Same-day vs. delayed buprenorphine prescribing and patient retention in an office-based buprenorphine treatment program

Background: Buprenorphine is a safe and effective treatment for opioid use disorder (OUD), yet a small fraction of people with OUD receive it, and rates of retention in treatment are suboptimal. Dropout most commonly occurs within 30 days of treatment initiation. Therefore, research needs to investigate modifiable factors contributing to early dropout. Requiring multiple visits for evaluation prior to providing an initial buprenorphine prescription (delayed prescription) may lead to more early dropout when compared with prescribing at the first medical visit (same-day prescription). Our objective was to determine whether same-day (vs. delayed) buprenorphine prescription was associated with 30-day retention in treatment. Methods: We conducted a retrospective cohort study of 237 patients who initiated buprenorphine treatment at an urban federally qualified community health center (FQHC) between June 1, 2015, and December 31, 2017. We measured prescription delays by determining the time between patients' first request for buprenorphine treatment (by calling, presenting to the FQHC in-person, or requesting treatment during a visit) and when providers wrote buprenorphine prescriptions. We included only patients with prescription delays less than or equal to 30 days in the analysis. We defined same-day prescription as the patient experiencing no delays in starting treatment and receiving a prescription during the first medical visit. We examined whether patients who received same-day prescriptions had different sociodemographic and clinical characteristics than patients who received delayed prescriptions. We also evaluated whether there was an association between the initial provider who made the decision about same-day vs. delayed buprenorphine prescribing and same-day prescription. We built a multivariable logistic regression model to evaluate the independent association between same-day vs. delayed prescription receipt and odds of 30-day retention in treatment. Results: Of the 237 patients who initiated buprenorphine treatment from June 1, 2015, to December 31, 2017, 222 had delays less than or equal to 30 days and we included them in the analysis. Of the 222 patients, the mean age was 46 (SD 10.4), the majority were Hispanic (n = 160, 72%), male (n = 175, 79%), and publicly insured (n = 165, 74%). The majority of patients experienced delayed buprenorphine prescription receipt (n = 133, 60%). The median time to buprenorphine prescription was 5 days (IQR 0–11). Of those who experienced a delay (n = 133), the median delay time was 8 days (IQR 5–20). Compared to those with same-day prescription receipt, more patients with delayed prescription receipt were non-Hispanic white (11% vs. 2%, p = 0.01), had a history of alcohol use (43% vs. 21%, p < 0.01) or benzodiazepine use (22% vs. 9%, p = 0.01), and had the buprenorphine coordinator as their initial provider (57 vs. 13%, p < 0.01). Same-day prescription receipt was not significantly associated with 30-day treatment retention in the adjusted analysis (AOR 1.92, 95% CI 0.81–4.56). Conclusion: Patients who received buprenorphine prescriptions on the same day as their initial evaluation differed from those who received delayed prescriptions. After adjustment for these differences, same-day prescription was not significantly associated with higher 30-day treatment retention. Providers may be delaying treatment when there is concern about alcohol and/or benzodiazepine use; however, providers could institute enhanced monitoring based on clinical concern for sedation or overdose risk without delaying buprenorphine prescription. Prospective studies of same-day vs. delayed buprenorphine receipt would elucidate the association between delays and retention more definitively.