Accurso Anthony J, Rastegar Darius A
Division of Chemical Dependence, Department of Internal Medicine, Johns Hopkins Bayview Medical Center, 5200 Eastern Ave, Mason F. Lord, West Tower 5th Floor, Baltimore, MD 21224.
Division of Chemical Dependence, Department of Internal Medicine, Johns Hopkins Bayview Medical Center, 5200 Eastern Ave, Mason F. Lord, West Tower 5th Floor, Baltimore, MD 21224.
J Subst Abuse Treat. 2016 Feb;61:74-9. doi: 10.1016/j.jsat.2015.09.004. Epub 2015 Oct 1.
The optimal dose for office-based buprenorphine therapy is not known. This study reports on the effect of a change in payer policy, in which the insurer of a subset of patients in an office-based practice imposed a maximum sublingual buprenorphine dose of 16 mg/day, thereby forcing those patients on higher daily doses to decrease their dose. This situation created conditions for a natural experiment, in which treatment outcomes for patients experiencing this dose decrease could be compared to patients with other insurance who were not challenged with a dose decrease.
Subjects were 297 patients with opioid use disorder in a primary care practice who were prescribed buprenorphine continuously for at least 3 months. Medical records were retrospectively reviewed for urine drug test results and treatment retention. Rates of aberrant urine drug tests were calculated in the period before the dose decrease and compared to rate after it with patients serving as their own controls. Comparison groups were formed from patients with the same insurance on buprenorphine doses of 16 mg/day or lower, patients with different insurance on 16 mg/day or lower, and patients with different insurance on greater than 16 mg/day. Rates of aberrant drug tests and treatment retention of patients on 16 mg/day or less of buprenorphine were compared to that of patients on higher daily doses.
The rate of aberrant urine drug tests among patients who experienced a dose decrease rose from 27.5% to 34.2% (p=0.043). No comparison group showed any significant change in aberrant drug test rates. Moreover, all groups who were prescribed buprenorphine doses greater than 16 mg/day displayed lower rates of aberrant urine drug tests than groups prescribed lower doses. Retention in treatment was also highest among those prescribed greater than 16 mg/day (100% vs. 86.8%, 90.1%, and 84.4% p=0.010).
An imposed buprenorphine dose decrease was associated with an increase in aberrant drug tests. Patients in a control group with higher buprenorphine doses had greater retention in treatment. These findings suggest that buprenorphine doses greater than 16 mg/day are more effective for some patients and that dose limits at this level or lower are harmful.
基于门诊的丁丙诺啡治疗的最佳剂量尚不清楚。本研究报告了支付方政策变化的影响，在一项门诊实践中，一部分患者的保险公司规定舌下含服丁丙诺啡的最大剂量为每日16毫克，从而迫使那些每日剂量较高的患者降低剂量。这种情况创造了一个自然实验的条件，在此实验中，可以将经历剂量降低的患者的治疗结果与未受到剂量降低挑战的其他保险患者的结果进行比较。
研究对象为297例在初级保健机构中患有阿片类药物使用障碍且连续服用丁丙诺啡至少3个月的患者。回顾医疗记录以获取尿液药物检测结果和治疗留存情况。计算剂量降低前阶段异常尿液药物检测的发生率，并将其与剂量降低后的发生率进行比较，患者自身作为对照。比较组由服用16毫克/天或更低剂量丁丙诺啡且保险相同的患者、服用16毫克/天或更低剂量丁丙诺啡且保险不同的患者以及服用超过16毫克/天丁丙诺啡且保险不同的患者组成。将服用16毫克/天或更低剂量丁丙诺啡的患者的异常药物检测率和治疗留存率与服用更高每日剂量的患者进行比较。
经历剂量降低的患者中，异常尿液药物检测率从27.5%升至34.2%（p = 0.043）。没有比较组显示异常药物检测率有任何显著变化。此外，所有服用丁丙诺啡剂量大于16毫克/天的组的异常尿液药物检测率均低于服用较低剂量的组。治疗留存率在服用大于16毫克/天剂量的患者中也最高（100%对86.8%、90.1%和84.4%，p = 0.010）。
强制降低丁丙诺啡剂量与异常药物检测增加有关。丁丙诺啡剂量较高的对照组患者治疗留存率更高。这些发现表明，对于某些患者，大于16毫克/天的丁丙诺啡剂量更有效，而在此水平或更低的剂量限制是有害的。
