1. So You Prescribed Suboxone: Do Patients Really Take It?
Discussion of Patient Adherence to Suboxone/Burprenorphine Regimens
Teresa Hudson, PharmD, PhD
Associate Professor, Department of Psychiatry
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2. NO Disclosures CE Credits: TEXT: 501-406-0076
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4. Objectives Discuss importance of buprenorphine adherence
Discuss current data on rates of adherence to buprenorphine regimens and identify factors that influence adherence
Compare data on buprenorphine adherence to data on medication adherence for other chronic diseases
Identify strategies that may be helpful in assessing and improving adherence

5. Buprenorphine - opioid medication
Unique because it is a partial agonist :
Less euphoria and physical dependence
Lower potential for abuse
Used primarily to treat opioid use disorder
Other medication assisted treatments (MAT) for OUD include: methadone and extended release naltrexone
Typically used as chronic medication
Available in multiple dosage forms (buprenorphine only):
Injectable
Sublingual tablet
Buccal film
Transdermal patch
Intradermal implant
Combined with naloxone
Sublingual film or tablet
Brand names: Bunavail, Suboxone, Zubsolve
Can be prescribed by a physician/nurse practitioner/physician’s assistant who have received an FDA Waiver

7. MAT decreases mortality among individuals with OUD: Data from 21 Pooled Studies
All Cause Mortality Rate per 100 person years
Ma et al Molecular Psychiatry 2018

8. MAT decreases mortality from overdose among individuals with OUD: Data from 16 pooled Studies
Overdose Mortality Rate per 100 person years
Ma et al Molecular Psychiatry 2018

9. MAT-specific Mortality rates
All Cause Mortality Rate per 100 person years
Ma et al Molecular Psychiatry 2018

10. Buprenorphine may improve neuropsychological function among individuals with OUD?
Small study of 20 adults with OUD who were treated with buprenorphine/naloxone
All were newly prescribed buprenorphine/naloxone
Buprenorphine induction at a community-based clinic then maintained on mg of buprenorphine/naloxone x 6 months
Neuropsychological testing at baseline and six months assessed:
Depressive symptoms
Buprenorphine-naloxone adherence
Substance use disorder
Neuropsychological functioning

11. Results: Population Characteristics
M(SD) or % (n)
Range
Female
29% (5)
Race:
Hispanic/Latino/a
African American
Missing
Non-Hispanic White
55% (11)
25% (5)
15% (3)
5% (1)
Age
45.2 (8.1)
32-61
Years of Education
11.7 (2.3)
7-18
WRAT-reading subtest
86.9 (14.0)
HIV positive
BDI-II total score
13.2 (9.2)
0-29.5
% adherence
91.4 (11.8)
64-100
Scott et al substance Abuse treatment Prevention, and Policy 2017

12. Change in Depressive Symptoms and Neuropsychological (NP) Functioning
Time 1
T-score M(SD)
Time 2
T Score M(SD)
Change Score
M(SD)
NP Domains
Global
41.8 (6.4)
44.5 (6.2)
−.01 (.46)
Learning
36.2 (11.7)
37.8 (9.3)
−.22 (.50)
Memory
36.9 (12.2)
38.5 (11.4)
−.12 (.89)
Verbal Fluency
46.3 (9.0)
47.3 (12.0)
−.13 (.94)
Processing Speed
Attention/Working Memory
44.3 (8.0)
46.9 (9.2)
. 04 (.98)
Motor
39.2 (9.9)
42.9 (9.0)
.09 (.68)
Executive Function
41.7 (6.7)
46.2 (8.8) .
.41 (.92)
Depressive Sx
No Change

13. Key findings
No significant change overall baseline compared with follow up for NP or depressive symptoms
Correlation between greater adherence to buprenorphine/naloxone and :
improved learning (r=.52, p=.019)
Improved Memory (r=.59, p=.006)
Improved global functioning (r=.6, p=.008)
Scott et al substance Abuse treatment Prevention, and Policy 2017

14. Buprenorphine may decrease healthcare utilization and costs among people with OUD
Analyses from claims from commercially insured and Medicaid recipients
Adherence was based on proportion of days covered (PDC)
Full adherence was defined as filling buprenorphine prescriptions to cover 80% of the 1 year observation period for each patient
PDC= Sum of days supply in 12 month observation period
365
Overall Adherence Rate:
37.1 Commercial Cohort PDC >/=.8
41.3 Medicaid cohort PDC >/=.8
Ronquest et al substance abuse and rehabilitation 2018

15. Commercial Cohort Characteristics n=16,085
Age, mean (SD)
32.9 (12.7)
Sex, n (%)
Male
Female
10,093 (62.7%
5992 (37.3%)
Rural/urban n(%)
Urban
Rural
Unknown
13,828 (86.0%)
2,102 (13.1%)
155 (1.0%)
Insurance type
Comprehensive/Indemnity
EPO/PPO
POS/POS with capitation
HMO
CDHP/HDHP
Other/Unknown
476 (3.0%)
9,394 (58.4%)
1,718 (10.7%)
2,407 (15.0%)
954 (5.9%)
1,136 (7.1%)
Pre-index comorbid conditions n(%)
Non-opioid drug use disorder
Alcohol use disorder
Depressive Disorder
4,566 (28.4%)
1,753 (10.9%)
4,711 (29.3%)
Ronquest et al substance abuse and rehabilitation 2018

16. Service utilization: Commercial Cohort
Ronquest et al substance abuse and rehabilitation 2018
* P<.001

17. Healthcare Costs: Commercial Cohort
Ronquest et al substance abuse and rehabilitation 2018
* P<.001

18. Factors associated with buprenorphine adherence
Ronquest et al substance abuse and rehabilitation 2018

19. Other Factors Associated with Adherence to Buprenorphine:
Race:
Some studies suggest that black race may be associated with non-adherence or discontinuation even when among patients who have similar insurance coverage
Physical Health
Higher levels of physical health comorbidities may be associated with non-adherence or discontinuation
MH and SUD comorbidities
Depression and bipolar disorder - increased severity Comorbid non-opioid sud - particularly alcohol
Buprenorphine dose:
At least two studies have found that lower buprenorphine dose is associated with lower levels of adherence
Severity of opioid withdrawal symptoms
One study examined this in pregnant women and found that more severe withdrawal symptoms were associated with greater risks of non-adherence

21. Chronic PH Medications
Factors associated with non-adherence
Buprenorphine
Adherence Rate:
30-40%
Chronic PH Medications
Adherence rate:
25-50%
Severity of MH symptoms Y
Physical Health Comorbidities
Race
Health Literacy ?
Complexity of treatment regimen
Physician factors
Rural residence
varies
Geographic Region
unclear
Comparison with Physical Health Medication Adherence

22. Additional References
Brown MT, Bussell JK. Mayo Clinic Proceedings 2011;886(4):
Coker JL, Catlin D, Ray-Griffith S, Knight B, Stowe ZN. Drug and Alcohol Dependence :
Kumari S, Manalai P, Leong S, Wooditch A, Mansoor M, Lawson W. The American Journal on Addictions :
Litz M, Leslie D. The American Journal on Addictions :
Manhapra A, Petrakis I, Rosenheck R. American Journal on Addictions :
Ronquest NA, Willson TM, Montejano LB, Nadipelli VR, Wollschlaeger BA. Substance Abuse and Rehabilitation 2018:9, 59-78

23. CE Credits: TEXT: 501-406-0076 Activity Code: 29473-24581
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