Risk factors for discontinuation of buprenorphine treatment for opioid use disorders in a multi-state sample of Medicaid enrollees

Abstract

Introduction: Recent U.S. trends demonstrate sharp rises in adverse opioid-related health outcomes, including opioid use disorder (OUD), overdose, and death. Yet few affected people receive treatment for OUD and a minority of those who receive treatment are effectively retained in care. The purpose of this study was to examine duration of buprenorphine treatment for OUD following treatment initiation to identify risk factors for early discontinuation. Methods: We analyzed insurance claims from the 2013–2015 MarketScan multi-state Medicaid database. The sample included adults 18–64 years old with an OUD diagnosis in the 6 months before initiating buprenorphine treatment, defined as 6 months without a buprenorphine claim prior to the index buprenorphine claim (N=17,329 individuals). We used Cox proportional hazards regression to estimate risk of discontinuing treatment (>30 days without buprenorphine supply), and logistic regression to estimate the odds of persistent treatment for a minimum of 180 days. Results: Over one-quarter of the sample discontinued buprenorphine in the first month of treatment (N=4,928; 28.4%) and most discontinued before 180 days (N=11,189; 64.6%). In the proportional hazards model, risk factors for discontinuation included a lower initial buprenorphine dose (≤4mg; Hazard Ratio [HR]=1.72, p<.001), male sex (HR=1.19, p<.001), younger age (HR=1.34, p<.001), minority race/ethnicity (black HR=1.31, p<.001; Hispanic HR=1.24, p=.01; other HR=1.09, p<.001), capitated insurance (HR=1.21, p<.001), comorbid substance use disorders (alcohol HR=1.07, p=.04; non-opioid drugs HR=1.14, p<.001), hepatitis C (HR=1.06, p=.01), opioid overdose history (HR=1.20, p=.001), or any inpatient care (HR=1.22, p<.001) in the 6-month baseline period. In logistic models, these risk factors were similarly associated with significantly lower odds of treatment retention for at least 180 days. Conclusion: For Medicaid beneficiaries with OUD treated with buprenorphine, there is a need to implement treatment models that more effectively address barriers to treatment retention. These barriers are particularly challenging for minorities, younger individuals, and those with additional substance use disorders.

Risk of Opioid Overdose Associated With Concomitant Use of Opioids and Skeletal Muscle Relaxants: A Population‐Based Cohort Study

“…We also excluded patients who had documented substance use disorder (SUD) or who used buprenorphine during the baseline period. We did not distinguish buprenorphine formulations approved for pain because they were infrequently used and may be used off‐label for opioid use disorder . Opioid formulations used for cough/cold were not included in the study.…”

Development of a Cascade of Care for responding to the opioid epidemic

“…The State Targeted Response funding for the opioid epidemic from SAMHSA via the 21st Century Cures Act now requires states to monitor population-level receipt of MOUD and adherence to treatment. This is critical as studies have repeatedly shown that many patients who receive buprenorphine (24)(25)(26) or XR-naltrexone (27,28) only do so for 30-60 days, falling far short of a minimum threshold of 6-12 months thought to be necessary to confer sustained benefit (29,30).…”

“…Further, premature treatment drop out has long plagued the field. Among the subgroup of people with OUD who initiate medication-based treatment, a great majority discontinue during the first few weeks or months (23)(24)(25)(26). Less is known about long-term recovery trajectories beyond 6 months (60).…”

Misalignment of Stakeholder Incentives in the Opioid Crisis

“…Induced by the healthcare system: The barriers include lack of full or proper insurance coverage (e.g., in the California Medicaid program, naloxone is covered as an FFS medication, and managed care plans like capitation do not cover the drug), high costs of medications, limited number of providers/counselors resulting in a dearth of programs or long waiting lists, a low percentage of licensed physicians having a secured waiver that is required to provide MAT or the majority of counties lacking a treatment-waivered physician, insufficient education among pharmacists (this can be resolved by educational materials through improved FDA-approved formulations), the short-term period of opioid substitution programs, and bureaucratic requirements for program entry/enrollment [ 73 , 77 , 78 , 79 , 80 , 81 , 82 , 83 , 84 ].…”