Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2023 Nov 1.
Published in final edited form as: Drug Alcohol Depend. 2023 Oct 13;252:110981. doi: 10.1016/j.drugalcdep.2023.110981

Trends in buprenorphine dosage and days supplied for new treatment episodes for opioid use disorder, 2010–2019

Alyssa Shell Tilhou 1,2, Eleanor Murray 3, Jiayi Wang 4, Benjamin P Linas 2,5, Laura White 6, Jeffrey H Samet 2,7, Marc LaRochelle 2,7
PMCID: PMC10615721  NIHMSID: NIHMS1932796  PMID: 37839942

Abstract

Background:

Buprenorphine reduces risk of opioid overdose mortality. However, its benefits are limited by low retention, particularly in early treatment. Optimizing initial dosage may impact retention. However, little is known about the prescription characteristics of new buprenorphine treatment episodes.

Methods:

In a US sample of commercial and employer-sponsored pharmacy claims, we identified new buprenorphine treatment episodes (days 1–30) from individuals ≥16 years following 90 days without buprenorphine from 2010–2019. Outcomes included first prescription average days supplied, first prescription average daily dosage, and average dosage on days 2, 8, 15 and 30. We assumed dosages of 0mg represented days without buprenorphine possession.

Results:

We identified 117,793 new episodes among 96,451 unique individuals. Episodes per 10,000 person-years decreased slightly over time. Stratifying by age, sex and region demonstrated decreasing episodes among individuals ≤34 years and increasing episodes among individuals ≥35 years. From 2010–2019, first prescription average days supplied and daily dosage decreased from 17.1 to 15.3 days and 13.6mg to 11.6mg, respectively. Simultaneously, the proportion of episodes without possession and with dosages <16mg increased across all days and years. By day 30, episodes without buprenorphine possession grew from 27.9% to 30.8% and episodes involving dosages of <16mg grew from 26.4% to 33.4%.

Conclusions:

We found that buprenorphine dosage and days supplied for new treatment episodes decreased from 2010 to 2019 while buprenorphine possession worsened. Further investigation examining the relationship between buprenorphine dosage and retention in the early treatment period is needed.

Keywords: opioid use disorder, buprenorphine, treatment retention

Introduction

Opioid overdose deaths continue increasing in the United States. Buprenorphine, a medication for opioid use disorder, reduces opioid overdose mortality.1 However, buprenorphine’s benefits are limited by low retention, particularly in the first month of treatment.1,2 Initial buprenorphine dosage and days supplied may impact early retention. In clinical trials, dosages ≥16mg are associated with higher retention than lower dosages.3 In addition, initial days supplied ≤7 or dosage ≤4mg have been associated with decreased 180-day retention.2,4 Yet, prescription characteristics such as initial dosage and days supplied are understudied. We describe buprenorphine dosage and days supplied over treatment days 1–30 from commercial and employer-sponsored insurance pharmacy claims, 2010 – 2019.

Methods

We examined a national sample of commercial and employer-sponsored pharmacy claims from Truven Health Analytics MarketScan® Commercial Claims Database (MarketScan®) to identify new buprenorphine treatment episodes.1 We included individuals ≥16 years receiving buprenorphine following 90 days without buprenorphine (washout). We required continuous enrollment during washout and 30 days after initiation. We allowed multiple episodes per individual. Episodes were assigned to a calendar year based on their start date, allowing a 90-day look back into the previous year and a 30-day follow up period into the following year. We calculated episode frequency per year stratified by age, sex and region to contextualize trends. Outcomes included first prescription average days supplied, first prescription average daily dosage, and average dosage on days 2, 8, 15 and 30. We selected these treatment days based on the common practice of prescribing medication in weekly intervals; thus, dosages on day 8, 15 and 30 might reflect the new dosage of a subsequent prescription. Average dosage was calculated from total milligrams dispensed and days supplied. Dosages of 0mg were assumed to represent days without possession of buprenorphine (herein, buprenorphine possession). We converted buprenorphine dosage into a categorial measure of no buprenorphine possession, dosage >0mg to <16mg (herein, low dosage), and dosage ≥16mg (herein, high dosage). We present trends in 1) episodes per 10,000 person-years and 2) dosage and days supplied from 2010–2019. To better understand the relationship between day 30 buprenorphine possession and initial dosage, we stratified episodes with buprenorphine possession on day 30 according to day 2 dosage category. Ethics committee approval was not sought as the data used for this study are statistically deidentified and thus do not constitute human subjects research. Analyses were conducted using SAS 9.4 statistical software (SAS Institute, Cary, NC).

Results

We identified 117,793 new episodes among 96,451 unique individuals from 2010–2019. Episodes per 10,000 person-years decreased slightly over time (Figure 1). Stratifying by age, sex and region demonstrated decreasing representation of episodes among individuals ≤34 years while representation among individuals ≥35 years rose (Figure 1). First prescription average days supplied and daily dosage decreased over the ten-year period from 17.1 to 15.3 days and 13.6mg to 11.6mg, respectively. From 2010–2019, the proportion of episodes without buprenorphine possession and with low dosages increased across all days and years (Figure 2). On day 30, episodes without buprenorphine possession grew from 27.9% to 30.8% and episodes involving low dosages grew from 26.4% to 33.4%. After stratifying by day 2 dosage, the percentage of episodes with buprenorphine possession on day 30 was higher among episodes with a high dose on day 2 relative to a low dosage (Figure 3). This advantage for episodes with high day 2 dosage grew over time, peaking in 2017 (75.6% vs. 62.9%, difference: 12.6%) and then decreasing in 2018 and 2019 (2019: 72.1% vs. 63.5%, difference: 8.6%).

Figure 1.

Figure 1.

Open in a new tab

Trends in buprenorphine treatment receipt (Panel A) stratified by age (Panel B), sex (Panel C), and region (Panel D), 2010–2019a,b

aSeveral health plans stopped contributing data to MarketScan® at the end of 2014.

bEpisodes are reported per 10,000 person-years of enrollees by category (as in the denominator includes all enrollees in the referenced category e.g. age 16–25 years).

Figure 2.

Figure 2.

Open in a new tab

Trends in proportion of buprenorphine treatment episodes by dosage range on Days 2, 8, 15 and 30 of treatment, 2010–2019

Figure 3.

Figure 3.

Open in a new tab

Proportion of episodes with buprenorphine possession on Day 30 based on Day 2 dosage, 2010–2019

Discussion

Using a large sample of commercial and employer-sponsored health plans, we identified decreasing buprenorphine dosage and days supplied for new treatment episodes from 2010 to 2019. Specifically, we found increased use of buprenorphine dosages under 16mg. These findings have potential implications for clinical practice. In trials, dosages ≥16mg are associated with higher retention than lower dosages.3 However, few trials compare buprenorphine dosages head to head, especially at dosages ≥16mg daily.5–8 If future research demonstrates that higher initial buprenorphine dosages increase likelihood of retention, it will be important for professional organizations to modify treatment guidelines, which, currently, acknowledge but do not advocate for dosages of ≥16mg by treatment day 2.9

In addition, this study demonstrated that buprenorphine possession by day 30 worsened from 2010 to 2019. By 2019, possession had decreased to less than 80% on day 8 and 66% on day 30. However, when used to treat OUD, buprenorphine is usually prescribed for twelve months or longer to control cravings and withdrawal symptoms, far beyond the first month of treatment.10 Moreover, we demonstrated greater buprenorphine possession among episodes with higher buprenorphine dosages early in treatment, specifically, day 2. While we did not directly measure treatment retention, and rather measured daily buprenorphine possession, treatment retention is typically operationalized as consecutive day gaps in buprenorphine possession (durations of seven11 and fourteen1 days are commonly used). Thus, our findings on decreasing dosage alongside decreasing buprenorphine possession suggest need for further investigation into whether higher initial dosages improve buprenorphine retention in the early treatment period.3

Our findings on buprenorphine possession seem to contrast those from analyses of Medicaid populations, which have demonstrated increased buprenorphine receipt during similar time periods.12–15 More directly, previous analyses have demonstrated higher rates of OUD treatment among patients with Medicaid than with private insurance coverage.16 It is likely that programmatic efforts by state Medicaid programs to expand buprenorphine utilization, such as through removal of prior authorization requirements,12,14 have not occurred in parallel in private insurance programs.17 Despite this research on buprenorphine possession, little research has examined trends in buprenorphine dosage, specifically.18 Further research on trends in buprenorphine dosage in both publicly and privately insured populations are needed.

Despite national efforts to expand MOUD treatment in the general population, buprenorphine receipt declined from 2010 to 2019. Stratifying by age revealed an initial rise among young adults ages 16–25, possibly reflecting new enrollment of previously uninsured individuals following implementation of the Affordable Care Act Dependent Coverage Provision in late 2010. This increase, however, was more than offset by subsequent declines,19 and identifies 16–25 year-olds as a key demographic group needing intervention.

Reasons for these trends in buprenorphine dosage and possession are unclear but may reflect efforts to expand treatment capacity and buprenorphine receipt.19 For example, low barrier treatment programs increasingly engage patients with high psychosocial complexity at risk for discontinuation.20 As such, decreasing rates of buprenorphine possession in our study could reflect growing representation of patients with increased complexity among those receiving OUD treatment rather than worsening outcomes of OUD treatment. In addition, increased clinical resources, reduced licensure requirements, and targeted training programs have boosted buprenorphine prescribing by nonspecialists and new prescribers, particularly advanced practice providers. Resulting compositional changes in the provider pool may have produced shifts in practice style resulting in prescribing of lower buprenorphine dosage.21 Finally, expansion of care to nonspecialized practice settings may have increased the proportion of treatment occurring in settings without addiction-focused care management, an intervention known to optimize outcomes like retention.19 In the background, rising fentanyl adulteration has complicated buprenorphine initiation promoting very early discontinuation.20 The increased challenge of initiating buprenorphine in the era of fentanyl may have contributed to the softened advantage of starting treatment on a high verse low dosage in 2018 and 2019.

This study had limitations. First, this study used pharmacy claims, which limited analyses because inferred buprenorphine possession and dosage from claims may differ from actual use, risking misclassification. For similar reasons, we could not identify intentionally low dosages of buprenorphine, a more recently developed buprenorphine initiation strategy known as microdosing. However, sensitivity analyses screening for episodes with an average daily dosage in line with microdosing revealed few plausible episodes. In addition, we did not include injectable formulations of buprenorphine such as Sublocade; a small number of episodes classified as 0mg may represent transitions to injectable buprenorphine from sublingual buprenorphine.22 Notably, the data did not include individuals covered by Medicaid, Medicare or self-pay, limiting generalizability. This study used pharmacy claims to identify treatment episodes without access to diagnosis codes. Thus, we could not exclude buprenorphine prescriptions for indications other than OUD such as chronic pain. Finally, we could not assess if detoxification admissions explained episodes without buprenorphine possession due to dose tapering.

In summary, from 2010 to 2019, low dosage buprenorphine treatment rose contrary to evidence-based guidance while buprenorphine possession decreased. Given rising opioid overdose rates, interventions to help clinicians improve buprenorphine initiation practices are urgently needed.

Highlights.

  • Early treatment buprenorphine dosage and days supplied decreased from 2010 to 2019

  • Buprenorphine possession, days with medication, also decreased from 2010 to 2019

  • Results show worsened early treatment retention, and may reflect decreased dosages

References

  • 1.Morgan JR, Schackman BR, Leff JA, Linas BP, Walley AY. Injectable naltrexone, oral naltrexone, and buprenorphine utilization and discontinuation among individuals treated for opioid use disorder in a United States commercially insured population. J Subst Abuse Treat. 2018;85:90–96. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Samples H, Williams AR, Olfson M, Crystal S. Risk factors for discontinuation of buprenorphine treatment for opioid use disorders in a multi-state sample of Medicaid enrollees. J Subst Abuse Treat. 2018;95:9–17. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2014;(2):CD002207. doi: 10.1002/14651858.CD002207.pub4 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Meinhofer A, Williams AR, Johnson P, Schackman BR, Bao Y. Prescribing decisions at buprenorphine treatment initiation: Do they matter for treatment discontinuation and adverse opioid-related events? J Subst Abuse Treat. 2019;105:37–43. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Ling W, Charuvastra C, Collins JF, et al. Buprenorphine maintenance treatment of opiate dependence: a multicenter, randomized clinical trial. Addiction. 1998;93(4):475–486. [DOI] [PubMed] [Google Scholar]
  • 6.Ahmadi J, Bahrami N. Buprenorphine treatment of opium-dependent outpatients seeking treatment in Iran. J Subst Abuse Treat. 2002;23(4):415–417. [DOI] [PubMed] [Google Scholar]
  • 7.Montoya ID, Gorelick DA, Preston KL, et al. Randomized trial of buprenorphine for treatment of concurrent opiate and cocaine dependence. Clin Pharmacol Ther. 2004;75(1):34–48. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Schottenfeld RS, Chawarski MC, Pakes JR, Pantalon MV, Carroll KM, Kosten TR. Methadone versus buprenorphine with contingency management or performance feedback for cocaine and opioid dependence. Am J Psychiatry. 2005;162(2):340–349. [DOI] [PubMed] [Google Scholar]
  • 9.TIp 63: Medications for Opioid Use Disorder. SAMHSA; 2020. [Google Scholar]
  • 10.Bentzley BS, Barth KS, Back SE, Book SW. Discontinuation of buprenorphine maintenance therapy: perspectives and outcomes. J Subst Abuse Treat. 2015;52:48–57. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.Chua KP, Nguyen TD, Zhang J, Conti RM, Lagisetty P, Bohnert AS. Trends in Buprenorphine Initiation and Retention in the United States, 2016–2022. JAMA. 2023;329(16):1402–1404. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Keshwani S, Maguire M, Goodin A, Lo-Ciganic WH, Wilson DL, Hincapie-Castillo JM. Buprenorphine use trends following removal of prior authorization policies for the treatment of opioid use disorder in 2 state Medicaid programs. In: JAMA Health Forum. Vol 3. American Medical Association; 2022:e221757–e221757. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Gordon AJ, Lo-Ciganic WH, Cochran G, et al. Patterns and quality of buprenorphine opioid agonist treatment in a large Medicaid program. J Addict Med. 2015;9(6):470–477. [DOI] [PubMed] [Google Scholar]
  • 14.Treitler P, Nowels M, Samples H, Crystal S. Buprenorphine Utilization and Prescribing Among New Jersey Medicaid Beneficiaries After Adoption of Initiatives Designed to Improve Treatment Access. JAMA Netw Open. 2023;6(5):e2312030–e2312030. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Mojtabai R, Mauro C, Wall MM, Barry CL, Olfson M. The Affordable Care Act and opioid agonist therapy for opioid use disorder. Psychiatr Serv. 2019;70(7):617–620. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Orgera K, Tolbert J. The Opioid Epidemic and Medicaid’s Role in Facilitating Access to Treatment. Kaiser Family Foundation; Accessed May 23, 2023. https://www.kff.org/medicaid/issue-brief/the-opioid-epidemic-and-medicaids-role-in-facilitating-access-to-treatment/ [Google Scholar]
  • 17.Humphreys K, Frank RG. The Affordable Care Act will revolutionize care for substance use disorders in the United States. Published online 2014. [DOI] [PubMed]
  • 18.Landis RK, Levin JS, Saloner B, et al. Sociodemographic differences in quality of treatment to Medicaid enrollees receiving buprenorphine. Subst Abuse. 2022;43(1):1057–1071. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Olfson M, Zhang V, Schoenbaum M, King M. Buprenorphine Treatment By Primary Care Providers, Psychiatrists, Addiction Specialists, And Others: Trends in buprenorphine treatment by prescriber specialty-primary care providers, psychiatrists, and addiction medicine specialists. Health Aff (Millwood). 2020;39(6):984–992. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Snyder H, Kalmin MM, Moulin A, et al. Rapid adoption of low-threshold buprenorphine treatment at California emergency departments participating in the CA bridge program. Ann Emerg Med. 2021;78(6):759–772. [DOI] [PubMed] [Google Scholar]
  • 21.Larochelle MR, Jones CM, Zhang K. Change in opioid and buprenorphine prescribers and prescriptions by specialty, 2016–2021. Drug Alcohol Depend. Published online 2023:109933. [DOI] [PubMed] [Google Scholar]
  • 22.Ling W, Shoptaw S, Goodman-Meza D. Depot buprenorphine injection in the management of opioid use disorder: from development to implementation. Subst Abuse Rehabil. Published online 2019:69–78. [DOI] [PMC free article] [PubMed] [Google Scholar]

RESOURCES