Buprenorphine Initiation Rates Stall Despite Policy Efforts to Boost Uptake

Monthly initiation rates for buprenorphine increased and then flattened from 2016 to 2022, suggesting that recent efforts to increase use of the treatment for opioid use disorder have been insufficient, an analysis of prescription data showed.

Using data from the IQVIA Longitudinal Prescription Database, an all-payer database that includes 92% of prescriptions dispensed in U.S. retail pharmacies, the monthly buprenorphine initiation rate increased from 12.5 to 15.9 per 100,000 from January 2016 through September 2018 (monthly percentage change 0.62%, 95% CI 0.40-0.84, P<0.001), reported Kao-Ping Chua, MD, PhD, of the University of Michigan Medical School in Ann Arbor, and co-authors.

The initiation rate then became flat from October 2018 through October 2022 (monthly percentage change -0.03%, 95% CI -0.16% to 0.09%, P=0.62), they noted in a JAMA research letter.

Of note, the median monthly retention rate was 22.2% from January 2016 to April 2022, and increased only slightly during that period (monthly percentage change 0.08%, 95% CI 0.005-0.15, P=0.04).

"Opioid overdose deaths are at a record high in the U.S.," Chua told MedPage Today in an email. "Despite this, our study shows that buprenorphine initiation rates have been flat since the end of 2018."

"This is disappointing, especially because there were a lot of policy and clinical efforts to maintain and expand access to buprenorphine during the COVID-19 pandemic, such as allowing buprenorphine to be prescribed via telehealth without an in-person visit and eliminating training requirements for the waiver that previously was required to prescribe buprenorphine," Chua added. "The fact that buprenorphine initiation rates did not rise after these efforts were implemented suggests that they were insufficient to meet the rising need for this medication."

The researchers noted that the pandemic was not responsible for the flattening of initiation rates, since the trend emerged earlier. However, the median monthly buprenorphine initiation rate during the early months of the pandemic did dip lower than the months before and after:

• January 2019 to February 2020: 15.5 per 100,000
• March 2020 to December 2020: 14.4 per 100,000
• January 2021 to October 2022: 15.0 per 100,000

Chua said that this study adds to the growing body of research that suggests clinicians have not maximized opportunities to initiate buprenorphine treatment for patients with opioid use disorder. He highlighted another study he was involved with that showed that just one in 12 patients were prescribed buprenorphine within 30 days of an emergency department visit for opioid overdose.

Throughout the current study period, just one in five patients who initiated buprenorphine remained on the therapy for at least 180 days, which the researchers said was similar to a prior study that examined data through 2020.

"A comprehensive approach is needed to eliminate barriers to buprenorphine initiation and retention, such as stigma and uneven access to prescribers," Chua and colleagues concluded.

Chua said that his hope is that this "study will further underscore to clinicians how much the healthcare system is under-using a critical tool to prevent opioid overdose deaths."

For this analysis, the researchers included 93,713,163 prescriptions. During the study period, 3,006,629 patients initiated buprenorphine, 42.9% of whom were female.

Chua and team defined initiation as a new prescription for a patient without buprenorphine dispensing in the previous 180 days. They defined retention as at least 180 days of continuous buprenorphine treatment following the initial prescription, without gaps exceeding 7 days.

Limitations to the study included a lack of data on race and ethnicity, in-clinic buprenorphine administration, and buprenorphine dispensing in methadone outpatient treatment programs. In addition, some patients may have initiated buprenorphine to treat pain instead of opioid use disorder.

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