Defining Low-threshold Buprenorphine Treatment

Abstract

Buprenorphine treatment for opioid use disorder is safe and effective, but only a fraction of Americans who need treatment receive it. One reason for this is that many buprenorphine treatment programs have rigid requirements for entry and continuation, limiting the number of people who receive treatment. “Low-threshold treatment” is a term used to describe an alternative approach that attempts to remove as many barriers to treatment as possible. However, few studies have described its essential features. In this article, we define low-threshold treatment and propose the approach be guided by the following principles: same-day treatment entry; harm-reduction approach; flexibility; and wide availability in places where people with opioid use disorder go. We discuss the evidence and rationale for these principles and directions for future research.

Using telehealth to improve buprenorphine access during and after COVID-19: A rapid response initiative in Rhode Island

“…Given the clear mortality benefit and safety profile of buprenorphine, the harms of limiting access far outweigh any potential benefits. Low-threshold models of buprenorphine treatment prioritize a harm reduction, patient-centered approach that includes same-day treatment availability and minimizing administrative barriers ( Jakubowski & Fox, 2020 ). Examples of low-threshold buprenorphine care include: unobserved buprenorphine initiation, as recommended in the latest American Society of Addiction Medicine guidelines ( Kampman & Jarvis, 2015 ); “bridge clinics,” which initiate buprenorphine treatment and link patients to community providers for maintenance treatment ( Snow et al, 2019 ); and telehealth for treatment maintenance, which has demonstrated comparable treatment retention, substance use, therapeutic alliance, and medication adherence compared to in-person care ( Eibl et al, 2017 ; Uscher-Pines et al, 2020 ; Zheng et al, 2017 ).…”

Office-Based Addiction Treatment Retention and Mortality Among People Experiencing Homelessness

“…These findings support a low-threshold harm reduction approach that prioritizes engagement in addiction care whenever possible regardless of lapses in previous attendance or ongoing illicit drug use. [26][27][28] Patients who were living in a shelter or on the street were less likely than housed individuals to be retained in OBAT care at 1 month but also less likely to die during follow-up. This finding could relate to the circumstances in which substance use occurs, with those in shelters or on the street having people nearby to respond to an overdose, whereas those in housing may be using drugs alone.…”

“…These findings support a low-threshold harm reduction approach that prioritizes engagement in addiction care whenever possible regardless of lapses in previous attendance or ongoing illicit drug use. 26 , 27 , 28 …”

A Harm Reduction Approach to Treating Opioid Use Disorder in an Independent Primary Care Practice: a Qualitative Study

“… 28 Reports from individual practices have described feasibility and patient satisfaction using low-threshold strategies to reduce the barriers to initiating buprenorphine. 17 – 20 , 29 A direct comparison with REACH is challenging, however, due to differences in the specific treatment designs and the clinical settings. A unique feature of REACH is that the low-barrier approach has been a foundational philosophy since its inception, rather than a change from a high-barrier one.…”