Linking patients with buprenorphine treatment in primary care: Predictors of engagement

Highlights

• Only 40% of primary care patients entering a buprenorphine program began medication.

• Early dropout was higher in those with recent polysubstance use and prior treatment.

• Programs should attempt to minimize barriers during initiation of treatment.

Abstract

Background

Office-based buprenorphine treatment promises to expand effective treatment for opioid use disorder. Unfortunately, patients may be lost during engagement, before induction with medication. Few data are available regarding rates and predictors of successfully reaching induction.

Methods

The sample included 100 consecutive patients seeking treatment in 2016 at an office-based buprenorphine treatment program in an urban, academic primary care clinic. Patients completed phone intake, nurse visit and physician visit prior to induction. We reviewed electronic medical records to describe the time to complete each step and used multivariable logistic regression to identify predictors of reaching induction.

Results

Sixty percent of the sample dropped out prior to induction, with the majority dropping out prior to the nurse visit. For patients who successfully completed induction, median time between screening and induction was 18 days (interquartile range 13-30 days). After adjustment for other factors, completing induction was significantly less likely in patients with recent polysubstance use (OR = 0.15, 95% CI = 0.04–0.53), prior methadone treatment (OR = 0.05, 95% CI = 0.01–0.36), prior buprenorphine treatment (OR = 0.60, 95% CI = 0.01–0.47), or other prior treatment (OR = 0.19, 95% CI = 0.04–0.98). Sociodemographic characteristics, such as younger age, minority race/ethnicity, homelessness, unemployment, history of incarceration and relationship status were not significant predictors.

Conclusions

Over half of patients beginning primary care buprenorphine treatment were not successful in starting medication. Those with polysubstance use or previous substance use treatment were least likely to be successful. Programs should carefully consider barriers that might prevent treatment-seeking patients from starting medications. Some patients might need enhanced support to successfully start treatment with buprenorphine.

Introduction

The U.S. is in the midst of a profound opioid epidemic, with 2.5 million Americans suffering from an opioid use disorder (Substance Abuse and Mental Health Services Administration, 2015) and rising mortality rates. Opioid overdose accounts for 30,000 deaths per year, a fourfold increase over the last 15 years (National Center for Health Statistics National Vital Statistics System, 2014). Unfortunately, only 20% of patients with an opioid use disorder receive any type of treatment (Saloner and Karthikeyan, 2015).

Methadone and buprenorphine are effective treatments for patients with an opioid use disorder. A 2014 Cochrane review concluded that these medications decrease illicit opioid use and increase retention in treatment (Mattick et al., 2014). Additionally, retention in treatment with medication improves quality of life (Ponizovsky and Grinshpoon, 2007) and decreases mortality (Clausen et al., 2008) as well as HIV risk behaviors (Sullivan et al., 2008). Conversely, detoxification or medically supervised withdrawal is associated with a high rate of relapse and is often not sufficient for long-term recovery (Smyth et al., 2010). In addition to Opioid Treatment Programs, buprenorphine can be prescribed through office-based settings. Consequently, office-based buprenorphine has the unique potential to increase the reach of opioid agonist therapy and provide substantial impact on the opioid epidemic. New models of care that engage the primary health care system in providing buprenorphine treatment access have shown promise (Chou et al., 2016). Successful treatment requires patients to seek care, engage with treatment, begin medication and be maintained in treatment. Consistent with the cascade of care framework (Socías et al., 2016), each of these steps is a potential point of failure or dropout. Examining success or failure at each of these stages allows for identification of barriers to successful buprenorphine treatment. Most previous research has focused on retention among patients who have already started medication. Data suggest that upwards of half of patients who start taking buprenorphine drop out within the first few months of treatment (Hser et al., 2014). Predictors of early dropout after starting medications include younger age (Marcovitz et al., 2016, Weinstein et al., 2017), Black or Hispanic race/ethnicity (Weinstein et al., 2017), polysubstance use (Hser et al., 2014), lower buprenorphine dose (Hser et al., 2014), use of non-prescribed opiates early during treatment (Stein et al., 2005) and unemployment (Weinstein et al., 2017). While this focus on retention is important, less is known about dropout during the initial engagement period, or the time between seeking care and starting medication.

Our study describes the engagement period at a buprenorphine program embedded within a primary care clinic at an urban, academic medical center. We examine the rates and predictors of dropout between the initial screening and induction with medication.