Linking inpatient and outpatient buprenorphine treatment reduced opioid abuse

A program that started hospitalized, opioid-dependent patients on buprenorphine and linked them to outpatient care effectively reduced their opioid use, a new study found.

The trial randomly assigned 139 opioid-dependent patients who were hospitalized between Aug. 1, 2009, and Oct. 31, 2012, to either 5-day buprenorphine detoxification with treatment referral information at discharge or an alternative intervention. The intervention consisted of buprenorphine induction, inpatient dose stabilization, and postdischarge transition to maintenance buprenorphine opioid agonist treatment (OAT) provided by the hospital's primary care clinic. Results were published online by JAMA Internal Medicine June 30.

Patients in the intervention group were significantly more likely to enter maintenance OAT than those in the detox group (72.2% vs. 11.9%; P<0.001). At 6 months, which was the end of the study's follow-up, 12 (16.7%) of the intervention group and only 2 (3.0%) of the detox patients were receiving buprenorphine OAT (P=0.007). At the same time, the researchers queried patients about their illicit opioid use and found that the intervention group reported much less use in the prior 30 days (incidence rate ratio, 0.60; P<0.01). Available urine drug tests were used to confirm that the participants' self-reports were not dramatically underreporting use.

The intervention was an effective means for getting hospitalized patients who were not seeking addiction treatment connected with a program and using fewer opioids, the researchers concluded. However, the dropoff in OAT participation during the 6-month follow-up is a problem, they acknowledged. The same treatment program has a retention rate of 51% at 12 months for patients who initiate outpatient therapy, although those patients are likely to be more motivated and less medically ill. Another limitation of the study is its generalizability: Hospitals without affiliated outpatient programs might have more difficulty linking patients to postdischarge treatment.

If hospitals wanted to implement such a program, they would need to identify drug users systematically, develop an active referral network of buprenorphine prescribers, and have a dedicated inpatient substance use consulting team to initiate and bridge treatment, the study authors said. According to an accompanying editorial, the study is “groundbreaking,” but one of the major obstacles to widespread adoption of the model is a shortage of outpatient physicians and inpatient clinical staff (physicians or nonphysicians who could advise them) trained in buprenorphine treatment.

Some other recent publications assessed the use, and probable overuse, of opioids in the U.S. A survey of active military (more than 2,000 recently deployed members of an infantry brigade) found that 44% reported chronic pain and 15.1% reported opioid use in the past month. Almost half of those who had used opioids had no or mild pain in the past month, which should be cause for concern about overuse, concluded the authors of the research letter, also published by JAMA Internal Medicine on June 30.

Rates of opioid prescribing vary widely from state to state, according to a new report in the CDC's July 1 Morbidity and Mortality Weekly Report. Overall, in 2012, prescribers wrote 82.5 opioid prescriptions per 100 persons, but rates varied 2.7-fold and were highest in the South. Prescriptions for long-acting/extended-release and high-dose opioids, which may lead to more abuse and overdoses, were highest in the Northeast. The results indicate the need to identify problematic prescribing practices, the authors concluded. Another report in the same issue described how the state of Florida has successfully accomplished this and reduced deaths from prescription opioid use.