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Published 2017. This article is a U.S. Government work and is in the public domain in the USA
ISSN: 1055-0496 print / 1521-0391 online
DOI: 10.1111/ajad.12553
572
review showed that few studies have reported buprenorphine groups based on the duration of retention in treatment: 0–30
retention beyond 6 months, and the scant studies with longer days, 31–365 days; 1–3 years; and more that 3 years. We then
term information include data for only up to 1 year.17 Two compared the four retention groups on sociodemographic,
recent insurance claims-based studies focusing on healthcare diagnostic, and service and psychotropic medication use
costs presented data on treatment retention, but lacked clinical characteristics from FY 2012 administrative data.
information on patient characteristics that are associated with
retention.14,18 Diagnostic Characteristics and Service, and
The Veterans Health Administration (VHA) is the largest Psychotropic Medication Use
integrated healthcare provider in United States serving over Sociodemographic characteristics included age, gender,
five million US veterans annually. Veterans appear to have income, receipt of Veterans Affairs (VA) disability compensa-
similar rates of SUD as the general population, but are more tion, or pension payments, service in the Iraq or Afghanistan
likely to receive treatment, although the overall treatment rates theater of war (OIF/OEF), and a designation of urban versus
remain low.19 Although overall utilization of buprenorphine rural residence based on zip codes and Rural–Urban Commut-
has increased substantially in VHA, since its introduction in ing Area (RUCA) codes (depts.washington.edu/uwruca).
2003, paralleling non-VA national trends,1,20–22 the long-term Recent homelessness was identified by participation in a
retention in buprenorphine treatment among veterans treated VHA specialized homeless service program or a V-60 code
at VHA facilities has not been studied. In this observational indicating housing problems. Information on ethnicity was
study of veterans with OUD initiated on Buprenorphine OAT obtained and included black, white, Hispanic, and mixed races.
during fiscal year (FY) 2012, we examined the duration of Clinical diagnostic data included psychiatric and medical
buprenorphine service use up to and beyond 3 years along with diagnoses based on International Classification of Diseases,
socio-demographic, diagnostic and health service, and 9th edition [ICD-9] codes that were assigned to each patient at
psychotropic medication use correlates of prolonged engage- least once during the study year. The Charlson Index,23 an
ment. These data will increase our understanding of correlates aggregate measure of medical co-morbidity diagnoses, has
of long-term retention in buprenorphine maintenance therapy, been shown to predict the 10-year mortality for patients based
potentially facilitating the development of interventions to on the presence of a broad range of co-morbid medical
increase such retention. conditions and was used to assess medical co-morbidity (see
reference24 for details). Individual diagnoses that compose the
Charlson index were also examined. We included eight pain
METHODS diagnoses, based on ICD-9 diagnostic codes: any pain
diagnosis, herpetic pain (053.12 or 729.2), fibromyalgia
Sample and Data Source pain (729.1), musculoskeletal pain (338.xx, 719.4, 780.96),
National VHA administrative records from FY 2012 skeletal-spasm pain (728.85, 781.0), pain from diabetes
(October 1, 2011–September 30, 2012) were used to identify (250.6, 357.2, 337.1), migraine and headache (346.x,
all veterans with the diagnosis of OUD (ICD-9-CM codes 784.0), and pain and neuropathy (250.6, 357.2, 337.1, 338.
304.0x, 305.5x, and 304.7x—either opioid abuse or opioid x, 719.4, 780.96, 729.1, 728.85, 781.0, 053.12, 729.2, 352.1,
dependence). We then identified patients, who filled at least 350.1).
one prescription for buprenorphine in VHA nationally during Data on co-morbid psychiatric diagnoses included all ICD-9
the FY 2012. Patients receiving buprenorphine treatment were codes 290.00 through 319.99 (coded into 11 classes; available
identified by prescription fill data that included all patients, on request or see reference24). VHA inpatient and outpatient
who received at least one prescription for buprenorphine or service utilization was documented including medical and
buprenorphine/naloxone tablets, and excluded patients receiv- surgical outpatient visits, and emergency room visits.
ing buprenorphine transdermal patch as it is designated for Outpatient mental health specialty care, substance abuse
pain management rather than OAT. clinic visits, medical-surgical visits, and emergency depart-
ment visits were identified by standard VHA clinic stop codes
Measures as were patients who experienced a psychiatric hospitalization
Duration of Buprenorphine Treatment during the year.
Using the VHA pharmacy benefits data, we identified the Pharmacy benefit records documenting all VHA prescrip-
first and last day each patient received buprenorphine tions filled were used to identify the total number of
prescription, from October 1, 2011 (first day of FY 2012) to prescriptions filled by these patients in five psychiatric
September 30, 2015 (last day of FY 2015), a maximum of medication classes: antidepressants, antipsychotics, sedative/
4 years. We then calculated, the duration of treatment from the hypnotics/anxiolytics, mood stabilizers (anti-epileptics), and
first day of buprenorphine fill in FY 2012 and the last date lithium (the individual medications in each class available on
buprenorphine was filled from FY 2012–2015. We excluded request or see reference24). The total number of psychotropic
veterans who received any buprenorphine in the first 60 days of prescriptions filled by each veteran during the year was
FY 12 to identify a sample, who newly started a new episode of determined by summing the numbers of prescriptions in each
treatment in FY 2012. We then divided them into four of these classes as well as the total number of classes from
buprenorphine OAT. In this VA sample over 90% were male, motivation for treatment. This study did not compare veterans
over 30% with current or recent homelessness, 74% had pain initiating buprenorphine OAT with others with OUD, but such
diagnoses, frequent diagnoses of other addictive disorders a comparison may further illuminate the distinctive character-
(half with alcohol use disorder, one-third with cocaine or istics of this sample.
amphetamine, one quarter marijuana) with high rates of As comprehensively summarized by Dreifuss et al,34
psychiatric comorbidity (with an average of two diagnoses per prior small studies have reported that OAT retention for
patient), and over 80% filling psychotropic medication OUD could be influenced by multiple individual patient
prescriptions during the year and almost one third with a level characteristic including younger age, black race, male
psychiatric hospitalization. While these high levels of co- gender, being unmarried/not living with a stable partner,
morbidity and psychotropic medication use suggest high cocaine use, problematic and/or frequent alcohol use,
vulnerability, they may also indicate high levels of distress and comorbid SUD, more severe psychiatric problems, and
African Americans with OUD appear to be facing two treatment program implementation showed substantial varia-
identifiable impediments regarding buprenorphine in that they tion in structure of treatment and adherence to guidelines
tend to be started on buprenorphine less frequently,35 and are across the state.41 Substantial variations across individual
retained for a shorter duration compared to other racial groups. VHA facilities nationally regarding buprenorphine utilization
Gryczynski et al36 in a study of buprenorphine retention reported in an earlier study42 and buprenorphine treatment
among African Americans have reported that despite a retention in our study together points to a need for further
majority wanting to stay in treatment for more than 6 months, qualitative examination of organizational level practice
a substantial proportion left treatment early. Only a small variations and possible policy interventions to increase
proportion left for other providers (14%), finished treatment buprenorphine utilization and retention among veterans
successfully (4%), or were dismissed due to positive urine treated in VHA.
toxicologies (9%), while that majority left due to program
related issues like conflict with staff (24%), missing too many
scheduled visits (17%), program conflict with life obligations Limitations
(17%), or discomfort with provider strictness (4%). Such Several limitations deserve note. We lacked data on dose
programs identified structural factors and other organizational strength of buprenorphine, duration, and severity of OUD,
factors that influenced buprenorphine adoption and retention type of opioid used or psychosocial factors, which can all
generally,37–40 and may have impacted African Americans influence treatment retention.14,18,34 We also did not have
more strongly than others. At present, however, the lower information on treatment interruptions, although we think
retention among black veterans lacks a clear explanation, but such interruptions do not diminish the importance of evidence
deserves further study. of sustained involvement. Prior studies have reported that
Since very few of the individual veterans characteristics about 70% of the patients retained up to 1 year on
were associated with buprenorphine retention in this study, it buprenorphine refilled it persistently,15 and more than 90%
is possible that structural and organizational variability of patients retained in buprenorphine treatment for 12 months
between programs are more likely to be salient as reflected were no longer actively using substances,31 suggesting that a
in the variability observed in retention between different substantial proportion of patients retained at 1 year are
facilities. A recent study from Medicaid program in the state of probably continuously engaged in treatment for OUD
Massachusetts that had a statewide office-based opioid successfully. Data on other details on treatment adherence