Department of Epidemiology, Columbia University Mailman School of Public Health, 722 W. 168(th) St., New York, NY 10032, United States of America.
Department of Psychiatry, New York State Psychiatric Institute, Columbia University Medical Center, 1051 Riverside Dr., New York, NY 10032, United States of America.
J Subst Abuse Treat. 2018 Dec;95:9-17. doi: 10.1016/j.jsat.2018.09.001. Epub 2018 Sep 7.
Recent U.S. trends demonstrate sharp rises in adverse opioid-related health outcomes, including opioid use disorder (OUD), overdose, and death. Yet few affected people receive treatment for OUD and a minority of those who receive treatment are effectively retained in care. The purpose of this study was to examine duration of buprenorphine treatment for OUD following treatment initiation to identify risk factors for early discontinuation.
We analyzed insurance claims from the 2013-2015 MarketScan multi-state Medicaid database. The sample included adults 18-64 years old with an OUD diagnosis in the 6 months before initiating buprenorphine treatment, defined as 6 months without a buprenorphine claim prior to the index buprenorphine claim (N = 17,329 individuals). We used Cox proportional hazards regression to estimate risk of discontinuing treatment (>30 days without buprenorphine supply), and logistic regression to estimate the odds of persistent treatment for a minimum of 180 days.
Over one-quarter of the sample discontinued buprenorphine in the first month of treatment (N = 4928; 28.4%) and most discontinued before 180 days (N = 11,189; 64.6%). In the proportional hazards model, risk factors for discontinuation included a lower initial buprenorphine dose (≤4 mg; Hazard Ratio [HR] = 1.72, p < .001), male sex (HR = 1.19, p < .001), younger age (HR = 1.34, p < .001), minority race/ethnicity (black HR = 1.31, p < .001; Hispanic HR = 1.24, p = .01; other HR = 1.09, p < .001), capitated insurance (HR = 1.21, p < .001), comorbid substance use disorders (alcohol HR = 1.07, p = .04; non-opioid drugs HR = 1.14, p < .001), hepatitis C (HR = 1.06, p = .01), opioid overdose history (HR = 1.20, p = .001), or any inpatient care (HR = 1.22, p < .001) in the 6-month baseline period. In logistic models, these risk factors were similarly associated with significantly lower odds of treatment retention for at least 180 days.
For Medicaid beneficiaries with OUD treated with buprenorphine, there is a need to implement treatment models that more effectively address barriers to treatment retention. These barriers are particularly challenging for minorities, younger individuals, and those with additional substance use disorders.
最近美国的趋势表明，阿片类药物相关的不良健康后果（包括阿片类药物使用障碍[OUD]、过量用药和死亡）急剧上升。然而，很少有受影响的人接受 OUD 治疗，而接受治疗的人中很少有人能有效地坚持治疗。本研究的目的是检查 OUD 患者在开始接受丁丙诺啡治疗后的丁丙诺啡治疗持续时间，以确定早期停药的风险因素。
我们分析了 2013-2015 年 MarketScan 多州医疗补助数据库的保险索赔数据。样本包括在开始丁丙诺啡治疗前 6 个月内有 OUD 诊断的 18-64 岁成年人，定义为在索引丁丙诺啡索赔前 6 个月内没有丁丙诺啡索赔（N=17329 人）。我们使用 Cox 比例风险回归估计停止治疗的风险（30 天以上无丁丙诺啡供应），并使用逻辑回归估计至少 180 天持续治疗的可能性。
在该样本中，超过四分之一的人在治疗的第一个月内停止了丁丙诺啡治疗（N=4928；28.4%），大多数人在 180 天前停止了治疗（N=11189；64.6%）。在比例风险模型中，停药的风险因素包括初始丁丙诺啡剂量较低（≤4mg；风险比[HR] =1.72，p<0.001）、男性（HR=1.19，p<0.001）、年龄较小（HR=1.34，p<0.001）、少数民族（黑人 HR=1.31，p<0.001；西班牙裔 HR=1.24，p=0.01；其他 HR=1.09，p<0.001）、人头付费保险（HR=1.21，p<0.001）、合并物质使用障碍（酒精 HR=1.07，p=0.04；非阿片类药物 HR=1.14，p<0.001）、丙型肝炎（HR=1.06，p=0.01）、阿片类药物过量史（HR=1.20，p=0.001）或任何住院治疗（HR=1.22，p<0.001）在 6 个月的基线期。在逻辑模型中，这些风险因素同样与至少 180 天的治疗保留的可能性显著降低相关。
对于接受丁丙诺啡治疗的 OUD 医疗补助受益人，需要实施更有效地解决治疗保留障碍的治疗模式。这些障碍对少数民族、年轻群体和有其他物质使用障碍的人来说尤其具有挑战性。
