Study data published in Neuropsychiatric Disease and Treatment outline the primary factors affecting attrition in buprenorphine (BUP) treatment for opioid use disorder (OUD). In a retrospective analysis of adults receiving BUP for OUD, retention rates were higher among women, White patients, patients with less severe OUD, patients with better global functioning, and patients not using other psychotropic medications. Additionally, retention was greater when BUP was initiated in an outpatient setting compared with an inpatient setting.
This retrospective analysis used electronic medical records data from 23 inpatient and outpatient clinics in 11 US states. Adults (≥16 years) with OUD who initiated BUP treatment in outpatient, inpatient, or intensive outpatient settings between January 2009 and December 2018 were included in analyses. Patients without complete BUP dosing information were excluded.
The primary outcome was treatment attrition, declared when 37 days had elapsed from the last treatment visit. Demographic and clinical information were extracted from treatment records. OUD severity and global functioning were measured using the 7-point Clinical Global Impression – Severity scale and the Global Assessment of Functioning scale, respectively. Survival analyses were used to compare attrition rates by demographic and clinical factors, as well as across treatment settings.
The study cohort comprised 5158 patients with OUD who initiated BUP treatment. The demographic distribution was as follows: 54.2% men; 45.8% women; 92.5% White; 3.3% Black; and 66.1% under the age of 35 years. The majority (60-70%) of patients had a diagnosis of an additional substance use disorder, including alcohol, stimulant, sedative/hypnotic/anxiolytic, or cannabis use disorders.
Treatment was initiated in an outpatient setting for 2409 patients and an inpatient or intensive outpatient setting for 2,749 patients. Retention was significantly higher with BUP initiation in an outpatient setting vs inpatient/intensive outpatient setting at two months (50% vs 25%), six months (27% vs 9%), and 12 months (14% vs 4%) followup. Regardless of the setting of BUP initiation, patients with greater illness severity were less likely to remain in treatment and patients with higher global functioning were more likely to remain in treatment.
Men were more likely than women to drop out of treatment. In the inpatient/intensive outpatient cohort, the retention probabilities for women and men at one month were 57% and 48%, respectively. Among outpatients, the respective probabilities were 67% and 62%. These trends persisted over time.
Among inpatients, younger patients were more likely to drop out. However, age had no apparent effect on attrition in the outpatient cohort. Comorbid alcohol use predicted greater retention among patients who initiated BUP in an inpatient/intensive outpatient setting, though not among patients who initiated in an outpatient setting.
Among outpatients only, concurrent use of psychotropic medication was associated with greater risk of dropout. Predictive modeling could not be conducted for race/ethnicity due to the small number of enrolled minority patients. However, Black patients appeared to be at elevated risk for attrition compared with White patients.
Results from this study suggest that high attrition rates prevent many patients with OUD from benefitting from BUP treatment. In particular, patients who initiated treatment in inpatient settings were more likely to discontinue treatment before one year.
Younger age, poorer global functioning, and psychiatric comorbidities further predicted attrition. As for study limitations, investigators cited the retrospective design and lack of data on certain social factors, including housing status, insurance status, and employment status. Additionally, data may not be generalizable to minority patients, who were substantially underrepresented in the study cohort.
“Of all the OUD patients who began BUP, 50–75% left treatment within 3 months, and most could be accurately identified,” investigators wrote. “This could facilitate patient-centered management to better retain OUD patients in BUP treatment.”
Disclosure: Several study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.
Ker S, Hsu J, Balani A, et al. Factors that affect patient attrition in buprenorphine treatment for opioid use disorder: a retrospective real-world study using electronic health records. Neuropsychiatr Dis Treat. October 28, 2021. doi:10.2147/NDT.S331442