The real‐world impact of dosing of methadone and buprenorphine in retention on opioid agonist therapies in Ukraine

Abstract

Background and Aims Ukraine's HIV epidemic remains concentrated among opioid‐dependent people who inject drugs (PWID) where opioid agonist therapies (OAT) like methadone (MMT) and buprenorphine (BMT) maintenance treatments are the most cost‐effective HIV prevention strategies, but remain under‐scaled. This study aimed to measure the association between dose and type of OAT prescribed and treatment retention. Design Observational longitudinal cohort study. Participants and Setting Patients (n = 15 290) prescribed OAT throughout Ukraine from 2004 through 2016. Measurements Data were analyzed using time–event strategies to estimate cumulative treatment retention, defined as time to OAT discontinuation. Cumulative retention proportions at 1, 12 and 36 months were assessed for outcomes. Cox regression with log‐rank likelihood assessed independent predictors of treatment discontinuation. Findings The proportion prescribed high (MMT: > 85 mg; BMT: ≥ 16 mg), medium (MMT: > 40–85 mg; BMT: > 6–15 mg) and low (MMT: ≤ 40 mg; BMT: ≤ 6 mg) dosages was 25, 43 and 32%, respectively. Retention was significantly higher for BMT than MMT both at 12 (89 versus 75%) and 36 months (80 versus 56%). Although dosing levels for BMT did not influence retention, increasing dosages for MMT were significantly associated with higher retention rates at 1 (90, 96, 99%), 12 (59, 78, 91%) and 36 (34, 59, 79%) months, respectively. Independent predictors associated with 12‐month OAT discontinuation were medium [adjusted hazard ratio (aHR) = 2.23; 95% confidence limit (CL) = 1.95–2.54] and low (aHR = 4.96; 95% CL = 4.37–5.63) OAT dosage relative to high dosage, male sex (aHR = 1.27; 95% CL = 1.14–1.41), MMT relative to BMT prescription (aHR = 1.57; 95% CL = 1.32–1.87) and receiving OAT in general (aHR = 1.22; 95% CL = 1.02–1.46) or tuberculosis (aHR = 1.43; 95% CL = 1.10–1.85) hospitals, relative to specialty addiction treatment and AIDS center settings. Lower dosages contributed more to dropout especially at 1 month (aHR 3.12; 95% CL = 2.21–4.41 and aHR 7.71; 95% CL = 5.51–10.79 for medium and low dosages, respectively). Younger age was significantly associated with OAT discontinuation only at 36 months (aHR = 1.08; 95% CI = 1.02–1.15). Conclusions Higher dosages of opioid agonist therapies, especially for methadone maintenance treatment patients, appear to be associated with higher levels of treatment retention in Ukraine.

Duration of use and outcomes among people with opioid use disorder initiating methadone and buprenorphine in Ontario: a population‐based propensity‐score matched cohort study

“…We defined ongoing use of methadone and buprenorphine/naloxone on the basis of successive refills with no gap in therapy exceeding 14 days. This definition of treatment discontinuation is aligned with recently published literature [21,22] and was selected because a gap in treatment exceeding 14 days would reflect a clinically meaningful break in therapy requiring the re-initiation of OAT. When this condition was not satisfied, people were deemed to have discontinued treatment.…”

The influence of poly-drug use patterns on the association between opioid agonist treatment engagement and injecting initiation assistance

“…Nevertheless, our findings extend previous research demonstrating that people enrolled in OAT and who use cocaine are more likely to report continued cocaine and heroin use when accessing these services compared to those who use other substances [ 26 , 27 ]. The current findings potentially indicate that alternative therapeutic approaches (e.g., buprenorphine), OAT dosing strategies, or tailored OAT engagement supports are needed to meet the needs of individuals who engage in complex poly-drug use [ 28 ].…”

Buprenorphine treatment receipt characteristics and retention among people who inject drugs at Integrated Care Centers in India

“…The Indian OST guidelines 25 for provision of buprenorphine recommend a lower daily maintenance dose of 8-12 mg compared to analogous guidelines in other countries 44,45 . While studies in many settings show that higher buprenorphine dose is associated with improved adherence and retention [46][47][48][49][50][51] , this recommendation in part was borne out of the earlier studies in India showing high retention with lower doses of buprenorphine 24,[33][34][35]52,53 . However, even by the Indian OST guidelines, more than three quarter of PWID at ICCs received less than 8 mg of buprenorphine daily.…”