From Chronic Opioids for Pain to Microgram Buprenorphine: Key Factors in an Increasingly Recommended Transition.

Abstract

Background: Guidelines on the use of opioids in chronic pain management increasingly recommend consideration of buprenorphine for patients on long-term full agonist opioid therapy. Published strategies for patients' transitions to buprenorphine vary widely in terms of study design, dose, formulation, and timing of buprenorphine initiation. A further limitation in informing an ideal transition strategy is the paucity of data describing factors that influence the likelihood of a successful transition.

Objectives: We sought to describe factors that influenced the likelihood of a successful transition to buprenorphine.

Study design: Retrospective cohort study.

Setting: This research used data from the national Corporate Data Warehouse of the Veterans Health Administration.

Methods: We reviewed the Veterans Affairs Corporate Data Warehouse for information concerning patients who had outpatient opioid prescriptions and had received microgram-strength buprenorphine. With this information in mind, we examined the factors associated with a successful transition to buprenorphine.

Results: We identified significant reductions in the number of patients prescribed full agonist opioids and in the total dose of opioids prescribed after buprenorphine exposure, with the largest effect observed in patients who continued using buprenorphine. While the potency and dose of baseline opioids were not predictive of the continued use of buprenorphine, higher opioid doses were associated with a decreased likelihood of continuation. Although factors correlating with patient support were associated with buprenorphine continuation, factors correlating with reduced support were associated with lower odds of continued buprenorphine use.

Limitations: Limitations inherent to large-scale observational studies are present, including imperfect data quality/ integrity, incomplete data, and the use of stop codes and CPT codes to determine the nature of a clinical encounter. The dataset is limited to the information collected, which excludes other factors likely associated with the outcomes. We used the continuous prescription of buprenorphine as a surrogate marker of a successful transition. Given the retrospective nature of the study, we are unable to determine if buprenorphine exposure is causally related to reduced opioid use. The population served by the Veterans Health Administration is not representative of other populations, and the results of this study may not generalize to other patient populations.

Conclusions: Our findings support the recommendation to trial buprenorphine in patients receiving chronic opioid therapy. This study's results also suggest that patient factors and shared decision-making are more important predictors of success than are the pharmacologic properties, potency, or dose of pre-rotation opioid exposure.