Patient outcomes following buprenorphine treatment for opioid use disorder: A retrospective analysis of the influence of patient- and prescriber-level characteristics in Massachusetts, USA.

Abstract

Background and aims: Opioid use disorder (OUD) is treatable with buprenorphine/naloxone (buprenorphine), but many patients discontinue treatment prematurely. The aim of this study was to assess the influence of patient- and prescriber-level characteristics relative to several patient outcomes following the initiation of buprenorphine treatment for OUD.

Design: This was a retrospective observational investigation. We used the Public Health Data Warehouse from the Massachusetts Department of Public Health to construct a sample of patients who initiated buprenorphine treatment between 2015 and 2019. We attributed each patient to a prescriber based on information from prescription claims. We used multilevel models to assess the influence of patient- and prescriber-level characteristics on each outcome.

Setting: Massachusetts, USA.

Participants: The study cohort comprised 37 955 unique patients and 2146 prescribers. Among patients, 64.6% were male, 52.6% were under the age of 35 and 82.2% were White, non-Hispanic. For insurance coverage, 72.1% had Medicaid.

Measurements: The outcome measures were poor medication continuity, treatment discontinuation and opioid overdose, all assessed within a 12-month follow-up period that began with a focal prescription for buprenorphine. Each patient had a single follow-up period. Poor medication continuity was defined as medication gaps totaling more than 7 days during the initial 180 days of buprenorphine treatment and treatment discontinuation was defined as having a medication gap for 2 consecutive months within the 12-month follow-up period.

Findings: The patient-level rates for poor medication continuity, treatment discontinuation and opioid overdose were 59.7% [95% confidence interval (CI) = 59.2-60.2], 57.4% (95% CI = 56.9-57.9) and 10.3% (95% CI = 10.0-10.6), respectively, with 1.1% (95% CI = 1.0-1.2) experiencing a fatal opioid overdose. At the patient level, after adjustment for covariates, adverse outcomes were associated with race/ethnicity as both Black, non-Hispanic and Hispanic patients had worse outcomes than did White, non-Hispanic patients (Black, non-Hispanic -- poor continuity: 1.50, 95% CI = 1.34-1.68; discontinuation: 1.44, 95% CI = 1.30-1.60; Hispanic -- poor continuity: 1.21, 95% CI = 1.12-1.31; discontinuation: 1.38, 95% CI = 1.28-1.48). Patients with insurance coverage through Medicaid also had worse outcomes than those with commercial insurance (poor continuity: 1.18, 95% CI = 1.11-1.26; discontinuation: 1.09, 95% CI = 1.03-1.16; overdose: 1.98, 95% CI = 1.75-2.23). Pre-treatment mental health conditions and other types of chronic illness were also associated with worse outcomes (History of mental health conditions -- poor continuity: 1.11, 95% CI = 1.06-1.17; discontinuation: 1.05, CI = 1.01-1.10; overdose: 1.47, 95% CI = 1.36-1.60; Chronic health conditions -- poor continuity: 1.15, 95% CI = 1.05-1.27; discontinuation: 1.15, 95% CI = 1.05-1.26; overdose: 1.83, 95% CI = 1.60-2.10; History of substance use disorder other than for opioids -- poor continuity: 1.54, 95% CI = 1.46-1.62; discontinuation: 1.54, 95% CI = 1.47-1.62; overdose: 1.93, 95% CI = 1.80-2.07). At the prescriber level, after adjustments for covariates, adverse outcomes were associated with clinical training, as primary care physicians had higher rates of adverse outcomes than psychiatrists (poor continuity: 1.12, 95% CI = 1.02-1.23; discontinuation: 1.04, 95% CI = 1.01-1.09). A larger prescriber panel size, based on number of patients being prescribed buprenorphine, was also associated with higher rates of adverse outcomes (poor continuity: 1.36, 95% CI = 1.27-1.46; discontinuation: 1.21, 95% CI = 1.14-1.28; overdose: 1.10, 95% CI = 1.01-1.19). Between 9% and 15% of the variation among patients for the outcomes was accounted for at the prescriber level.

Conclusions: Patient- and prescriber-level characteristics appear to be associated with patient outcomes following buprenorphine treatment for opioid use disorder. In particular, patients' race/ethnicity and insurance coverage appear to be associated with substantial disparities in outcomes, and prescriber characteristics appear to be most closely associated with medication continuity during early treatment.