Low-Dose Buprenorphine Falls Short for Fentanyl Users

TOPLINE:

Outpatient low-dose initiation (LDI) of buprenorphine has a low rate of success in people with opioid use disorder (OUD) using fentanyl, with a completion rate of just 34% and retention rates of 18%-21%, a new cohort study suggests.

METHODOLOGY:

• The cohort study analyzed data from 126 adults (median age, 35 years; 71% men; 52% White individuals) with OUD who self-reported daily fentanyl use across 175 buprenorphine initiation attempts at two clinics in San Francisco from 2021 to 2022.
• Participants selected either a 4-day protocol (72 LDI attempts, 41%) or a 7-day protocol (103 LDI attempts, 59%). The 4-day protocol used four-times-a-day dosing, while the 7-day protocol used twice- or thrice-a-day dosing.
• Primary outcome measures included successful buprenorphine initiation, defined as self-reported LDI completion and pickup of a refill maintenance prescription, as well as buprenorphine retention.
• Associations between LDI protocol types and successful initiation were analyzed, while adjusting for multiple attempts, age, gender identity, race, ethnicity, and housing status.

TAKEAWAY:

• Successful initiation occurred in only 60 attempts (34%), with rates of 38% (27 attempts) in the 4-day protocol and 28% (29 attempts) in the 7-day protocol. Adjusted models showed no significant differences between the protocols (adjusted odds ratio [aOR], 1.5; 95% CI, 0.8-2.8).
• Repeated attempts had lower odds of successful initiation than first attempt (first vs second attempt aOR, 0.3; first vs third or later attempts aOR, 0.2).
• Participants in transitional housing or without housing had lower odds of successful attempts than those with stable housing (aOR, 0.3 and 0.4, respectively).
• Retention rates at 28 days were low and did not differ significantly between the 4-day (21%) and 7-day protocols (18%).

IN PRACTICE:

“LDI has become an increasingly common strategy for initiating buprenorphine treatment among a cohort of publicly insured or uninsured persons using fentanyl. However, successful LDI completion in outpatient settings remains low, and successive attempts at LDI yield diminishing returns,” the investigators wrote.

However, authors of an accompanying editorial noted that “until further evidence accumulates, we should be cautious about recommending widespread adoption of any specific alternative as the default initiation strategy” in fentanyl use.

SOURCE:

The study was led by Leslie W. Suen, MD, Division of General Internal Medicine, San Francisco General Hospital, University of California, San Francisco. The editorial was led by Justin Berk, MD, Alpert Medical School, Brown University, Providence, Rhode Island. Both were published online on January 24 in JAMA Network Open.

LIMITATIONS:

The retrospective data collection and participants’ self-selection of the LDI protocol may have introduced bias and the small sample size may have reduced the power to detect differences between the protocols. The findings were also not generalizable to other settings or populations. Additionally, the extent of the clinician’s influence on the patient’s choice of LDI type remained unclear.

DISCLOSURES:

The study was funded by grants from the Agency for Healthcare Research and Quality and the National Institute on Drug Abuse (NIDA). Suen reported serving unpaid on the board of directors of the Association for Multidisciplinary Education and Research in Substance Use and Addiction and the National Coalition to Liberate Methadone outside the submitted work, while another investigator reported receiving grants from the National Institutes of Health. Two editorialists reported receiving grants from NIDA during the study.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.