Long-Term Retention in Buprenorphine Medication-Assisted Treatment Programs

By Janice Wright, MPH, LCADC, CCS, Executive Director, Mount Pocono Medical

What Factors Keep People in Opioid Addiction Treatment?

The 2020 National Survey on Drug Use and Health (2020 NSDUH) indicates that in the U.S. in 2020, 2.9 million people over the age of 12 said they’d used illicit opioids in the month before taking the survey, 2.5 million people over the age of 12 said they’d misused a prescription pain reliever in the month before taking the survey, and a total of 2.7 million people over the age of 12 met the clinical criteria of opioid use disorder (OUD).

Let’s define those terms.

Illicit Opioids

The Centers for Disease Control (CDC) defines illicit opioids as any drug in the opioid class – prescription or otherwise – obtained illegally. Illicit opioids include street drugs like heroin and illegally produced or distributed medications like oxycodone.

Prescription Pain Reliever Misuse

The National Institute on Drug Abuse (NIDA) defines misuse of a prescription drug – including pain relievers – as “…taking a medication in a manner or dose other than prescribed, taking someone else’s prescription, or taking a medication for nonmedical purposes, such as to feel euphoria (a.k.a. get high).”

Opioid Use Disorder (OUD)

The Diagnostic and Statistical Manual of Mental Disorders, Volume 5 (DSM-V) defines opioid use disorder as “…a problematic use of opioids that leads to serious impairment of distress.” When a person displays two of the following eleven criteria in a 12-month period, they meet the criteria for OUD:

1. Opioids taken in larger amounts or for longer period than intended.
2. A desire to stop using opioids, or unsuccessful efforts to stop using opioids.
3. Spending significant time thinking about or obtaining opioids.
4. Strong cravings for opioids.
5. Opioid use impairs ability to fulfill work, school, or family responsibilities.
6. Continued opioid use, despite use causing significant problems at work, home, or school.
7. Giving up social, work, or recreational activities because of opioid use.
8. Opioid use which results in physical danger, such as using opioids before driving.
9. Continued opioid use, despite use exacerbating emotional or psychological issues.
10. Developing tolerance, which means more of the drug is needed to achieve the same effect.
11. Displaying withdrawal symptoms, which are physical, emotional, and psychological reactions to the absence of opioids in the body.

We know the data, we know the definitions, and we know that last year, over seventy-thousand people in the U.S. died of opioid-related overdose.

We also know something else: there’s a lifesaving approach to treating OUD called medication-assisted treatment (MAT), which involves the use of specific medications – methadone, buprenorphine, and naltrexone – to mitigate withdrawal symptoms, reduce cravings, and help people with OUD participate in treatment and achieve long-term recovery.

To learn more about the benefits of MAT, please read our article here.

Back to this specific topic: what we know about OUD and how to treat it. We know that the longer a person stays in treatment, called time-in-treatment, the better chance they have of avoiding relapse and maintaining recovery. This article discusses data published recently in a paper called “Factors Associated with Long-Term Retention in Buprenorphine-Based Addiction Treatment Programs: a Systematic Review.”

The paper is about exactly what the title implies: the factors that keep people in MAT programs. Specifically, what keeps people in buprenorphine-based programs longer?

This question is of critical importance to us, because – as we mention above – the longer a person stays in an MAT program, the better their chances at lifelong recovery. That’s what we want: people with OUD to achieve recovery for life.

Let’s have a look at the study.

Buprenorphine MAT Programs: Factors Affecting Time-in-Treatment

The study in question is what’s known as a review study, sometimes called a meta-analysis, which means that the researchers researched the available research to identify consistent trends on a particular topic over time. Okay – that’s kind of a funny sentence – but research the research means they found every peer-reviewed journal article they could about buprenorphine and examined those articles to address one basic question: what keeps people in buprenorphine programs?

The average length of stay in a buprenorphine program is six months. However, data indicates that people who stay in treatment longer than six months have a much greater chance of staying in recovery and avoiding relapse.

Researchers found 14,000 articles about buprenorphine, but their strict inclusion criteria filtered almost all of them out, and they settled on nine studies for analysis. All nine studies were random-controlled trials (RCTs), which are known for their accuracy and reliability.

They looked at three factors they hypothesized affected time-in-treatment:

1. Buprenorphine dosage
2. The presence or absence of behavioral therapy during buprenorphine treatment, compared to standard counseling
3. The setting in which treatment was initiated

Here’s what they found: six months after initiating treatment, 10%-69% of people were still in treatment, and one year after initiating treatment, 49-59% of those people were still in treatment. Now let’s take a look at the possible factors affecting these differences.

Factor Affecting Retention During Buprenorphine-Based MAT

• Daily Dosage:
  • Three studies compared 1mg doses of 8mg doses of buprenorphine
  • Higher doses were associated with longer time-in-treatment
    • 1-3 mg doses: 17%-46% stayed in treatment longer than six months
    • 4-8 mg doses: 63%-78% stayed in treatment longer than six months
  • Presence/Absence of Behavioral Therapy:
    • One trial compared longer behavioral sessions with shorter behavioral sessions
    • Another trial compared standard drug counseling with cognitive behavioral therapy (CBT)
    • A third trial compared standard drug counseling with intensive outpatient therapy (IOP)
    • None of the studies identified a relationship between the presence or absence of counseling/behavioral therapy on time-in-treatment
  • Setting of Treatment Initiation
    • One trial compared initiation in a hospital setting with initiation in an outpatient care setting
    • One trial compared initiation in a criminal justice setting against initiation in an outpatient care setting
    • These trials showed that initiating treatment in a hospital setting and initiating treatment in a criminal justice setting resulted in longer time-in-treatment than initiating treatment in an outpatient setting

Let’s summarize that data. The study authors concluded that higher doses of buprenorphine kept people in treatment longer, behavioral therapy did not increase time-in-treatment compared to standard counseling, and starting treatment in a hospital or criminal justice setting led to longer time-in-treatment.

How This Information Helps Us in the Opioid Crisis

Every new piece of data helps addiction professionals tailor treatment to maximize the benefit for patients, improve outcomes, and reduce overall harm among people with OUD. This new data can help us develop more effective strategies on at least two levels. It gives us new information on how much buprenorphine we should give people upon initiation and the setting in which we initiate treatment. The data on counseling is neutral. It doesn’t give us any information with regards to time-in-treatment. But it does remind us – and anyone researching MAT in general – that standard drug counseling is a default component of buprenorphine treatment.

What we need to know now is how we can tailor our counseling/therapy strategies – more often, more of a different kind, the question is open – to increase time-in-treatment, thereby increasing treatment success, which means achieving long-term recovery.

We eagerly await research on this topic – and we’ll report it here when we learn anything new.

About Mount Pocono Medical

Mount Pocono Medical is one of Pinnacle Treatment Centers’ buprenorphine-based MAT programs located in Pennsylvania and is a PA Department of Human Services Center of Excellence. We provide outpatient medication-assisted treatment for opiate addiction, supported with a full complement of clinical and case management services. We provide patients with a safe, trusting, and respectful environment to help break the cycle of addiction. Call 570-839-7246 for more information.