Comparative effectiveness of buprenorphine-naloxone versus methadone for treatment of opioid use disorder: a population-based observational study protocol in British Columbia, Canada

Abstract

Introduction: Despite a recent meta-analysis including 31 randomised controlled trials comparing methadone and buprenorphine for the treatment of opioid use disorder, important knowledge gaps remain regarding the long-term effectiveness of different treatment modalities across individuals, including rigorously collected data on retention rates and other treatment outcomes. Evidence from real-world data represents a valuable opportunity to improve personalised treatment and patient-centred guidelines for vulnerable populations and inform strategies to reduce opioid-related mortality. Our objective is to determine the comparative effectiveness of methadone versus buprenorphine/naloxone, both overall and within key populations, in a setting where both medications are simultaneously available in office-based practices and specialised clinics.

Methods and analysis: We propose a retrospective cohort study of all adults living in British Columbia receiving opioid agonist treatment (OAT) with methadone or buprenorphine/naloxone between 1 January 2008 and 30 September 2018. The study will draw on seven linked population-level administrative databases. The primary outcomes include retention in OAT and all-cause mortality. We will determine the effectiveness of buprenorphine/naloxone vs methadone using intention-to-treat and per-protocol analyses-the former emulating flexible-dose trials and the latter focusing on the comparison of the two medication regimens offered at the optimal dose. Sensitivity analyses will be used to assess the robustness of results to heterogeneity in the patient population and threats to internal validity.

Ethics and dissemination: The protocol, cohort creation and analysis plan have been approved and classified as a quality improvement initiative exempt from ethical review (Providence Health Care Research Institute and the Simon Fraser University Office of Research Ethics). Dissemination is planned via conferences and publications, and through direct engagement and collaboration with entities that issue clinical guidelines, such as professional medical societies and public health organisations.

Keywords: epidemiology; primary care; public health; statistics & research methods; substance misuse.

Figure 1

Study-specific dates, databases and their data extraction period. Data extraction time window: BC, British Columbia, Canada; BC corrections (1 January 1996–31 December 2017); DAD, discharge Abstract database (1 January 1996–30 September 2018); MSP, medical services plan (1 January 1996–30 September 2018); NACRS, national ambulatory care reporting system (1 April 2012–30 September 2018); OAT, opioid agonist treatment; PNET, PharmaNet (1 January 1996–30 September 2018); PSBC, perinatal services British Columbia (10 March 2000–14 August 2012); VS, vital statistics (1 January 1996–30 September 2018).