Effect of lowering initiation thresholds in a primary care-based buprenorphine treatment program

Bjorn E Payne; Jared W Klein; Claire B Simon; Jocelyn R James; Sara L Jackson; Joseph O Merrill; Rui Zhuang; Judith I Tsui

doi:10.1016/j.drugalcdep.2019.03.009

Effect of lowering initiation thresholds in a primary care-based buprenorphine treatment program

Drug Alcohol Depend. 2019 Jul 1:200:71-77. doi: 10.1016/j.drugalcdep.2019.03.009. Epub 2019 May 1.

Authors

Bjorn E Payne¹, Jared W Klein², Claire B Simon³, Jocelyn R James², Sara L Jackson², Joseph O Merrill², Rui Zhuang⁴, Judith I Tsui²

Affiliations

¹ University of Washington School of Medicine, Seattle, WA, USA. Electronic address: payneb2@uw.edu.
² Department of Medicine, University of Washington, Seattle, WA, USA; Harborview Medical Center, Seattle, WA, USA.
³ University of Washington School of Medicine, Seattle, WA, USA.
⁴ Department of Biostatistics, University of Washington, Seattle, WA, USA.

PMID: 31103879
DOI: 10.1016/j.drugalcdep.2019.03.009

Abstract

Background: Office-based buprenorphine treatment is effective for opioid use disorder. Scant research has examined programmatic factors impacting successful initiation of treatment. To increase initiation of eligible patients, our buprenorphine program implemented changes to lower treatment thresholds. Most notable among these was elimination of a requirement that patients demonstrate abstinence from stimulants prior to initiating buprenorphine.

Methods: This observational, retrospective study included patients screened for primary care-based buprenorphine treatment under high- and low-threshold conditions from 2015 to 2017. Background characteristics and treatment data were extracted from the electronic medical record and clinical registry. Chi-squared tests were used to compare proportions of patients initiated within 90 days of screening and retained to 60 days after initiation, under both conditions. Multivariate logistic regression was employed to compare relative odds of buprenorphine initiation after adjustment for several covariates. All analyses were stratified by recent stimulant use.

Results: The sample of 168 patients included 96 in the high-threshold group and 72 in the low-threshold group. Among patients with recent stimulant use, low-threshold conditions were associated with a higher proportion of patients initiated (69% versus 35%, p = 0.002) and higher relative odds of initiation (aOR = 7.01, 95% CI = 2.26-21.80) but also with a lower proportion of patients retained (63% versus 100%, p = 0.004). Among patients without recent stimulant use, low-threshold conditions did not change these measures by a statistically significant margin.

Conclusions: Lower-threshold policies may increase buprenorphine treatment initiation for patients with co-occurring stimulant use. However, patients using stimulants may require additional supports to remain engaged.

Keywords: Buprenorphine; Cascade of care; Low-threshold; Opioid use disorder; Primary care; Stimulants.

Publication types

Observational Study
Research Support, Non-U.S. Gov't
Research Support, U.S. Gov't, P.H.S.

MeSH terms

Adult
Buprenorphine / therapeutic use*
Female
Humans
Male
Middle Aged
Narcotic Antagonists / therapeutic use*
Opiate Substitution Treatment / methods*
Opioid-Related Disorders / diagnosis
Opioid-Related Disorders / drug therapy*
Opioid-Related Disorders / psychology
Patient Participation / methods*
Patient Participation / psychology
Primary Health Care / methods*
Retrospective Studies
Treatment Outcome

Substances

Narcotic Antagonists
Buprenorphine