HIV Insight: Correlates of Nine-Month Retention following Interim Buprenorphine-Naloxone Treatment in Opioid Dependence: A Pilot Study

Interim medication-only treatment has been suggested for the initiation of opioid maintenance treatment (OMT) in opioid-dependent subjects, but this rarely has been studied using buprenorphine instead of methadone. Following a pilot trial assessing interim buprenorphine-naloxone treatment in order to facilitate transfer into OMT, we here aimed to study retention, and potential correlates of retention, in full-scale treatment. Thirty-six patients successfully referred from a waiting list through an interim treatment phase were followed for nine months in OMT. Baseline characteristics, as well as urine analyses during the interim phase and during full-scale OMT, were studied as potential correlates of retention. The nine-month retention in OMT was 83 percent (n = 30). While interim-phase urine samples positive for benzodiazepines did not significantly predict dropout from full-scale OMT (p = 0.09), urine samples positive for benzodiazepines within full-scale OMT were significantly associated with dropout (p < 0.01), in contrast to other substances and baseline characteristics. Retention remained high through nine months in this pilot study sample of patients referred through buprenorphine-naloxone interim treatment, but use of benzodiazepines is problematic, and the present data suggest that it may be associated with treatment dropout.

…The use of benzodiazepines during interim treatment and during full-scale OMT was the only variable associated with dropout in the present study. Although the number of dropouts in this pilot study was low, urines positive for benzodiazepines in the interim condition tended to be associated with a negative outcome once referred to the full-scale program but did not reach statistical significance (p = 0.09). However, significantly, a negative outcome in full-scale OMT was associated with the use of benzodiazepines within that OMT treatment setting, which was not the case for any other substance, suggesting that benzodiazepines may play a major role in the clinical picture of patients with a negative treatment course in opioid dependence.

The seemingly negative association between retention and benzodiazepine use during treatment of opioid dependence may require further attention in research and in clinical practice. In the present study, at baseline, the frequency of use of benzodiazepines was comparable to that of the main drug of these primarily opioid-dependent subjects. In contrast to the high rates of continued benzodiazepine use, urine samples positive for opiates were very infrequent in the full-scale OMT phase, markedly lower than in many other studies [35,36], and opioid-positive urines were not associated with dropout in OMT. The role of benzodiazepines in the present results, compared to the role of opioids, strengthens the impression that polydrug use, particularly including the use of benzodiazepines, may present a potentially even larger challenge in the treatment of severe opioid dependence than the actual primary opioid-related disorder.

Patients with a high level of benzodiazepine use could represent a group with more complicated psychiatric problems and more severe substance-related problems [29, 37]. In the present study, patients dropping out of treatment did not report more use of benzodiazepines during the last 30 days prior to study start, but still, this type of substance use was associated with a negative outcome once in full-scale treatment. It cannot be excluded that intake of benzodiazepines actually increases when the intake of illicit opioids decreases in treatment, at least in a subset of individuals…

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