In the JournalsPerspective

Many patients struggle to stop buprenorphine use

Zoe Weinstein
Zoe M. Weinstein

Many patients who want to stop using buprenorphine for opioid use disorder were not able to, according to findings recently published in Drug and Alcohol Dependence.

“Every day in my clinic one of my patients tells me he/she is thinking about tapering off buprenorphine and often when I try to start patients on medication, they are reluctant to start as they are concerned about eventually coming off,” Zoe M. Weinstein MD, MS, the director of the Addiction Consult Service, Boston Medical Center, told Healio Family Medicine. “I know tapering off is an important goal for many of my patients, but I felt I did not have enough information to counsel them correctly.”

Researchers conducted a retrospective cohort study of 1,308 adults receiving buprenorphine. During a median follow-up of 316 days, 48 patients tapered off the medication, for an estimated proportion of 15% (95% CI, 10–21) of all patients. Only 22 of these tapers were medically supervised, and after a median follow-up of 490 days, 13 of the 48 patients resumed buprenorphine treatment.

Characteristics of the 48 patients who were able to taper off buprenorphine included: mean age of initial opioid use was 22 years; mean age of enrolling in an office-based addiction treatment clinic was 38 years; 74.5% were white; 37.5% were women; and 30.8% had not finished high school. In addition, 41.7% of the 48 patients who were able to stop using buprenorphine had a lowest mean daily dose of more than 8 mg before taper completion, 31.3% of patients had a minimum daily dose 4 mg or less prior to completing the taper, and 27.1% had a minimum dose between 8 mg and 5 mg.

“Coming off a chronic medication is hard for any disease. Patients who want to make diet and lifestyle changes and get off diabetes and BP medications struggle to do so, so I was not surprised how few patients were able to taper off and remain off medications,” Weinstein said.

“These findings highlight the chronic relapsing nature of [the opioid epidemic], and that we need to help people get into and stay in care. Some insurances have put caps on how long people can be on buprenorphine. These findings show that many people need indefinite maintenance, and we need to make sure people can continue on with lifesaving care, which is why health care parity is essential in addressing the opioid epidemic,” she added. – by Janel Miller

Disclosure: The authors report no relevant financial disclosures.

 

Zoe Weinstein
Zoe M. Weinstein

Many patients who want to stop using buprenorphine for opioid use disorder were not able to, according to findings recently published in Drug and Alcohol Dependence.

“Every day in my clinic one of my patients tells me he/she is thinking about tapering off buprenorphine and often when I try to start patients on medication, they are reluctant to start as they are concerned about eventually coming off,” Zoe M. Weinstein MD, MS, the director of the Addiction Consult Service, Boston Medical Center, told Healio Family Medicine. “I know tapering off is an important goal for many of my patients, but I felt I did not have enough information to counsel them correctly.”

Researchers conducted a retrospective cohort study of 1,308 adults receiving buprenorphine. During a median follow-up of 316 days, 48 patients tapered off the medication, for an estimated proportion of 15% (95% CI, 10–21) of all patients. Only 22 of these tapers were medically supervised, and after a median follow-up of 490 days, 13 of the 48 patients resumed buprenorphine treatment.

Characteristics of the 48 patients who were able to taper off buprenorphine included: mean age of initial opioid use was 22 years; mean age of enrolling in an office-based addiction treatment clinic was 38 years; 74.5% were white; 37.5% were women; and 30.8% had not finished high school. In addition, 41.7% of the 48 patients who were able to stop using buprenorphine had a lowest mean daily dose of more than 8 mg before taper completion, 31.3% of patients had a minimum daily dose 4 mg or less prior to completing the taper, and 27.1% had a minimum dose between 8 mg and 5 mg.

“Coming off a chronic medication is hard for any disease. Patients who want to make diet and lifestyle changes and get off diabetes and BP medications struggle to do so, so I was not surprised how few patients were able to taper off and remain off medications,” Weinstein said.

“These findings highlight the chronic relapsing nature of [the opioid epidemic], and that we need to help people get into and stay in care. Some insurances have put caps on how long people can be on buprenorphine. These findings show that many people need indefinite maintenance, and we need to make sure people can continue on with lifesaving care, which is why health care parity is essential in addressing the opioid epidemic,” she added. – by Janel Miller

Disclosure: The authors report no relevant financial disclosures.

 

    Perspective
    Lawrence Greenblatt

    Lawrence Greenblatt

    This article, written by a group of researchers based at a large, urban, safety net primary care clinic that offers treatment with buprenorphine for those with opioid use disorder, highlights the real-world difficulties of tapering off treatment. The researchers did not create an intervention, but instead identified in their extensive database patients who had either requested a taper from their treatment provider or who had tapered on their own.

    Increasing numbers of primary care providers have been obtaining their DATA 2000 waiver and offering treatment with buprenorphine typically in combination with naloxone in their office as part of their general practice. On occasion, patients will suggest tapering off medication in part because of convenience or stigma, although sometimes out of personal preferences and values. Treatment providers know that long-term, medication-assisted therapy reduces many adverse outcomes, including return to opioid abuse, overdose, criminal behavior, acquisition of hepatitis C and HIV, and others. Currently, the optimal duration of therapy is unknown and most patients prefer to stay in treatment and are typically treated long-term on a stable dose.

    In addition, most PCPs who offer treatment for opioid use disorder struggle with accommodating as many patients as need treatment in their practice or community as PCPs are often in high demand for primary care services, as well. Thus, having a patient successfully taper creates an opening for an individual provider to take on new patients who need treatment.

    Weinstein and colleagues describe a low number of patients who initiate a treatment taper, with the majority doing it on their own. Somewhat less than half did it under medical supervision and these patients were typically tapered much more slowly. Overall, most individuals were unable to complete their taper and stop medication. Of those who did, the majority went back on treatment, typically years later. While it is not known what happened to those patients in the interim, it is likely that most of them relapsed prior to re-engaging in treatment.

    What can primary care providers take away from this article? First, few practitioners who are experienced in working with individuals suffering from opioid use disorder will be surprised. The vast majority of individuals prefer to stay on treatment and find it invaluable in maintaining their sobriety. Even if PCPs are not actively engaged in providing medication-assisted treatment, they should support their patients who are receiving this highly effective therapy and encourage them to feel good about maintaining treatment if it helps them to avoid relapse and the dangers of active opioid abuse.

    PCPs who are providing treatment need to feel comfortable that this will be a long-term and possibly lifelong therapy for their patients. We can support those who are motivated to taper, though PCPs should always welcome them back into treatment and facilitate this process should it become necessary. Lastly, policymakers must recognize the need for a large primary care workforce to provide effective therapy for the millions of individuals currently suffering from opioid use disorder, as these individuals require frequent visits and many years of treatment.


     

     

    • Lawrence Greenblatt, MD
    • professor of medicine and community and family medicine, Duke University School of Medicine

    Disclosures: Greenblatt reports no relevant financial disclosures.

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