title: Public sector low threshold office-based buprenorphine treatment: outcomes at year 7.
abstract: Buprenorphine maintenance for opioid dependence remains of limited availability among underserved populations, despite increases in US opioid misuse and overdose deaths. Low threshold primary care treatment models including the use of unobserved, "home," buprenorphine induction may simplify initiation of care and improve access. Unobserved induction and long-term treatment outcomes have not been reported recently among large, naturalistic cohorts treated in low threshold safety net primary care settings.
  
  
  
  This prospective clinical registry cohort design estimated rates of induction-related adverse events, treatment retention, and urine opioid results for opioid dependent adults offered buprenorphine maintenance in a New York City public hospital primary care office-based practice from 2006 to 2013. This clinic relied on typical ambulatory care individual provider-patient visits, prescribed unobserved induction exclusively, saw patients no more than weekly, and did not require additional psychosocial treatment. Unobserved induction consisted of an in-person screening and diagnostic visit followed by a 1-week buprenorphine written prescription, with pamphlet, and telephone support. Primary outcomes analyzed were rates of induction-related adverse events (AE), week 1 drop-out, and long-term treatment retention. Factors associated with treatment retention were examined using a Cox proportional hazard model among inductions and all patients. Secondary outcomes included overall clinic retention, buprenorphine dosages, and urine sample results.
  
  
  
  Of the 485 total patients in our registry, 306 were inducted, and 179 were transfers already on buprenorphine. Post-induction (n = 306), week 1 drop-out was 17%. Rates of any induction-related AE were 12%; serious adverse events, 0%; precipitated withdrawal, 3%; prolonged withdrawal, 4%. Treatment retention was a median 38 weeks (range 0-320) for inductions, compared to 110 (0-354) weeks for transfers and 57 for the entire clinic population. Older age, later years of first clinic visit (vs. 2006-2007), and baseline heroin abstinence were associated with increased treatment retention overall.
  
  
  
  Unobserved "home" buprenorphine induction in a public sector primary care setting appeared a feasible and safe clinical practice. Post-induction treatment retention of a median 38 weeks was in line with previous naturalistic studies of real-world office-based opioid treatment. Low threshold treatment protocols, as compared to national guidelines, may compliment recently increased prescriber patient limits and expand access to buprenorphine among public sector opioid use disorder patients.
authors.affiliation: Department of Population Health, NYU School of Medicine, 227 East 30th St, New York, NY, 10016, USA.|Department of Medicine, Division of General Internal Medicine and Clinical Innovation, NYU School of Medicine, New York, NY, USA.
authors.forename: Elenore Patterson
authors.initials: EP
authors.lastname: Bhatraju
authors.affiliation: Department of Medicine, Division of General Internal Medicine and Clinical Innovation, NYU School of Medicine, New York, NY, USA.
authors.forename: Ellie
authors.initials: E
authors.lastname: Grossman
authors.affiliation: Department of Population Health, NYU School of Medicine, 227 East 30th St, New York, NY, 10016, USA.|Department of Medicine, Division of General Internal Medicine and Clinical Innovation, NYU School of Medicine, New York, NY, USA.
authors.forename: Babak
authors.initials: B
authors.lastname: Tofighi
authors.affiliation: Department of Population Health, NYU School of Medicine, 227 East 30th St, New York, NY, 10016, USA.|Department of Medicine, Division of General Internal Medicine and Clinical Innovation, NYU School of Medicine, New York, NY, USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: McNeely
authors.affiliation: Department of Population Health, NYU School of Medicine, 227 East 30th St, New York, NY, 10016, USA.
authors.forename: Danae
authors.initials: D
authors.lastname: DiRocco
authors.affiliation: Department of Population Health, NYU School of Medicine, 227 East 30th St, New York, NY, 10016, USA.
authors.forename: Mara
authors.initials: M
authors.lastname: Flannery
authors.affiliation: Department of Medicine, Division of General Internal Medicine and Clinical Innovation, NYU School of Medicine, New York, NY, USA.
authors.forename: Ann
authors.initials: A
authors.lastname: Garment
authors.affiliation: Department of Population Health, NYU School of Medicine, 227 East 30th St, New York, NY, 10016, USA.
authors.forename: Keith
authors.initials: K
authors.lastname: Goldfeld
authors.affiliation: Department of Population Health, NYU School of Medicine, 227 East 30th St, New York, NY, 10016, USA.
authors.forename: Marc N
authors.initials: MN
authors.lastname: Gourevitch
authors.affiliation: Department of Medicine, Division of General Internal Medicine and Clinical Innovation, NYU School of Medicine, New York, NY, USA. joshua.lee@nyumc.org.|Department of Population Health, NYU School of Medicine, 227 East 30th St #712, New York, NY, 10016, USA. joshua.lee@nyumc.org.
authors.forename: Joshua D
authors.initials: JD
authors.lastname: Lee
mesh_terms: D002047:Buprenorphine / Q000008:administration & dosage*; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D009292:Narcotic Antagonists / Q000008:administration & dosage*; D009518:New York; D009819:Office Visits / Q000706:statistics & numerical data*; D009293:Opioid-Related Disorders / Q000188:drug therapy*; D011320:Primary Health Care; D014481:United States
chemical_list: D009292:Narcotic Antagonists; D002047:Buprenorphine
keywords: Buprenorphine; Induction; Office-based treatment; Opioid dependence; Primary care