Medication Treatment With Methadone or Buprenorphine: Differential Reasons for Premature Discharge.

OBJECTIVES: Medication treatment with methadone or buprenorphine has shown demonstrated effectiveness for opioid dependence; while premature discharge is associated with adverse outcomes. Specific reasons for premature discharge generally fall into 2 broad categories (ie, patient- and program-initiated). Previous studies have typically failed to distinguish between different types of discharge reasons among patients who leave treatment early. This study sought to determine whether type of medication was associated with differential discharge reasons among medication treatment patients who were prematurely discharged. METHODS: Data were derived from electronic health records for 5486 patients prematurely discharged from 41 for-profit licensed opioid treatment programs in the United States from 2012 to 2013. All patients were treated with methadone or buprenorphine. Patients were studied through retrospective chart review until premature discharge. RESULTS: Buprenorphine patients who left treatment prematurely were 2.18 times (95% confidence interval [CI] 1.89-2.53) more likely to be discharged against medical advice relative to methadone patients after controlling for intake differences. Methadone patients were 1.76 times (95% CI 1.47-2.10) more likely to be administratively discharged after adjustment for covariates. CONCLUSIONS: Further research is warranted to determine whether individually-tailored strategies may improve retention for certain patients based on medication. Ongoing review of program rules and policies may benefit methadone patients, who are nearly twice as likely to be discharged for an administrative, program-initiated reason. Strategies including contingency management, motivational incentives, and psychoeducation regarding the advantages of retention may benefit buprenorphine patients who are over 2 times more likely to leave treatment early due to a patient-initiated reason.

The Role of Patient Payment Method in Premature Discharge from Methadone Maintenance Treatment.

BACKGROUND: Premature discharge is a pervasive problem in methadone maintenance treatment (MMT), and is associated with numerous adverse outcomes. Although a number of demographic variables have consistently been found to impact MMT retention, method of payment has received considerably less attention. A notable limitation of prior work is that most studies classify all patients who leave treatment early, irrespective of reason, as treatment dropouts and fail to account for specific reasons. OBJECTIVE: This study sought to determine whether method of payment for MMT services was associated with differential reasons for premature discharge. METHODS: The sample was comprised of 4158 patients prematurely discharged from 33 MMT facilities located throughout the U.S. from 2009 to 2012. Patients were classified into two groups based on their method of payment: self-pay and insurance (largely Medicaid). Patients were studied through retrospective electronic chart review. RESULTS: Binary logistic regression indicated that insurance patients who were prematurely discharged were significantly more likely to be discharged due to a program-initiated reason (administrative), while self-pay patients were more likely to be discharged due to a patient-initiated reason (against medical advice) after controlling for significant intake demographic and clinical covariates. CONCLUSIONS: Further research is needed to determine whether insurance patients may require different supports in place compared to self-pay patients in order to improve compliance with program guidelines (e.g. behavioral contracts providing a detailed description of rules both at admission and throughout treatment with an emphasis on the potential consequences of noncompliance), and whether self-pay patients may benefit from motivational incentives and interventions to remain engaged in treatment.

Patient adherence to multi-component continuing care discharge plans.

Intuitively, it is assumed that greater patient adherence to treatment recommendations in substance use disorder (SUD) treatment is associated with favorable outcomes, but surprisingly, there is limited research systematically examining the adherence-outcome relationship in the context of the continuing care phase post-discharge from residential treatment. This study sought to determine the effect of adherence to multi-component continuing care plans on long-term outcomes among patients following the primary treatment episode. Data were abstracted from electronic medical records for 271 patients (59.0% male) discharged from a U.S. residential program between 2013 and 2015. Patients were categorized based on their level of adherence to their individualized continuing care discharge plan, and studied through retrospective record review for 12months post-discharge. 12-month outcomes included past 30-day and continuous abstinence, re-admission, and quality of life. With the exception of re-admission rate, fully adherent patients demonstrated significantly better results on all study outcomes at 12months compared to patients who were partially or non-adherent. Fully adherent patients were 9.46 times (95% CI: 5.07-17.62) more likely to be continuously abstinent through 12months relative to the other adherence groups. Fully adherent patients were 7.53 times (95% CI: 2.41-23.50) more likely to report a positive quality of life at 12months relative to the other adherence groups. The findings support the widely held contention that greater adherence to continuing care discharge plans is associated with favorable long-term outcomes, and provide insight into realistic outcomes expectations for patients who are adherent to their multi-component continuing care discharge plans.

Importance of short-term continuing care plan adherence on long-term outcomes among patients discharged from residential substance use treatment.

BACKGROUND: Patients adherent to their recommended treatment regimen demonstrate favorable outcomes. However, it is unclear whether there are specific short-term continuing care performance variables indicative of better long-term prognosis. OBJECTIVE: This study determined the impact of attendance at an outpatient appointment within 7 days post-discharge from residential treatment on 12-month outcomes. METHOD: Data were abstracted from electronic medical records for 275 patients (58.9% male) discharged from a single residential treatment program. All discharge plans included a 7-day outpatient appointment with a provider in their home community. Patients were dichotomized based on their attendance at the initial appointment to yield a re-engagement variable. Twelve-month outcomes included past 30-day and continuous abstinence rates, quality of life, and long-term adherence to continuing care plans. RESULTS: Patients attending their initial outpatient appointment within 7 days of discharge evidenced better long-term outcomes relative to patients who did not with respect to continuous abstinence (75.4% vs. 37.3%), past-30-day abstinence (92.0% vs. 70.6%), quality of life (94.2% vs. 78.4%), and adherence (66.4% vs. 9.8%). Re-engagement remained a significant predictor of continuous abstinence and quality of life at 12 months after controlling for 12-month adherence and relevant demographic characteristics. CONCLUSION: Treatment providers are encouraged to emphasize the relative importance of attending initial post-discharge appointments in achieving successful long-term outcomes. Allocation of resources to enhance engagement during residential treatment may be justified in that there may be value in actively encouraging patients to participate in continuing care activities, particularly shortly following discharge.

AiRCare: A naturalistic evaluation of the effectiveness of a protracted telephone-based recovery assistance program on continuing care outcomes.

BACKGROUND & OBJECTIVE: Substance use disorder treatments are increasingly being contextualized within a disease management framework. Within this context, there is an identified need to maintain patients in treatment for longer periods of time in order to help them learn how to manage their disease. One way to meet this need is through telephone-based interventions that engage patients, and include more active outreach attempts and involvement of the patient's family. This study sought to evaluate the effectiveness of three formats of an intensive 12-month post-discharge telephone-based case management approach (AiRCare) on adherence to continuing care plans and substance use outcomes. METHODS: Data were abstracted from electronic medical records for 379 patients (59.9% male) discharged from a residential treatment program located in the southwestern U.S. from 2013 to 2015. Patients were categorized into one of three groups and received telephone contacts based on their self-selection upon admission to residential treatment (i.e., patient only, family only, and both patient and family). Outcome variables included re-engagement and re-admission rates, quality of life, abstinence rates at 6 and 12 months, and compliance with continuing care plans. RESULTS & CONCLUSIONS: Favorable short- and long-term outcomes were found for the majority of patients, irrespective of case management group. There appeared to be some value in the addition of family contacts to patient contacts with respect to reducing risk for 12-month re-admission to residential care. These positive but preliminary indications of the effectiveness of AiRCare require replication in a well-powered, randomized controlled trial.

Predictors of patient retention in methadone maintenance treatment.

This study sought to determine whether select pretreatment demographic and in-treatment clinical variables predict premature treatment discharge at 6 and 12 months among patients receiving methadone maintenance treatment (MMT). Data were abstracted from electronic medical records for 1,644 patients with an average age of 34.7 years (SD = 11.06) admitted to 26 MMT programs located throughout the United States from 2009 to 2011. Patients were studied through retrospective chart review for 12 months or until treatment discharge. Premature discharge at 6- and 12-month intervals were the dependent variables, analyzed in logistic regressions. Clinical predictor variables included average methadone dosage (mg/d) and urinalysis drug screen (UDS) findings for opioids and various nonopioid substances at intake and 6 months. Pretreatment demographic variables included gender, race/ethnicity, employment status, marital status, payment method, and age at admission. UDS findings positive (UDS+) for cocaine at intake and 6 months were found to be independent predictors of premature discharge at 12 months. UDS+ for opioids at 6 months was also an independent predictor of premature discharge at 12 months. Higher average daily methadone dosages were found to predict retention at both 6 and 12 months. Significant demographic predictors of premature discharge at 6 months included Hispanic ethnicity, unemployment, and marital status. At 12 months, male gender, younger age, and self-pay were found to predict premature discharge. Select demographic characteristics may be less important as predictors of outcome after patients have been in treatment beyond a minimum period of time, while others may become more important later on in treatment.

Effects of injectable extended-release naltrexone (XR-NTX) for opioid dependence on residential rehabilitation outcomes and early follow-up.

BACKGROUND AND OBJECTIVES: Little is known about the use of extended-release naltrexone (XR-NTX) during residential rehabilitation, and its effects on early outcomes and rates of follow-up treatment. This study examined patient characteristics and rates of treatment completion and engagement in post-residential care of opioid dependent patients who received XR-NTX during residential rehabilitation, compared with patients who did not receive this medication. METHODS: Electronic records for opioid dependent patients from three Pennsylvania residential detoxification and treatment facilities (N = 7,687) were retrospectively analyzed. We determined the proportion of patients who received XR-NTX (INJ), and compared rates of treatment completion and engagement in follow-up care relative to a naturalistic control group of patients recommended for, but not administered, XR-NTX (Non-INJ). Data on whether the patient initiated follow-up care were available from one site (N = 3,724). RESULTS: Overall, 598 (7.8%) patients were recommended for XR-NTX and of these, 168 (28.1%) received injections. Compared to non-INJ patients, INJ patients were less likely to leave against medical advice (4.8% vs. 30.2%, p < .001) and more likely to initiate follow-up care (37.7% vs. 19.7%, p < .001). These differences remained significant after controlling for demographic covariates using regression analysis. CONCLUSIONS: XR-NTX was associated with higher rates of residential and early post-residential care engagement in patients with opioid dependence. SCIENTIFIC SIGNIFICANCE: XR-NTX may be an effective adjunct in the residential treatment and aftercare of patients with opioid dependence.

A naturalistic comparison of the effectiveness of methadone and two sublingual formulations of buprenorphine on maintenance treatment outcomes: findings from a retrospective multisite study.

OBJECTIVE: This study sought to compare the effectiveness of the 3 most commonly prescribed maintenance medications in the United States indicated for the treatment of opioid dependence in reducing illicit drug use and retaining patients in treatment. METHOD: Data were abstracted from electronic medical records for 3,233 patients admitted to 34 maintenance treatment facilities located throughout the United States during the period of July 1, 2012, through July 1, 2013. Patients were grouped into 1 of 3 medication categories based on their selection at intake (methadone [n = 2,738; M dosage = 64.64 mg/d, SD = 25.58], Suboxone [n = 102; M dosage = 9.75 mg/d, SD = 4.04], or Subutex [n = 393; M dosage = 12.21 mg/d, SD = 5.31]) and were studied through retrospective chart review for 6 months or until treatment discharge. Two measures of patient retention in treatment and urinalysis drug screen (UDS) findings for both opioids and various nonopioid substances comprised the study outcomes. RESULTS: The average length of stay (LOS) in terms of days in treatment for the methadone group (M = 169.86, SE = 5.02) was significantly longer than both the Subutex (M = 69.34, SE = 23.43) and Suboxone (M = 119.35, SE = 20.82) groups. The Suboxone group evinced a significantly longer average LOS relative to the Subutex group. After adjustment for relevant covariates, patients maintained on methadone were 3.73 times (95% confidence interval [CI]= 2.82-4.92) and 2.48 times (95% CI = 1.57-3.92) more likely to be retained in treatment at 6 months than patients prescribed Subutex and Suboxone, respectively. The 6-month prevalence rates of positive UDS findings for both opioids and nonopioid substances were similar across medication groups. CONCLUSIONS: Comparable rates of illicit drug use at 6 months may be expected irrespective of maintenance medication, while increased retention may be expected for patients maintained on methadone relative to those maintained on Suboxone or Subutex.

The continuing care model of substance use treatment: what works, and when is "enough," "enough?".

There is little disagreement in the substance use treatment literature regarding the conceptualization of substance dependence as a cyclic, chronic condition consisting of alternating episodes of treatment and subsequent relapse. Likewise, substance use treatment efforts are increasingly being contextualized within a similar disease management framework, much like that of other chronic medical conditions (diabetes, hypertension, etc.). As such, substance use treatment has generally been viewed as a process comprised of two phases. Theoretically, the incorporation of some form of lower intensity continuing care services delivered in the context of outpatient treatment after the primary treatment phase (e.g., residential) appears to be a likely requisite if all stakeholders aspire to successful long-term clinical outcomes. Thus, the overarching objective of any continuing care model should be to sustain treatment gains attained in the primary phase in an effort to ultimately prevent relapse. Given the extant treatment literature clearly supports the contention that treatment is superior to no treatment, and longer lengths of stay is associated with a variety of positive outcomes, the more prudent question appears to be not whether treatment works, but rather what are the specific programmatic elements (e.g., duration, intensity) that comprise an adequate continuing care model. Generally speaking, it appears that the duration of continuing care should extend for a minimum of 3 to 6 months. However, continuing care over a protracted period of up to 12 months appears to be essential if a reasonable expectation of robust recovery is desired. Limitations of prior work and implications for routine clinical practice are also discussed.