Medication-Assisted Treatment With Buprenorphine: Assessing the Evidence

Thomas, Cindy; Fullerton, Catherine A.; Kim, Meelee; Montejano, Leslie; Lyman, D. Russell; Dougherty, Richard H.; Daniels, Allen S.; Ghose, Sushmita Shoma; Delphin-Rittmon, Miriam E.

doi:10.1176/appi.focus.130309

Cited by 39 publications

(45 citation statements)

References 40 publications

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“…21,25,[37][38][39][40] Recent metaanalyses have found that buprenorphine-naloxone and methadone were essentially equally efficacious across these traditional metrics when sufficient (i.e., medium-or high-dose, but not low-dose) buprenorphine-naloxone or methadone were used. 18,21,38 Risk of death While shown to be essentially as efficacious as methadone in clinical trials, 18,21,38 the partial opioid agonist buprenorphine-naloxone has several safety advantages over methadone (a full opioid agonist), including a reduced risk of fatal overdose because of its lower potential for respiratory depression. 16,17,19,25 According to a large retrospective study conducted in the United Kingdom, which included more than 19 million prescriptions over a six-year period…”

Section: Initiate Opioid Agonist Treatment With Methadone When Treatmmentioning

confidence: 99%

Management of opioid use disorders: a national clinical practice guideline

Bruneau

Ahamad

Goyer

et al. 2018

CMAJ

323

392

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Section: Initiate Opioid Agonist Treatment With Methadone When Treatmmentioning

confidence: 99%

Management of opioid use disorders: a national clinical practice guideline

Bruneau

Ahamad

Goyer

et al. 2018

CMAJ

323

392

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“…In 2015 an estimated 2.0 million people had a pain reliever use disorder, and 828,000 people had used heroin in the previous year. 1 Buprenorphine maintenance treatment is effective for opioid use disorder, 2 and major efforts have been made to expand its availability. The Drug Addiction Treatment Act of 2000 allows physicians who complete training to obtain a Drug Enforcement Agency (DEA) waiver that permits prescribing buprenorphine to treat opioid use disorder.…”

Section: Introductionmentioning

confidence: 99%

Barriers Rural Physicians Face Prescribing Buprenorphine for Opioid Use Disorder

2017

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Opioid use disorder is a serious public health problem. Management with buprenorphine is an effective, office-based, medication-assisted treatment, but 60.1% of rural counties in the United States lack a physician with a Drug Enforcement Agency waiver to prescribe buprenorphine. This national study surveyed all rural physicians who have received a waiver in the United States and found that those who were not actively prescribing buprenorphine reported significantly more barriers than those who were, regardless of whether they were treating the maximum number of patients their waiver allowed. These findings suggest the need for tailored strategies to address barriers to providing buprenorphine for opioid use disorder and to support physicians who are adding or maintaining this service. INTRODUCTIONT he opioid abuse epidemic is a serious and persistent public health problem. In 2015 an estimated 2.0 million people had a pain reliever use disorder, and 828,000 people had used heroin in the previous year.1 Buprenorphine maintenance treatment is effective for opioid use disorder, 2 and major efforts have been made to expand its availability. The Drug Addiction Treatment Act of 2000 allows physicians who complete training to obtain a Drug Enforcement Agency (DEA) waiver that permits prescribing buprenorphine to treat opioid use disorder. Despite a more than threefold increase in the number of physicians with a DEA waiver since 2006, 3 60.1% of rural counties lack a physician with a waiver. 4 Access to treatment continues to be a challenge for rural populations. Many physicians with a waiver are not using it to its full extent or at all. 5,6 A few studies, limited to 1 or only a few states, have looked at the barriers physicians face providing buprenorphine maintenance treatment, but none has examined nationally the differences between physician groups who are and are not actively using their waivers or accepting new patients.7-10 This study's purpose was to understand the barriers physicians with waivers face in providing buprenorphine maintenance treatment. METHODSWe surveyed all rurally located physicians in the United States on the DEA list (April 2016) who had received waivers to prescribe buprenorphine. We categorized physicians as rural using the Federal Information Processing Standards county code of the physicians' address if they had an Urban Influence Code of 3 through 12. 360nonrespondents using DEA, American Medical Association, National Provider Identifier, or Google Search result addresses until the physician's practice was found. Participants received the questionnaire at that address twice more, 2 weeks apart, followed by an abbreviated version of the questionnaire as a tear-off return postcard 1 month after follow-up began. Physicians responding to the tear-off postcard were not asked the barriers question. We telephoned nonrespondents up to 3 times, at 2-week intervals. Data collection occurred from July through November 2016.Physicians were classified into 4 categories based on whether the...

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“…Other sources of data have suggested that buprenorphine could be more effective than methadone in reducing mortality, especially from overdose . Unlike methadone, there is a ceiling for respiratory depressant effects of buprenorphine as dose increases, and the probability of triggering arrhythmias is lower .…”

Section: Discussionmentioning

confidence: 99%

Reduction in mortality risk with opioid agonist therapy: a systematic review and meta‐analysis

Bahji

Cheng

Gray

et al. 2019

Acta Psychiatr Scand

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Reduction in mortality risk with opioid agonist therapy: a systematic review and meta-analysis Bahji A, Cheng B, Gray S, Stuart H. Reduction in mortality risk with opioid agonist therapy: a systematic review and meta-analysis Introduction: Opioid agonist therapies are effective medications that can greatly improve the quality of life of individuals with opioid use disorder. However, there is significant uncertainty about the risks of cause-specific mortality in and out of treatment.Objective: This systematic review and meta-analysis explored the association between methadone and buprenorphine with cause-specific mortality among opioid-dependent persons. Methods: We searched six online databases to identify relevant cohort studies, calculating all-cause and overdose-specific mortality rates during periods in and out of treatment. We pooled mortality estimates using multivariate random effects meta-analysis of the crude mortality rate per 1000 person-years of follow-up as well as relative risks comparing mortality in vs. out of treatment. Results: A total of 32 cohort studies (representing 150 235 participants, 805 423.6 person-years, and 9112 deaths) met eligibility criteria. Crude mortality rates were substantially higher among methadone cohorts than buprenorphine cohorts. Relative risk reduction was substantially higher with methadone relative to buprenorphine when time intreatment was compared to time out-of-treatment. Furthermore, the greatest mortality reduction was conferred during the first 4 weeks of treatment. Mortality estimates were substantially heterogeneous and varied significantly by country, region, and by the nature of the treatment provider. Conclusion: Precautions are necessary for the safer implementation of opioid agonist therapy, including baseline assessments of opioid Significant outcomes• This review provides an update of Sordo and colleagues' 2017 meta-analysis, and lends further support to the harm-reduction potential of opioid agonist therapy for persons with opioid use disorder.• The risk of all-cause and overdose-specific mortality-and the mortality reduction effects associated with opioid agonist therapies-are greatest during the first four weeks of treatment.• Improving access to opioid agonist therapies in conjunction with precautions and clinician education can improve patient care and promote harm reduction efforts in the context of the global opioid epidemic. Limitations• Despite multiple attempts to explain and account for heterogeneity, there remained substantial residual heterogeneity in our meta-analysis estimates.• The risk of all-cause and overdose-specific mortality-and the mortality reduction effects associated with opioid agonist therapies-are greatest during the first four weeks of treatment.• All participants were remitted BD patients under various therapeutic regimens, and changes in the levels of low-grade inflammation and cardiometabolic markers may be related to medication use.

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Medication-Assisted Treatment With Buprenorphine: Assessing the Evidence

Cited by 39 publications

References 40 publications

Management of opioid use disorders: a national clinical practice guideline

Management of opioid use disorders: a national clinical practice guideline

Barriers Rural Physicians Face Prescribing Buprenorphine for Opioid Use Disorder

Reduction in mortality risk with opioid agonist therapy: a systematic review and meta‐analysis

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