Very early disengagement and subsequent re-engagement in primary care Office Based Opioid Treatment (OBOT) with buprenorphine

Abstract

Introduction Patients with opioid use disorder often require multiple treatment attempts before achieving stable recovery. Rates of disengagement from buprenorphine are highest in the first month of treatment and termination of buprenorphine therapy results in return to use rates as high as 90%. To better characterize these at-risk patients, this study aims to describe: 1) the frequency and characteristics of patients with very early disengagement (≤1 month) from Office Based Opioid Treatment (OBOT) with buprenorphine and 2) the frequency and characteristics of patients who re-engage in care at this same OBOT clinic within 2 years, among the subset of very early disengagers. Methods This is a retrospective cohort study of adult patients enrolled in a large urban OBOT program. Descriptive statistics were used to characterize the sample and the proportion of patients with very early (≤1 month) disengagement and their re-engagement. Multivariable logistic regression models were used to identify patient characteristics associated with the outcomes of very early disengagement and re-engagement. Potential predictors included: sex, age, race/ethnicity, education, employment, opioid use history, prior substance use treatments, urine drug testing, and psychiatric diagnoses. Results Overall, very early disengagement was unusual, with only 8.4% (104/1234) of patients disengaging within the first month. Among the subset of very early disengagers with 2 years of follow-up, the proportion who re-engaged with this OBOT program in the subsequent 2 years was 11.9% (10/84). Urine drug test positive for opiates within the first month (AOR: 2.01, 95% CI: 1.02–3.93) was associated with increased odds of very early disengagement. Transferring from another buprenorphine prescriber (AOR: 0.09, 95% CI: 0.01–0.70) was associated with decreased odds of very early disengagement. No characteristics were significantly associated with re-engagement. Conclusions Early disengagement is uncommon; however, continued opioid use appeared to be associated with higher odds of treatment disengagement and these patients may warrant additional support. Re-engagement was uncommon, suggesting the need for a more formal explicit system to encourage and facilitate re-engagement among patients who disengage.

Three-Year Retention in Buprenorphine Treatment for Opioid Use Disorder Among Privately Insured Adults

“…In addition, compared with patients with commercial insurance, they were a decade older, had greater access to comprehensive care for substance use disorders, and were likely to have far lower copays (38,39). Higher age, a consistent predictor of better buprenorphine treatment retention (21,(40)(41)(42)(43), may also have contributed to better retention in the VHA. However, in the Massachusetts study that showed high retention (37), the age distribution was similar to that in the study reported here.…”

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

“…In previous research, higher average daily doses of buprenorphine (approximately 16 mg) predicted better treatment retention (Hser et al, 2014; Khemiri, Kharitonova, Zah, Ruby, & Toumi, 2014; Timko et al, 2016), and higher doses received early in treatment were shown to be particularly important for stabilizing and retaining patients (Gryczynski et al, 2014; Timko et al, 2016). Furthermore, higher doses of buprenorphine are associated with lower rates of opioid use during treatment, which is a risk factor for relapse and premature discontinuation (Hser et al, 2014; Hui et al, 2017; Mattick, Breen, Kimber, & Davoli, 2014). A recent study of medical records identified relapse as the most common reason for early discontinuation, particularly among those who discontinued in the first year compared to those with longer treatment (Weinstein et al, 2017).…”

“…We defined buprenorphine treatment discontinuation as >30 days without buprenorphine supply. Previous studies examining buprenorphine treatment episodes used longer, 60-day (Saloner et al, 2017) and 90-day (Hui et al, 2017) definitions of discontinuation. Our goal was to capture discontinuation, rather than gaps in treatment, while also producing results that correspond to the relatively short period after discontinuing treatment in which risk for adverse opioid-related outcomes (e.g.…”

A Research Agenda for Advancing Strategies to Improve Opioid Safety: Findings from a VHA State of the Art Conference

“…Discontinuation of treatment can occur for a variety of reasons related to patient (e.g., relapse), provider (e.g., quality of care), and system factors (e.g., arbitrary limits of duration of care). [21][22][23][24][25][26] Research priorities include understanding how to implement chronic disease management for MOUD, understanding factors leading to MOUD discontinuation, and re-engaging patients who discontinue care. 27 Finally, studying interventions to link patients who have a non-fatal overdose to MOUD treatment was deemed a high priority.…”