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Published Online: 25 June 2021

Sublingual Buprenorphine-Naloxone Compared With Injection Naltrexone for Opioid Use Disorder: Potential Utility of Patient Characteristics in Guiding Choice of Treatment

Abstract

Objective:

Sublingual buprenorphine-naloxone and extended-release injection naltrexone are effective treatments, with distinct mechanisms, for opioid use disorder. The authors examined whether patients’ demographic and clinical characteristics were associated with better response to one medication or the other.

Methods:

In a multisite 24-week randomized comparative-effectiveness trial of assignment to buprenorphine-naloxone (N=287) compared with extended-release naltrexone (N=283) comprising inpatients planning to initiate medication treatment for opioid use disorder, 50 demographic and clinical characteristics were examined as moderators of the effect of medication assignment on relapse to regular opioid use and failure to initiate medication. Moderator-by-medication interactions were estimated using logistic regression with correction for multiple testing.

Results:

In the intent-to-treat sample, patients who reported being homeless had a lower relapse rate if they were assigned to receive extended-release naltrexone (51.6%) compared with buprenorphine-naloxone (70.4%) (odds ratio=0.45, 95% CI=0.22, 0.90); patients who were not homeless had a higher relapse rate if they were assigned to extended-release naltrexone (70.9%) compared with buprenorphine-naloxone (53.1%) (odds ratio=2.15, 95% CI=1.44, 3.21). In the subsample of patients who initiated medication, the interaction was not significant, with a similar pattern of lower relapse with extended-release naltrexone (41.4%) compared with buprenorphine (68.6%) among homeless patients (odds ratio=0.32, 95% CI=0.15, 0.68) but less difference among those not homeless (extended-release naltrexone, 57.2%; buprenorphine, 52.0%; odds ratio=1.24, 95% CI=0.80, 1.90). For failure to initiate medication, moderators were stated preference for medication (failure was less likely if the patient was assigned to the medication preferred), parole and probation status (fewer failures with extended-release naltrexone for those on parole or probation), and presence of pain and timing of randomization (more failure with extended-release naltrexone for patients endorsing moderate to severe pain and randomized early while still undergoing medically managed withdrawal).

Conclusions:

Among patients with opioid use disorder admitted to inpatient treatment, homelessness, parole and probation status, medication preference, and factors likely to influence tolerability of medication initiation may be important in matching patients to buprenorphine or extended-release naltrexone.

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Information & Authors

Information

Published In

Go to American Journal of Psychiatry
Go to American Journal of Psychiatry
American Journal of Psychiatry
Pages: 660 - 671
PubMed: 34170188

History

Received: 9 June 2020
Accepted: 1 March 2021
Published online: 25 June 2021
Published in print: July 2021

Keywords

  1. Buprenorphine
  2. Extended-Release Injection Naltrexone
  3. Opioid Use Disorder
  4. Homelessness
  5. Criminal Justice
  6. Relapse
  7. Naltrexone Induction

Authors

Details

Edward V. Nunes Jr., M.D. [email protected]
New York State Psychiatric Institute and Columbia University Irving Medical Center, New York (Nunes, Scodes, Campbell); Department of Biostatistics, Columbia University Mailman School of Public Health, New York (Pavlicova); and New York University Grossman School of Medicine, New York (Lee, Novo, Rotrosen).
Jennifer M. Scodes, M.S.
New York State Psychiatric Institute and Columbia University Irving Medical Center, New York (Nunes, Scodes, Campbell); Department of Biostatistics, Columbia University Mailman School of Public Health, New York (Pavlicova); and New York University Grossman School of Medicine, New York (Lee, Novo, Rotrosen).
Martina Pavlicova, Ph.D.
New York State Psychiatric Institute and Columbia University Irving Medical Center, New York (Nunes, Scodes, Campbell); Department of Biostatistics, Columbia University Mailman School of Public Health, New York (Pavlicova); and New York University Grossman School of Medicine, New York (Lee, Novo, Rotrosen).
Joshua D. Lee, M.D., M.Sc.
New York State Psychiatric Institute and Columbia University Irving Medical Center, New York (Nunes, Scodes, Campbell); Department of Biostatistics, Columbia University Mailman School of Public Health, New York (Pavlicova); and New York University Grossman School of Medicine, New York (Lee, Novo, Rotrosen).
Patricia Novo, M.P.A., M.P.H.
New York State Psychiatric Institute and Columbia University Irving Medical Center, New York (Nunes, Scodes, Campbell); Department of Biostatistics, Columbia University Mailman School of Public Health, New York (Pavlicova); and New York University Grossman School of Medicine, New York (Lee, Novo, Rotrosen).
Aimee N.C. Campbell, Ph.D.
New York State Psychiatric Institute and Columbia University Irving Medical Center, New York (Nunes, Scodes, Campbell); Department of Biostatistics, Columbia University Mailman School of Public Health, New York (Pavlicova); and New York University Grossman School of Medicine, New York (Lee, Novo, Rotrosen).
John Rotrosen, M.D.
New York State Psychiatric Institute and Columbia University Irving Medical Center, New York (Nunes, Scodes, Campbell); Department of Biostatistics, Columbia University Mailman School of Public Health, New York (Pavlicova); and New York University Grossman School of Medicine, New York (Lee, Novo, Rotrosen).

Notes

Send correspondence to Dr. Nunes ([email protected]).

Competing Interests

Dr. Nunes has served as an uncompensated consultant to Alkermes, Braeburn-Camurus, and Pear Therapeutics; he has served as an investigator on studies funded by Braeburn-Camurus and on studies with medication donated by Alkermes and Indivior (formerly Reckitt-Benckiser) and a smartphone app donated by Pear Therapeutics; studies in planning are anticipating donated and/or discounted medication from Alkermes, Indivior, Braeburn Pharmaceuticals, Inc., and smartphone apps from Pear Therapeutics and CHESS Health. Dr. Lee has served as an investigator on studies with medication provided by Alkermes and Indivior. Dr. Rotrosen has served as an uncompensated consultant to Alkermes, and he has served as an investigator on studies with medication and/or funds provided by Alkermes and Indivior; studies in planning are anticipating donated and/or discounted medication from Alkermes, Indivior, Braeburn Pharmaceuticals, Inc., and smartphone apps from Pear Therapeutics, CHESS Health, and Data Cubed. The other authors report no financial relationships with commercial interests.

Funding Information

Supported by the National Institute on Drug Abuse Clinical Trial Network (grants U10DA013046, UG1/U10DA013035, UG1/U10DA013034, U10DA013045, UG1/U10DA013720, UG1/U10DA013732, UG1/U10DA013714, UG1/U10DA015831, U10DA015833, HHSN271201200017C, HHSN271201500065C, and K24DA022412).

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