More than two in five people receiving buprenorphine, a drug commonly used to treat opioid addiction, are also given prescriptions for other opioid painkillers - and two-thirds are prescribed opioids after their treatment is complete, a new Johns Hopkins Bloomberg School of Public Health study suggests.
The findings, published Feb. 23 in the journal Addiction, demonstrate the need for greater resources devoted to medication-assisted treatment, a common clinical tool to address the epidemic.
The idea behind medication-assisted treatment is that patients are given low-dose opioids that produce some of the effects of opioids while staving off physical withdrawal symptoms. The low-dose opioids produce weaker effects than drugs such as oxycodone or heroin, which come with the risk of addiction and overdose. With medication-assisted treatment, rigorous studies have shown that patients are more able to remain healthy and productive members of society.
Historically, the most common drug to treat opioid use disorders has been methadone, though over the past 15 years, buprenorphine, a shorter-acting opioid similar to methadone, has been increasingly used instead. For this study, the researchers looked at prescriptions for buprenorphine and Suboxone, a combination of buprenorphine and naloxone, an anti-overdose medication. Rather than requiring a special clinic like methadone does, buprenorphine can be prescribed in a doctor's office, making it accessible to more patients.
"Policymakers may believe that people treated for opioid addiction are cured, but people with substance use disorders have a lifelong vulnerability, even if they are not actively using," says study leader G. Caleb Alexander, MD, MS, an associate professor of epidemiology at the Johns Hopkins Bloomberg School of Public Health and the co-director of the School's Center for Drug Safety and Effectiveness. "Our findings highlight the importance of stable, ongoing care for these patients."
Increases in prescription opioid use over the past two decades have led to an epidemic of addiction, injuries and deaths in the United States. In 2013, providers wrote nearly 250 million opioid prescriptions, enough to supply every adult in the United States with a bottle of pills. While it is sometimes appropriate for a patient to receive a prescription opioid during medication-assisted treatment - patients who are in acute pain from a major trauma or surgery may require short-term prescription opioids in addition to their medication-assisted treatment - the researchers say they are concerned to see such high rates of combined use of these products. This pattern suggests that many patients do not have well-coordinated treatment for opioid use disorders and chronic pain, which could lead to higher rates of relapse or overdose, Alexander says.
For their study, Alexander and his colleagues examined pharmacy claims for more than 38,000 new buprenorphine users who filled prescriptions between 2006 and 2013 in 11 states. They looked at non-buprenorphine opioid prescriptions before, during, and after each patient's first course of buprenorphine treatment, which typically lasted between one to six months. Even though there are no universally agreed-upon guidelines regarding the optimal length of treatment, most people discontinued buprenorphine within three months.
They found that 43 percent of patients who received buprenorphine filled an opioid prescription during treatment and 67 percent filled an opioid prescription during the 12 months following buprenorphine treatment. Most patients continued to receive similar amounts of opioids before and after buprenorphine treatment.
Because the study data lacked information on patients' use of illegal opioids like heroin, the results likely underestimate the proportion of patients using opioids during and after buprenorphine treatment. "The statistics are startling," says Alexander, "but are consistent with studies of patients treated with methadone showing that many patients resume opioid use after treatment."
Recent federal efforts have tried to improve the availability of medication-assisted treatment, so providing ongoing professional education and support to these providers will be important.
"Unlike methadone, buprenorphine can be prescribed for opioid use disorders in primary care, so it is an important treatment option for clinicians and patients to have," says study co-author Matthew Daubresse, a doctoral student in the Department of Epidemiology at the Bloomberg School. "But many patients, especially those with shorter lengths of treatment, appear to be continuing to use prescription opioids during and after buprenorphine treatment. We need to find better ways to keep patients engaged in long-term treatment, and these efforts couldn't be more urgent given how many Americans continue to die or get injured from opioids."
"Non-Buprenorphine Opioid Utilizations Among Patients Using Buprenorphine" was written by Matthew Daubresse, Brendan Saloner, Harold A. Pollack and G. Caleb Alexander.
The work was funded by the Centers for Disease Control and Prevention under Cooperative Agreement U01CE002499.
Alexander is chair of the FDA's Peripheral and Central Nervous System Advisory Committee, serves as a paid consultant to a mobile start-up PainNavigator, serves as a consultant to QuintileIMS and serves on its advisory board. This arrangement has been reviewed and approved by Johns Hopkins University in accordance with its conflict of interest policies.