Treatment outcomes in opioid dependent patients with different buprenorphine/naloxone induction dosing patterns and trajectories

Abstract

Background and Objectives Induction is a crucial period of opioid addiction treatment. This study aimed to identify buprenorphine/naloxone (BUP) induction patterns and examine their association with outcomes (opioid use, retention, and related adverse events [AEs]). Methods The secondary analysis of a study of opioid-dependent adults seeking treatment in eight treatment settings included 740 participants inducted on BUP with flexible dosing. Results Latent class analysis models detected six distinctive induction trajectories: bup1-started and remained on low; bup2-started low, shifted slowly to moderate; bup3-started low, shifted quickly to moderate; bup4-started high, shifted to low; bup5-started and remained on moderate; bup6-started moderate, shifted to high dose (Fig. 1). Baseline characteristics, including Clinical Opioid Withdrawal Scale (COWS), were important predictors of retention. When controlled for the baseline characteristics, bup6 participants were three times less likely to drop out the first 7 days than bup1 participants (adjusted hazard ratio (aHR) = .28, p = .03). Opioid use and AEs were similar across trajectories. Participants on ≥16 mg BUP compared to those on <16 mg at Day 28 were less likely to drop out (aHR = .013, p = .001) and less likely to have AEs during the first 28 days (aOR = .57, p = .03). Discussion and Conclusions BUP induction dosing was guided by an objective measure of opioid withdrawal. Participants with higher baseline COWS whose BUP doses were raised more quickly were less likely to drop out in the first 7 days than those whose doses were raised slower. Scientific Significance This study supports the use of an objective measure of opioid withdrawal (COWS) during BUP induction to improve retention early in treatment.

Neuromodulation with percutaneous electrical nerve field stimulation is associated with reduction in signs and symptoms of opioid withdrawal: a multisite, retrospective assessment

“…The majority of patients in this study fell into the moderate range of withdrawal, which is consistent with other studies using pharmacotherapy as initial treatment. (9,10,15) A recent study that compared treatment outcomes in opioid-dependent patients with different buprenorphine/naloxone induction doses found that baseline COWS scores influence treatment retention rates. (8) A different study that investigated predictors of outcomes using methadone and buprenorphine therapy concluded that higher withdrawal scores are associated with poorer retention.…”

Optimal dose of buprenorphine in opioid use disorder treatment: a review of pharmacodynamic and efficacy data

“…That doses of 16 mg and higher may be associated with lower drop-out during the induction phase has been shown in analyses of outcome trajectories from the START clinical trial in the US [40,50]. Interestingly, in this study the statistically significant difference in retention for patients treated with 16 mg BUP versus <16 mg BUP was found only for drop-out during the first 28 days, and not for drop out during the later stage of the trial [50]. The importance of a dose of 16 mg daily SL BUP or higher Opioid negaƟve samples (%)…”

“…In addition, approximately 24% of patients withdrew during the 7-14 day SL BUP run-in period in a trial of an extended-release BUP formulation [7]. That doses of 16 mg and higher may be associated with lower drop-out during the induction phase has been shown in analyses of outcome trajectories from the START clinical trial in the US [40,50]. Interestingly, in this study the statistically significant difference in retention for patients treated with 16 mg BUP versus <16 mg BUP was found only for drop-out during the first 28 days, and not for drop out during the later stage of the trial [50].…”

High‐dose buprenorphine for treatment of high potency opioid use disorder

“…It is possible that the patient could have been stabilised on a lower dose of buprenorphine/naloxone if more time had been given before further titrating her dose, given the long half‐life of buprenorphine. However, recent research has demonstrated that higher initial starting doses of buprenorphine are helpful in improving retention in treatment and decreasing illicit substance use . Ultimately, dosing buprenorphine/naloxone at high doses should proceed with caution given concerns for sedation and other side effects.…”