”

Long-term outcomes of office-based buprenorphine/naloxone maintenance therapy

“…Post-release studies have shown bup/nx to significantly reduce opioid withdrawal symptoms, improve retention in substance abuse treatment, and improve treatment completion roughly similar to methadone treatment (Amass et al, 1994; Caldiero et al, 2006; Fiellin et al, 2002; Gibson et al, 2003; Johnson et al, 1995; Krook et al, 2002; Moore et al, 2007; Stein et al, 2005; Auriacombe et al, 1994; Giacomuzzi et al, 2005; Johnson et al, 2000; Kakko et al, 2003; Kosten et al, 1993; Mattick et al, 2003; O'Connor et al, 1998; Strain et al, 1994). …”