Only One-Third of Daily Fentanyl Users Report Success With Low-Dose Buprenorphine

Low-dose buprenorphine initiation among individuals who use fentanyl daily is often unsuccessful, suggesting that clinicians may need to provide more support for withdrawal symptoms in these individuals, according to a study issued in JAMA Network Open.

“… [F]entanyl is hypothesized to accumulate in fat stores much longer than other opioids, and individuals initiating buprenorphine can still undergo severe precipitated withdrawal, despite waiting until experiencing withdrawal [to begin buprenorphine treatment],” wrote Leslie W. Suen, M.D., of the University of California, San Francisco, and colleagues. “The emerging practice of low-dose initiation of buprenorphine presents an opportunity to improve outcomes in the fentanyl era.”

Suen and colleagues analyzed medical records for 126 adults with opioid use disorder who self-reported daily fentanyl use and requested to receive low-dose buprenorphine initiation using a four-day or seven-day protocol.

Success was defined as self-reported initiation completion and subsequent pickup of a refill prescription of buprenorphine within one month of initiation; the researchers also assessed buprenorphine retention rates.

Researchers adjusted the results for multiple attempts and demographic data, including housing status.

Overall, the 126 participants underwent 175 initiation attempts. Low-dose buprenorphine initiation attempts were successful in 60 participants (34%), including 27 among four-day protocol and 29 among seven-day protocol attempts. The researchers’ analysis found no significant differences between successful initiation and protocol length. However, repeated attempts had lower odds of success.

Buprenorphine treatment retention rate at 28 days was 21% for a four-day protocol and 18% for a seven-day protocol. Unadjusted and adjusted models did not detect a significant difference in retention between protocol type.

Success and treatment retention rates for low-dose buprenorphine initiation were significantly lower than those in prior studies among people using heroin or prescription opioids in the pre-fentanyl era, the researchers noted. This is due in part to “the pharmacologic challenges associated with chronic fentanyl use and the higher risk for precipitated withdrawal, although the significantly lower rate of success highlights the need to improve buprenorphine care and retention,” they wrote.

“Individuals using low-dose initiation may need more frequent support from clinicians on how to manage withdrawal symptoms,” the researchers continued. They noted that clinicians can normalize some withdrawal during counseling, consider prescribing more adjunctive medications, utilize bubble-pack medications to reduce user errors, offer support through closer follow-up calls, and provide a contact person to call for issues.

For related information, see the Psychiatric News article “Are Buprenorphine Doses Too Low?”

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Contingency Management App Improved OUD Treatment Outcomes

Augmenting medications for opioid use disorder (MOUD) with smartphone app–based contingency management resulted in improved treatment outcomes in a group of underinsured patients, according to a study issued yesterday in JAMA Network Open.

Traditionally delivered in clinics, contingency management (CM) provides financial incentives for accomplishing treatment goals, typically an opioid-negative finding on urine drug screens, wrote Elise N. Marino, Ph.D., from the University of Texas Health Science Center at San Antonio, and colleagues. “Although many individuals benefit from adding CM to MOUD, a long-standing limitation of this treatment is the requirement to attend multiple in-person appointments per week.”

The researchers used data from 3,759 uninsured or underinsured adults with opioid use disorder who were receiving publicly funded opioid treatment—including MOUD—from physicians’ offices or specialized clinics in Texas from November 2020 through November 2023. Participants were also given the option to receive a smartphone app–delivered CM program for one year. The app provided online individual and group support facilitated by peers; daily goal setting related to both substance use and recovery/self-care; encouragement; progress-tracking; and the ability to earn up to $800 in retail gift cards as an incentive.

In all, 622 participants (16.5%) opted to take part in the app-based CM. The researchers compared treatment outcomes of 300 participants who used the CM app with 300 participants who were similar in terms of age, sex, race, and ethnicity and chose to receive only MOUD.

Participants who chose the CM app reported significantly fewer days of opioid use at the end of treatment (8 days) compared with those who chose to receive MOUD only (12 days). Overall, 62% of the CM app group remained in treatment for the full year, compared with just 39% of the MOUD-only group. App participants were also significantly more likely to stay in treatment longer (290 days), compared with 236 days among MOUD-only participants.

“As a virtual treatment, app-based CM has fewer infrastructure barriers to implementation and should provide opportunities for rapid dissemination to patients,” Marino and colleagues wrote. “[H]owever, less than one-fifth of our entire sample chose to use it. Obtaining, owning, and navigating app-enabled devices may be barriers for some patients, and these apps require consistent use, which may become burdensome or unappealing over time, leading to low use. It is also possible that clinicians themselves may benefit from additional education and training to support adoption.”

For related information, see the Psychiatric News article “Experts Discuss Options for Treating Stimulant Use Disorder.”

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Low-Resource Patients With OUD Engaged With Collaborative Care Intervention

Patients with co-occurring mental illness and opioid use disorders in a low-resource community engaged with a collaborative care treatment program and stuck with it, according to a study in JAMA Network Open today.

“Opioid use disorders (OUDs) remain undertreated, particularly when co-occurring with mental illness,” wrote Katherine E. Watkins, M.D., M.S.H.S., with the RAND Corporation in Santa Monica, California, and colleagues. “The collaborative care model (CoCM), an evidence-based approach for integrating behavioral health treatment in primary care, offers a potential solution, but the extent to which the CoCM can engage high-risk populations with fidelity in community settings is poorly understood.”

Watkins and colleagues tapped into data from a randomized clinical trial in 14 low-resourced primary care clinics in New Mexico involving adults with probable OUD and co-occurring mental illness who were assigned to a six-month CoCM program between 2021 and 2023. About one-quarter of the adults had used fentanyl or heroin in the 30 days prior to enrollment, and three-quarters were prescribed medications for OUD.

The CoCM deployed addiction-certified psychiatric consultants, primary care clinicians, and community health workers as care managers, supported by a caseload tracking tool. Engagement was defined as participating in an intake interview, while fidelity was defined as having at least two care manager encounters, at least two assessments of OUD and mental health symptom severity, and a treatment plan review by a psychiatric consultant.

Of the 369 adults assigned to the CoCM, 297 participants (81%) engaged with it. Of those who engaged, 206 (69%) stuck with the CoCM, with a median of nine care encounters. Rates varied by substance used: Just 54% of individuals with stimulant co-use participated with fidelity, whereas 81% of those who misused only prescription pain medication did so.

Further work is needed to determine whether fidelity to the CoCM is associated with positive patient outcomes, the authors wrote. Limitations included the study’s use of observational data from one arm of a clinical trial in just one state with high OUD rates.

“Our results indicate that the CoCM may offer a solution to the undertreatment of OUD for patients with complex conditions,” researchers wrote. “When community health workers are used, the CoCM may be an efficient approach to address behavioral health professional shortages.”

For related information, see the Psychiatric News article “Three Health Systems Find Success With Collaborative Care.”

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Treatment for Opioid Use Disorder in 'Bridge' Clinics Offers Some Advantages, Study Finds

Hospitalized patients with opioid use disorder who were referred to an on-site clinic that provides wraparound services during the transition to outpatient care (a bridge clinic) reported fewer overdoses and more refills of medications like buprenorphine in the weeks following discharge, a study in JAMA Network Open found. However, the use of the bridge clinic was not associated with a faster discharge compared with usual opioid use disorder (OUD) care, nor did it reduce hospital readmissions or health care costs.

“Bridge clinics offer presumed care advantages, including timely provision of [medications] while a long-term clinician is identified, and notwithstanding other barriers, including stigma, they may offer the ability to discharge patients early,” wrote David Marcovitz, M.D., of the Vanderbilt University School of Medicine and colleagues.

Marcovitz and colleagues recruited 335 hospitalized adults with OUD (median age of 38) who were being seen in an addiction consultation service. Patients were randomized to receive usual care or care in the bridge clinic, which was co-located with the addiction consultation service. Patients assigned to the bridge clinic received enhanced case management during and after their hospitalizations, as well as a buprenorphine-naloxone prescription at discharge. They were asked to present weekly to the bridge clinic for the first eight weeks, then twice monthly based on their clinical presentations. Patients in the usual care group were referred to a community clinic and received a buprenorphine-naloxone prescription at discharge.

At 16 weeks, patients reported their recurrent opioid use, overdoses, and the number of buprenorphine-naloxone prescriptions they filled; they also reported whether they had been successfully linked to health care professionals who provided medications for OUD. Information on health care utilization was collected from the patients’ electronic medical records.

The median lengths of stay in the hospital did not differ between patients in the bridge clinic or in usual care (5.7 days compared with 5.9 days, respectively). After discharge, patients in the bridge clinic group had fewer hospital-free days, experienced more hospital readmissions, and had higher care costs. The total median cost of care was $9,482 in the bridge clinic group compared with $1,705 in the usual care group.

Eighty-eight patients completed the 16-week follow-up calls. Compared with the usual care group, those in the bridge clinic group were less likely to report having experienced an overdose and more likely to report linkage to health care professionals who provided medications for OUD. They also reported refilling more buprenorphine prescriptions.

The finding that the bridge clinic group incurred greater costs and more may be a result of patients utilizing care that they previously had not, wrote Marlene Martin, M.D., of the University of California, San Francisco, and Noa Krawczyk, Ph.D., of the NYU Grossman School of Medicine, in an accompanying commentary. “This finding may also reflect increased trust in the health care system associated with the bridge clinic group, as stigma often prevents patients with OUD from seeking and accessing care.”

For related information, see the Psychiatric News article “Bridge Clinic Cuts Emergency Department Use in Patients With OUD.”

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ADHD Diagnoses, Prescription Stimulants Rise in Patients With OUD

Diagnoses of attention-deficit/hyperactivity disorder (ADHD) among patients with opioid use disorder (OUD) tripled between 2007 and 2017, a study in Psychiatric Services has found. At the same time, the prevalence of ADHD pharmacotherapy increased by 22% for patients with co-occurring ADHD and OUD.

Tae Woo Park, M.D., M.Sc., of the University of Pittsburgh and colleagues conducted two separate analyses of claims data from commercially insured patients between the ages of 13 and 64 years.

In the first analysis, the researchers studied data from 387,980 patients with OUD to estimate the prevalence of ADHD diagnoses and pharmacotherapy. They found that the proportion of patients with OUD and ADHD grew from 4.6% in 2007 to 15.1% in 2017. Among patients with both OUD and ADHD, the rate of those receiving medication for ADHD increased from 42.6% to 51.8%.

In the second analysis, the researchers studied data from 158,591 patients who received medications for OUD to examine the characteristics of those who received concurrent stimulant medication and those who did not. The researchers found that 10.5% of the patients in this analysis received concurrent prescription medications. Those who received concurrent stimulant medications tended to be younger, female, and diagnosed as having one or more psychiatric conditions compared with those who did not receive stimulants. Patients who had been diagnosed with other substance use disorders were less likely to receive a concurrent stimulant medication, the authors found.

The researchers noted that although ADHD diagnoses and treatments have grown steadily worldwide, particularly among adults, increases in ADHD diagnoses appear to have grown faster among patients with OUD than in the general population over the same period.

“Increased recognition of the role of ADHD in developing opioid use disorder and other substance use disorders has likely resulted in this rise in [ADHD] diagnoses,” Park and colleagues wrote. “Conversely, opioid use disorder may exacerbate ADHD symptoms over time and cause greater functional impairment, leading to an increased rate of ADHD diagnoses among patients with opioid use disorder compared with the general population.”

The researchers encouraged health professionals to exercise caution when prescribing stimulants for patients with ADHD who are taking medications for OUD.

“Given the potential for increased overdose risk and the potential risks for diversion and misuse associated with stimulant medications, clinicians managing ADHD symptoms of patients receiving [medication for OUD] should carefully weigh the risks and benefits of stimulant treatment on a per-patient basis,” they wrote.

For related information, see the American Journal of Psychiatry article “Personalizing the Treatment of Substance Use Disorders.”

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