Buprenorphine compliance rates

Choose you evidence carefully by rocket ship
Choose you evidence carefully by rocket ship

The following abstract popped up today.

The purpose of the study was to look at factors associated with completion of the 6 month, primary care based program.

What struck me was the completion rate–35.7%. For all the crowing about ORT, this seems really low. (And, they said this completion rate is consistent with prior studies.) This is particularly underwhelming when the researchers identify physical injury as a predictor of completions and speculate that this is related to chronic pain. These subjects constitute 71.7% of completers. So…when you omit those with injuries, the completion rate drops to 24%.

Primary care patient characteristics associated with completion of 6-month buprenorphine treatment

BACKGROUND: Opioid addiction is prevalent in the United States. Detoxification followed by behavioral counseling (abstinence-only approach) leads to relapse to opioids in most patients. An alternative approach is substitution therapy with the partial opioid receptor agonist buprenorphine, which is used for opioid maintenance in the primary care setting. This study investigated the patient characteristics associated with completion of 6-month buprenorphine/naloxone treatment in an ambulatory primary care office.
METHODS: A retrospective chart review of 356 patients who received buprenorphine for treatment of opioid addiction was conducted. Patient characteristics were compared among completers and non-completers of 6-month buprenorphine treatment.
RESULTS: Of the 356 patients, 127 (35.7%) completed 6-month buprenorphine treatment. Completion of treatment was associated with counseling attendance and having had a past injury.
CONCLUSIONS: Future research needs to investigate the factors associated with counseling that influenced this improved outcome. Patients with a past injury might suffer from chronic pain, suggesting that buprenorphine might produce analgesia in addition to improving addiction outcome in these patients, rendering them more likely to complete 6-month buprenorphine treatment. Further research is required to test this hypothesis. Combination of behavioral and medical treatment needs to be investigated for primary care patients with opioid addiction and chronic pain.

Overprescription of opioids is bad medicine

Artist: Ashley Mackenzie Via: High Fructose
Artist: Ashley Mackenzie
Via: High Fructose

Keith Humphreys points out that the problem with the explosion of prescriptions for opioids isn’t just addiction and overdose. They are often just not good medicine.

Opioids typically have a miraculous effect on acute pain, but this does not necessarily translate to chronic pain relief, particularly as tolerance sets in over time. Even more disturbing, my colleague Dr. Jodie Trafton and I are among many researchers who have found that a portion of long-term opioid users became hyperalgesic, i.e., they experience more rather than less pain.

This is not the only line of scientific findings that flies in the face of the assumption that if opioids are used less often, more pain will be the inevitable result. In a study my colleagues and I conducted with surgery patients (first author Dr. Ian Carroll; publication here), the amount of time individuals stayed on opioids after surgery, surprisingly, bore no relationship to their level of pain. People stay on opioids for a range of reasons not necessarily linked to pain; in our study taking them for long periods was well-predicted by pre-existing depression, for example. Many people who are on these medications would be in better health and equal or less pain if they were weaned off them.

A further dangerous side-effect of long-term opioids is hormonal, as Meier explains:

These drugs have a very powerful impact on our production of sexual hormones — testosterone in men and estrogen in women. Lower hormone production is not just about growing hair or sexual performance; it’s about your entire energy level. These drugs are depleting people of energy. There are even data showing that the more powerful opioids, the long-acting OxyContin, methadone, fentanyl, which is sold as Duragesic, have an even more powerful effect on depressing hormone production than short-acting opioids.


Balancing pain management and public health

Advertisement for curing morphine addictions f...
Advertisement for curing morphine addictions from Overland Monthly, January 1900 (Photo credit: Wikipedia)

I blogged before about the availability of opiates for pain management and the need to try to limit their diversion. While others have complained about draconian limitations on the prescribing of opiates and being too afraid to treat pain, I pointed out the explosion in opiate prescriptions and overdoses. It’s a complex problem that demands a solution that balances the needs of pain patients with the public health risks of easily available opiates.

Here’s a new study looking at the issue [emphasis mine]:

While overdose death rates related to heroin, cocaine, sedative hypnotics, and psychostimulants increased between 1999 and 2009, deaths related to pharmaceutical opioids increased most dramatically, nearly 4-fold. In 2000, the Joint Commission on the Accreditation of Health Care Organizations introduced new standards for pain management which focused on increased awareness of patient’s right to pain relief which contributed to an increase in prescribing of opioid analgesics (Phillips, 2000 and Federation of State Medical Boards of the US, 1998). The average milligrams of morphine prescribed per patient per year increased more than 600% from 1997 to 2007, which led to an increased availability of pharmaceutical opioids for illicit use (US Department of Justice, 2012). From 1999 to 2007, substance abuse treatment admissions for pharmaceutical opioid abuse increased nearly 4-fold and emergency department visit rates related to pharmaceutical opioids increased 111% from 2004 to 2008; visit rates were highest for oxycodone, hydrocodone, and methadone (SAMHSA, 2009aSAMHSA, 2009b and SAMHSA, 2011). Risks associated with pharmaceutical opioid related overdose included taking high daily doses of opioids and seeking care from multiple healthcare providers to obtain many prescriptions (Paulozzi et al., 2012 and Hall et al., 2008). “Doctor shopping” has also been associated with opioid diversion and illicit use (SAMHSA, 2010 and Rigg et al., 2012). National survey data showed that 75% of pharmaceutical opioid users were using opioids prescribed to someone else (Substance Abuse and Mental Health Services Administration, 2010).