Homelessness, patient preferences important factors in opioid use disorder treatment
Researchers identified factors for matching patients with opioid use disorder admitted to inpatient treatment to either buprenorphine or extended-release naltrexone, according to study results published in American Journal of Psychiatry.
These included homelessness, parole and probation status, medication factors and factors likely to affect tolerability of medication initiation.
“In a trial conducted in Norway among patients with opioid use disorder who had completed withdrawal from opioids and were thus ready to initiate naltrexone, extended-release naltrexone was noninferior to sublingual buprenorphine-naloxone on the co primary outcomes of retention in treatment (70% of patients assigned to extended-release naltrexone and 68% assigned to buprenorphine-naloxone completed 12 weeks of treatment) and number of opioid-negative urine tests,” Edward V. Nunes, Jr., MD, of the New York State Psychiatric Institute and Columbia University Irving Medical Center, and colleagues wrote. “In the Extended-Release Naltrexone Versus Buprenorphine-Naloxone for Opioid Relapse Prevention (X:BOT) trial, which was conducted in the United States in patients with opioid use disorder admitted to inpatient units, assignment to extended-release naltrexone was associated with a significantly higher rate of relapse to regular opioid use (65%) compared with buprenorphine-naloxone (57%) over the 24-week trial, a difference accounted for mainly by relapse among patients who failed to complete withdrawal from opioids and thus failed to initiate naltrexone.”
Because of significant dropout and relapse rates with both medications in these and other studies, it remains unclear whether personalization of care, and thus identification of patient characteristic that may guide the choice for each individual’s best treatment, could improve effectiveness, according to the researchers. In the current study, Nunes and colleagues conducted a multisite 24-week randomized comparative-effectiveness trial of assigned to buprenorphine-naloxone vs. extended-release naltrexone among inpatients who planned to initiate medication treatment for opioid use disorder. The researchers assessed 50 demographic and clinical characteristics as moderators of the effect of medication assignment on relapse to regular opioid use and medication initiation failure. Further, they used logistic regression with correction for multiple testing to estimate moderator-by-medication interactions.
Results showed that among the intent-to-treat sample, patients who reported homelessness who were assigned to receive extended-release naltrexone had a lower relapse rate (51.6%) compared with those assigned to receive buprenorphine-naloxone (70.4%) (OR = 0.45; 95% CI, 0.22-0.9). Those who were not homeless who were assigned to receive extended-release naltrexone exhibited a higher relapse rate (70.9%) compared with those assigned to receive buprenorphine-naloxone (53.1%) (OR = 2.15; 95% CI, 1.44-3.21). Among the subsample of patients who initiated medication, the researchers noted the interaction was not significant, and they observed a similar pattern of lower relapse with extended-release naltrexone (41.4%) vs. buprenorphine (68.6%) among patients who were homeless (OR = 0.32; 95% CI, 0.15-0.68); however, they observed less difference among those who were not homeless, with a relapse rate of 57.2% for extended-release naltrexone and 52% for buprenorphine (OR = 1.24; 95% CI, 0.8-1.9). Among those who failed to initiate medication, the researchers reported moderators of stated preference for medication, with failure less likely for patients assigned to their preferred medication; parole and probation status, with fewer failures for extended-release naltrexone among those on parole or probation; and presence of pain and timing of random assignment, with more failure for extended-release naltrexone among patients who endorsed moderate to severe pain and who were randomly assigned early while still undergoing medically managed withdrawal.
“The pragmatic implications are that social circumstances likely to affect adherence to medication, the likelihood of tolerating withdrawal from opioids and naltrexone initiation, and a patient’s preferences should be considered in helping to determine the choice of medication for treatment of opioid use disorder,” Nunes and colleagues wrote.