Adjunct interventions to standard medical management of buprenorphine in outpatient settings: A systematic review of the evidence

Wyse, Jessica J.; Morasco, Benjamin J.; Dougherty, Jacob; Edwards, Beau; Kansagara, Devan; Gordon, Adam J.; Korthuis, P. Todd; Tuepker, Anaïs; Lindner, Stephan; Mackey, Katherine; Williams, Beth E.; Herreid-O’Neill, Anders; Paynter, Robin; Lovejoy, Travis I.

doi:10.1016/j.drugalcdep.2021.108923

Cited by 19 publications

(8 citation statements)

References 56 publications

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“…We also found that a large minority of providers felt that insufficient behavioral support services were a barrier to MOUD prescribing, suggesting that some respondents feel they cannot or should not prescribe MOUD if patients are not obtaining adequate behavioral support services. With respect to BUP, the literature is mixed regarding effectiveness of adding counseling to MOUD services [ 27 , 28 ], and we are not aware of studies comparing efficacy of NTX with counseling to NTX without counseling. The American Society of Addiction Medicine’s OUD treatment practice guidelines recommend that clinicians offer behavioral health services alongside MOUD but urge against requiring behavioral health services [ 29 ].…”

Section: Discussionmentioning

confidence: 99%

Perceptions of buprenorphine barriers and efficacy among nurse practitioners and physician assistants

Andraka‐Christou

Page

Schoebel

et al. 2022

Addict Sci Clin Pract

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Background Medications for opioid use disorder (MOUDs), including methadone, buprenorphine, and naltrexone, decrease mortality and morbidity for people with opioid use disorder (OUD). Buprenorphine and methadone have the strongest evidence base among MOUDs. Unlike methadone, buprenorphine may be prescribed in office-based settings in the U.S., including by nurse practitioners (NPs) and physician assistants (PAs) who have a federal waiver and adhere to federal patient limits. Buprenorphine is underutilized nationally, particularly in rural areas, and NPs/PAs could help address this gap. Therefore, we sought to identify perceptions of buprenorphine efficacy and perceptions of prescribing barriers among NPs/PAs. We also sought to compare perceived buprenorphine efficacy and perceived prescribing barriers between waivered and non-waivered NPs/PAs, as well as to compare perceived buprenorphine efficacy to perceived naltrexone and methadone efficacy. Methods We disseminated an online survey to a random national sample of NPs/PAs. We used Mann–Whitney U tests to compare between waivered and non-waivered respondents. We used non-parametric Friedman tests and post-hoc Wilcoxon signed-rank tests to compare perceptions of medication types. Results 240 respondents participated (6.5% response rate). Most respondents agreed buprenorphine is efficacious and believed counseling and peer support should complement buprenorphine. Buprenorphine was generally perceived as more efficacious than both naltrexone and methadone. Perceived buprenorphine efficacy and prescribing barriers differed by waiver status. Non-waivered practitioners were more likely than waivered practitioners to have concerns about buprenorphine affecting patient mix. Among waivered NPs/PAs, key buprenorphine prescribing barriers were insurance prior authorization and detoxification access. Conclusions Our results suggest that different policies should target perceived barriers affecting waivered versus non-waivered NPs/PAs. Concerns about patient mix suggest stigmatization of patients with OUD. NP/PA education is needed about comparative medication efficaciousness, particularly regarding methadone. Even though many buprenorphine treatment patients benefits from counseling and/or peer support groups, NPs/PAs should be informed that such psychosocial treatment methods are not necessary for all buprenorphine patients.

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Section: Discussionmentioning

confidence: 99%

Perceptions of buprenorphine barriers and efficacy among nurse practitioners and physician assistants

Andraka‐Christou

Page

Schoebel

et al. 2022

Addict Sci Clin Pract

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“…Neither supervision of medication consumption nor integration of medical, psychiatric, or social services nor information-technology approaches were found to improve retention [ 70 , 72 , 73 ]. The evidence with regard to psychosocial and behavioral interventions was mixed, with some reviews finding no improvement in retention and others finding some degree of improvement, primarily for contingency management [ 70 , 72 , 74 , 77 ]. In fealty to its low barrier approach, the IDEA Miami SSP did not require mutual support organization attendance, directly observed therapy, or psychiatric counseling for participation in this pilot.…”

Section: Discussionmentioning

confidence: 99%

Adaptation of the Tele-Harm Reduction intervention to promote initiation and retention in buprenorphine treatment among people who inject drugs: a retrospective cohort study

et al. 2023

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Background: At the start of the pandemic, relaxation of buprenorphine prescribing regulations created an opportunity to create new models of medications for opioid use disorder (MOUD) delivery and care. To expand and improve access to MOUD, we adapted and implemented the Tele-Harm Reduction (THR) intervention; a multicomponent, telehealth-based and peer-driven intervention to promote HIV viral suppression among people who inject drugs (PWID) accessing a syringe services program (SSP). This study examined buprenorphine initiation and retention among PWID with opioid use disorder who received the adapted THR intervention at the IDEA Miami SSP. Methods: A retrospective chart review of participants who received the THR intervention for MOUD was performed to examine the impact of telehealth on buprenorphine retention. Our primary outcome was three-month retention, defined as three consecutive months of buprenorphine dispensed from the pharmacy. Results: A total of 109 participants received the adapted THR intervention. Three-month retention rate on buprenorphine was 58.7%. Seeing a provider via telehealth at baseline or any follow up visit (aOR = 7.53, 95% CI: [2.36, 23.98]) and participants who had received an escalating dose of buprenorphine after baseline visit (aOR = 8.09, 95% CI: [1.83, 35.87]) had a higher adjusted odds of retention at three months. Participants who self-reported or tested positive for a stimulant (methamphetamine, amphetamine, or cocaine) at baseline had a lower adjusted odds of retention on buprenorphine at three months (aOR = 0.29, 95% CI: [0.09, 0.93]). Conclusions: Harm reduction settings can adapt dynamically to the needs of PWID in provision of critical lifesaving buprenorphine in a truly destigmatising approach. Our pilot suggests that an SSP may be an acceptable and feasible venue for delivery of THR to increase uptake of buprenorphine by PWID and promote retention in care. KEY MESSAGES The Tele-Harm Reduction intervention can be adapted for initiating and retaining people who inject drugs with opioid use disorder on buprenorphine within a syringe services program setting Using telehealth was associated with increased three-month buprenorphine retention Baseline stimulant use was negatively associated with three-month buprenorphine retention

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“…More research is needed to identify interventions to support retention in MOUD. Recent systematic reviews found that most psychosocial interventions, integration of MOUD with medical, psychiatric or social services, telehealth, and extended-release buprenorphine do not improve retention [ 43 , 44 ]. Studies of contingency management that incentivized opioid abstinence in agonist MOUD found no improvement in retention, but contingency management in antagonist treatment that incentivized treatment adherence or attendance did improve retention, suggesting that contingency management in agonist treatment incentivizing retention should be investigated [ 43 ].…”

Section: Discussionmentioning

confidence: 99%

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

Carter

Chen

et al. 2022

Addict Sci Clin Pract

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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.

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Adjunct interventions to standard medical management of buprenorphine in outpatient settings: A systematic review of the evidence

Cited by 19 publications

References 56 publications

Perceptions of buprenorphine barriers and efficacy among nurse practitioners and physician assistants

Perceptions of buprenorphine barriers and efficacy among nurse practitioners and physician assistants

Adaptation of the Tele-Harm Reduction intervention to promote initiation and retention in buprenorphine treatment among people who inject drugs: a retrospective cohort study

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

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