Public sector low threshold office-based buprenorphine treatment: outcomes at year 7

Abstract

BackgroundBuprenorphine maintenance for opioid dependence remains of limited availability among underserved populations, despite increases in US opioid misuse and overdose deaths. Low threshold primary care treatment models including the use of unobserved, “home,” buprenorphine induction may simplify initiation of care and improve access. Unobserved induction and long-term treatment outcomes have not been reported recently among large, naturalistic cohorts treated in low threshold safety net primary care settings.MethodsThis prospective clinical registry cohort design estimated rates of induction-related adverse events, treatment retention, and urine opioid results for opioid dependent adults offered buprenorphine maintenance in a New York City public hospital primary care office-based practice from 2006 to 2013. This clinic relied on typical ambulatory care individual provider-patient visits, prescribed unobserved induction exclusively, saw patients no more than weekly, and did not require additional psychosocial treatment. Unobserved induction consisted of an in-person screening and diagnostic visit followed by a 1-week buprenorphine written prescription, with pamphlet, and telephone support. Primary outcomes analyzed were rates of induction-related adverse events (AE), week 1 drop-out, and long-term treatment retention. Factors associated with treatment retention were examined using a Cox proportional hazard model among inductions and all patients. Secondary outcomes included overall clinic retention, buprenorphine dosages, and urine sample results.ResultsOf the 485 total patients in our registry, 306 were inducted, and 179 were transfers already on buprenorphine. Post-induction (n = 306), week 1 drop-out was 17%. Rates of any induction-related AE were 12%; serious adverse events, 0%; precipitated withdrawal, 3%; prolonged withdrawal, 4%. Treatment retention was a median 38 weeks (range 0–320) for inductions, compared to 110 (0–354) weeks for transfers and 57 for the entire clinic population. Older age, later years of first clinic visit (vs. 2006–2007), and baseline heroin abstinence were associated with increased treatment retention overall.ConclusionsUnobserved “home” buprenorphine induction in a public sector primary care setting appeared a feasible and safe clinical practice. Post-induction treatment retention of a median 38 weeks was in line with previous naturalistic studies of real-world office-based opioid treatment. Low threshold treatment protocols, as compared to national guidelines, may compliment recently increased prescriber patient limits and expand access to buprenorphine among public sector opioid use disorder patients.

The LASSO Program in Oslo: Harm Reduction Using Buprenorphine-Naloxone (Suboxone®) in a Low Threshold Setting

“…Similar literature is lacking to answer this question. The closest study conducted at a New York City public hospital primary care office evaluated prescribed BPN for unobserved self-medicated home induction [18]. This 7-year study determined BPN to be feasible and safe with no serious "induction-related adverse events," consistent with our findings.…”

“…In addition, the subset of patients defined "in treatment" may have continued on to treatment elsewhere prior to completing 30 days and therefore cannot necessarily be considered less successful than those "stabilized in treatment." The New York self-medicated buprenorphine study demonstrated higher "self-reported" median retention rates 38 weeks over a 7-year period as opposed to LASSO's 51.7% of patient's retention of 52 days over 6 years [18]. However, the following issues must be taken into consideration when making such a comparison: LASSO data is objective, using free BPNX on "hard to treat" patients which know they will be welcomed back with no penalty.…”

“…However, the following issues must be taken into consideration when making such a comparison: LASSO data is objective, using free BPNX on "hard to treat" patients which know they will be welcomed back with no penalty. Other studies using buprenorphine in higher threshold settings have demonstrated higher retention rates or the ability to transfer to stable OMT [13,[18][19][20][21].…”

Routes of non-traditional entry into buprenorphine treatment programs

“…Buprenorphine, unlike methadone, does not need to be administered in a drug treatment facility; and studies have shown that both in-office and home induction are effective [10,11]. Buprenorphine can also be combined with an antagonist naloxone to limit the recreational potential and street value, as well as potential diversion relative to methadone [11].…”

The case for a medication first approach to the treatment of opioid use disorder

“…The risk of premature discontinuation is also greater for clients prescribed XR-naltrexone compared to buprenorphine-naloxone (13), while only buprenorphine and methadone have been shown to reduce mortality (14). The agonist properties of methadone and buprenorphine mean they can be initiated quickly after opioid use (15,16), unlike XR-naltrexone.…”