Characterizing opioid agonist treatment discontinuation trends in British Columbia, Canada, 2012–2018

Krebs, Emanuel; Homayra, Fahmida; Min, Jeong Eun; MacDonald, Sue; Gold, Leila; Carter, Connie; Nosyk, Bohdan

doi:10.1016/j.drugalcdep.2021.108799

Cited by 9 publications

(9 citation statements)

References 29 publications

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“…Additionally, increases in the use of fentanyl have increased the risk of opioid dependence, mortality, and treatment discontinuation over time. 9,64 The brief survey among the clinical advisory committee further supported the results found in our assessment of the assumptions A2, A4a, and A4b. Because clinical evidence of comparative effectiveness of the available treatment options in the fentanyl era is extremely limited, clinicians may choose between forms of OAT depending on their clinical experience, or their client's comorbid conditions, contraindications with other medications, or illicit drug of use.…”

Section: Descriptionsupporting

confidence: 78%

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Comparative Analysis of Instrumental Variables on the Assignment of Buprenorphine/Naloxone or Methadone for the Treatment of Opioid Use Disorder

Homayra,

Enns,

Min

et al. 2023

Epidemiology

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Background: Instrumental variable (IV) analysis provides an alternative set of identification assumptions in the presence of uncontrolled confounding when attempting to estimate causal effects. Our objective was to evaluate the suitability of measures of prescriber preference and calendar time as potential IVs to evaluate the comparative effectiveness of buprenorphine/naloxone versus methadone for treatment of opioid use disorder (OUD). Methods: Using linked population-level health administrative data, we constructed five IVs: prescribing preference at the individual, facility, and region levels (continuous and categorical variables), calendar time, and a binary prescriber’s preference IV in analyzing the treatment assignment–treatment discontinuation association using both incident-user and prevalent-new-user designs. Using published guidelines, we assessed and compared each IV according to the four assumptions for IVs, employing both empirical assessment and content expertise. We evaluated the robustness of results using sensitivity analyses. Results: The study sample included 35,904 incident users (43.3% on buprenorphine/naloxone) initiated on opioid agonist treatment by 1585 prescribers during the study period. While all candidate IVs were strong (A1) according to conventional criteria, by expert opinion, we found no evidence against assumptions of exclusion (A2), independence (A3), monotonicity (A4a), and homogeneity (A4b) for prescribing preference-based IV. Some criteria were violated for the calendar time-based IV. We determined that preference in provider-level prescribing, measured on a continuous scale, was the most suitable IV for comparative effectiveness of buprenorphine/naloxone and methadone for the treatment of OUD. Conclusions: Our results suggest that prescriber’s preference measures are suitable IVs in comparative effectiveness studies of treatment for OUD.

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Section: Descriptionsupporting

confidence: 78%

“…Additionally, increases in the use of fentanyl have increased the risk of opioid dependence, mortality, and treatment discontinuation over time. 9,64…”

Section: Discussionmentioning

confidence: 99%

Comparative Analysis of Instrumental Variables on the Assignment of Buprenorphine/Naloxone or Methadone for the Treatment of Opioid Use Disorder

Homayra,

Enns,

Min

et al. 2023

Epidemiology

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“…Qualitative data furthermore suggest that daily dispensation is a substantial barrier to sustained retention, increases stigma among patients and can negatively impact upon personal responsibilities such as employment [11]. Concerns regarding diversion must also be balanced against the starkly elevated risk of mortality due to the toxicity of the illicit drug supply and declining OAT retention rates in recent years [12].…”

Section: Discussionmentioning

confidence: 99%

Incremental expenditures attributable to daily dispensation and witnessed ingestion for opioid agonist treatment in British Columbia: 2014–20

et al. 2023

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Background and aim: While daily witnessed opioid agonist treatment (OAT) ingestion is common in British Columbia (BC), Canada, and elsewhere, sparse evidence supports this resource-intensive practice. Many settings across North America relaxed restrictions for take-home dosing during the COVID-19 pandemic and have reported consistent or improved patient outcomes. This study measured excess expenditures attributed to daily witnessed pharmacy dispensing compared with weekly or biweekly dispensation schedules.Design, setting and participants: This study was a population-level retrospective analysis. We included all methadone, buprenorphine/naloxone and slow-release oral morphine dispensations in BC from 1 January 2014 to 30 December 2020. A total of 24 357 107 OAT dispensations among 51 195 unique individuals with 122 793 personyears of follow-up were included during the study period.Measurements: Total expenditures for each person-week of OAT with an estimated expenditure under two scenarios are as follows: (1) a weekly dispensation scenario and(2) a biweekly dispensation scenario.

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“…Baseline characteristics of the primary cohort of 5774 individuals, stratified by time to taper initiation, are described in Table 1. The median (IQR) age at index was 34 (28)(29)(30)(31)(32)(33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44) years, and 3462 participants (60.0%) were male. The population was mostly urban (4852 individuals [84.0%]) and of low socioeconomic status (3296 individuals [57.1%] were in the first and second income quintiles).…”

Section: Resultsmentioning

confidence: 99%

“…There is substantial variation in the literature in defining MOUD discontinuation. Sixty days, 36 , 37 2 times the days supplied, 38 6 days, 39 10 days, 40 and 14 days 41 have been used previously. We used 14 days to describe discontinuation because among those undergoing a taper who discontinue therapy and feel discomfort, return to MOUD may be rapid.…”

Section: Methodsmentioning

confidence: 99%

Prescribing Characteristics Associated With Opioid Overdose Following Buprenorphine Taper

Bozinoff

Men²,

Kurdyak

et al. 2022

JAMA Netw Open

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ImportanceRetention in buprenorphine therapy is associated with a lower risk of opioid overdose. Nevertheless, many patients discontinue treatment, and there is limited evidence to guide buprenorphine tapering.ObjectiveTo understand what prescribing characteristics are associated with opioid overdose following buprenorphine taper.Design, Setting, and ParticipantsThis is a population-based, retrospective, cohort study of adults who were maintained on buprenorphine for at least 60 days and underwent a buprenorphine taper. The study was conducted in the Canadian province of Ontario, using linked administrative health data. New buprenorphine treatment episodes were accrued between January 1, 2013, and January 1, 2019, and the maximum follow-up was April 30, 2020. Data analysis was performed from December 2020 to August 2022.ExposuresThe primary exposure of interest was time to taper initiation (≤1 year vs &gt;1 year). Secondary exposures included mean rate of taper, percentage days during which the dose was decreasing, and taper duration.Main Outcomes and MeasuresThe primary outcome measure was time to fatal or nonfatal opioid overdose within 18 months following treatment discontinuation.ResultsAmong 5774 individuals, the median (IQR) age at index date was 34 (28-44) years, and 3462 individuals (60.0%) were male. Time to taper initiation longer than 1 year vs 1 year or less (6.73 vs 10.35 overdoses per 100 person-years; adjusted hazard ratio [aHR], 0.69; 95% CI, 0.48-0.997), a lower mean rate of taper (≤2 mg per month, 6.95 overdoses per 100 person-years; &gt;2 to ≤4 mg per month, 11.48 overdoses per 100 person-years; &gt;4 mg per month, 17.27 overdoses per 100 person-years; ≤2 mg per month vs &gt;4 mg per month, aHR, 0.65; 95% CI, 0.46-0.91; &gt;2 to ≤4 mg per month vs &gt;4 mg per month, aHR, 0.69; 95% CI, 0.51-0.93), and dose decreases in 1.75% or less of days vs more than 3.50% of days during the taper period (5.87 vs 13.87 overdoses per 100 person-years; aHR, 0.64; 95% CI, 0.43-0.93) were associated with reduced risk of opioid overdose; however, taper duration was not.Conclusions and RelevanceIn this retrospective cohort study, buprenorphine tapers undertaken after at least 1 year of therapy, a slower rate of taper, and a lower percentage of days during which the dose was decreasing were associated with a significantly lower risk of opioid overdose, regardless of taper duration. These findings underscore the importance of a carefully planned taper and could contribute to reduction in opioid-related overdose death.

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Characterizing opioid agonist treatment discontinuation trends in British Columbia, Canada, 2012–2018

Cited by 9 publications

References 29 publications

Comparative Analysis of Instrumental Variables on the Assignment of Buprenorphine/Naloxone or Methadone for the Treatment of Opioid Use Disorder

Comparative Analysis of Instrumental Variables on the Assignment of Buprenorphine/Naloxone or Methadone for the Treatment of Opioid Use Disorder

Incremental expenditures attributable to daily dispensation and witnessed ingestion for opioid agonist treatment in British Columbia: 2014–20

Prescribing Characteristics Associated With Opioid Overdose Following Buprenorphine Taper

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