Risk of mortality on and off methadone substitution treatment in primary care: a national cohort study

Cousins, Gráinne; Boland, Fiona; Courtney, Brenda; Barry, Joseph; Lyons, Suzi; Fahey, Tom

doi:10.1111/add.13087

Cited by 62 publications

(57 citation statements)

References 35 publications

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“…Multiple large-scale studies have found all-cause mortality to be significantly higher in patients after disengagement from buprenorphine or methadone maintenance therapy compared with all-cause mortality during treatment. (Bell, Trinh, Butler, Randall, & Rubin, 2009; Clausen, Anchersen, & Waal, 2008; Cousins et al, 2016) Although some very early disengagers may have sought buprenorphine or methadone treatment elsewhere, some patients may have died without treatment. This may partially explain this clinic’s low re-engagement rates of very early disengagers.…”

Section: 0 Discussionmentioning

confidence: 99%

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

Hui

Weinstein

Cheng

et al. 2017

Journal of Substance Abuse Treatment

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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.

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Section: 0 Discussionmentioning

confidence: 99%

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

Hui

Weinstein

Cheng

et al. 2017

Journal of Substance Abuse Treatment

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“…Overdoses frequently occur among persons who were recently discharged from detoxification programs, treatment, or criminal justice settings (Binswanger et al, 2007; Cousins, Boland, Courtney, et al, 2015; Ravndal & Amundsen, 2010; Sordo, Barrio, Bravo, et al, 2017; Strang, Mccambridge, Best, et al, 2003). Unintentional overdose death is often a consequence of untreated or improperly treated opioid use disorder (OUD), reflecting a long-standing addiction treatment gap in the United States and the difficulties patients face in accessing evidence-based care (Ghitza & Tai, 2014; Volkow, Friedan, Hyde, & Cha, 2014).…”

Section: Introductionmentioning

confidence: 99%

Developing an opioid use disorder treatment cascade: A review of quality measures

Williams

Nunes

Bisaga

et al. 2018

Journal of Substance Abuse Treatment

125

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Background Despite increasing opioid overdose mortality, problems persist in the availability and quality of treatment for opioid use disorder (OUD). Three FDA-approved medications (methadone, buprenorphine, and naltrexone) have high quality evidence supporting their use, but most individuals with OUD do not receive them and many experience relapse following care episodes. Developing and organizing quality measures under a unified framework such as a Cascade of Care could improve system level practice and treatment outcomes. In this context, a review was performed of existing quality measures relevant to the treatment of OUD and the literature assessing the utility of these measures in community practice. Methods Systematic searches of two national quality measure clearinghouses (National Quality Forum and Agency for Healthcare Research and Quality) were performed for measures that can be applied to the treatment of OUD. Measures were categorized as structural, process, or outcome measures. Second stage searches were then performed within Ovid/Medline focused on published studies investigating the feasibility, reliability, and validity of identified measures, predictors of their satisfaction, and related clinical outcomes. Results Seven quality measures were identified that are applicable to the treatment of OUD. All seven were process measures that assess patterns of service delivery. One recently approved measure addresses retention in medication-assisted treatment for patients with OUD. Twenty-nine published studies were identified that evaluate the quality measures, primarily focused on initiation and engagement in care for addiction treatment generally. Most measures and related studies do not specifically incorporate the evidence base for the treatment of OUD or assess patient level outcomes such as overdose. Conclusion Despite considerable progress, gaps exist in quality measures for OUD treatment. Development of a unified quality measurement framework such as an OUD Treatment Cascade will require further elaboration and refinement of existing measures across populations and settings. Such a framework could form the basis for applying strategies at clinical, organizational, and policy levels to expand access to quality care and reduce opioid-related mortality.

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“…26 During and after tapering, close contact with the patient should be maintained because discontinuation of maintenance carries high risks of relapse to the use of illicit drugs and overdoses that may lead to death. 11,52,53 The effectiveness of methadone maintenance is well established, and this drug is listed among "essential medications" by the World Health Organization. 11,45 Maintenance programs decrease mortality by approximately 50% among persons with opioid-use disorders, decrease acquisition of HIV infection and hepatitis, decrease crime and illicit-substance use, improve social functioning, and increase the rate of retention in rehabilitation programs.…”

Section: Methadone Maintenance Approachesmentioning

confidence: 99%

Treatment of Opioid-Use Disorders

Benumof

2016

N Engl J Med

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Risk of mortality on and off methadone substitution treatment in primary care: a national cohort study

Abstract: Among primary care patients undergoing methadone treatment, continuing in methadone treatment is associated with a reduced risk of death. Patients' risk of all-cause mortality increases following treatment cessation, and is highest in the initial 4-week period.

Cited by 62 publications

References 35 publications

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

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

Developing an opioid use disorder treatment cascade: A review of quality measures

Treatment of Opioid-Use Disorders

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