Opinion
Massachusetts and the opioid crisis: Can involuntary holds work?
Dr. Dinah Miller asks whether involuntary holds on substance users are an effective way to tackle the epidemic.
SAN DIEGO – an observational study found.
“Opioid use disorder and overdose deaths are devastating many communities across the country,” lead study author Ajay Manhapra, MD, said at the annual meeting and scientific symposium of the American Academy of Addiction Psychiatry. “We know that engagement in opioid agonist treatment with buprenorphine/methadone is associated with a two-thirds reduction in mortality and lower morbidity. However, 1-year retention rates are generally less than 50%.”
Dr. Ajay ManhapraDr. Manhapra of Yale University, New Haven, Conn., noted that while psychotherapy and counseling traditionally have been the bedrock of opioid use disorder (OUD) treatment, recent trials suggest that psychotherapy might not be that essential. In fact, four studies showed no benefit from adding a behavioral intervention to buprenorphine plus medication management, while four other studies indicated some benefit for specific behavioral interventions, primarily contingency management (Am J Psych. 2017 Aug;174[8]:738-47).
Doug Brunk/Frontline Medical News
As part of a larger study on 3-year buprenorphine retention, Dr. Manhapra and his associates set out to investigate what factors predict long-term retention in buprenorphine treatment. From patients with an OUD diagnosis in the Marketscan database, they identified 16,190 individuals who filled their prescription of buprenorphine after the first 60 days of 2011 as new starts and calculated the treatment retention period as the time between the date of their first prescription to the last prescription until the end of 2014. The researchers used CPT codes to identify the receipt of any outpatient psychotherapy and multivariate Cox survival analysis to examine the effect of psychotherapy receipt on buprenorphine retention.
Dr. Manhapra reported that of the 16,190 patients, 15% were engaged in buprenorphine treatment for 30 days or fewer, 40% were engaged for 31 days to 1 year, 31% were engaged between 1 and 3 years, and 14% were engaged for more than 3 years. The mean duration of retention was 1.23 years. At the same time, the outpatient psychotherapy receipt rate in 2011 was 30.29% among those retained for 0-30 days, 35.30% among those retained for 31-364 days, 37.59% among those retained for 1-3 years, and 39.20% among those retained for more than 3 years.
Multivariate Cox survival analysis revealed that receipt of any psychotherapy in 2011 was associated with a lower risk of discontinuation of buprenorphine treatment (hazard ratio, 0.86; P less than .0001). “Is this a direct effect of psychotherapy? I don’t know,” said Dr. Manhapra, who also practices at the Hampton (Virginia) VA Medical Center. “Is this a selection bias not accounted for by the variables available? That is, those who have a better chance of sustained retention might have been selected for or chosen to receive psychotherapy. Those are possibilities. We need further observational and qualitative studies, and maybe more randomized trials.”
Dr. Manhapra disclosed that he has received support from the VA Interprofessional Fellowship in Addiction Treatment and from Research in Addiction Medicine Scholars.
SOURCE: Manhapra A et al. AAAP 2017. Paper session A5.