Measuring time in buprenorphine treatment stages among people with HIV and opioid use disorder by retention definition and its association with cocaine and hazardous alcohol use

Abstract

Background: We use a novel, longitudinal approach to describe average time spent in opioid use disorder (OUD) cascade of care stages for people with HIV (PWH) and with OUD, incorporating four definitions of treatment retention. Using this approach, we describe the impact of cocaine or hazardous alcohol use on time spent retained on buprenorphine.

Methods: We followed PWH with OUD enrolled in the Johns Hopkins HIV Clinical Cohort from their first buprenorphine treatment episode between 2013 and 2020. We estimated 4-year restricted mean time spent on buprenorphine below buprenorphine retention threshold, on buprenorphine above retention threshold, off buprenorphine and in HIV care, loss to follow-up, and death. Retention definitions were based on retention threshold (180 vs 90 days) and allowable treatment gap (7 vs 30 days). Differences in 2-year restricted mean time spent retained on buprenorphine were estimated for patients with and without cocaine or hazardous alcohol use.

Results: The study sample (N = 179) was 63% male, 82% non-Hispanic Black, and mean age was 53 (SD 8) years. Patients spent on average 13.9 months (95% CI 11.4, 16.4) on buprenorphine over 4 years. There were differences in time spent retained on buprenorphine based on the retention definition, ranging from 6.5 months (95% CI 4.6, 8.5) to 9.6 months (95% CI 7.4, 11.8). Patients with cocaine use spent fewer months retained on buprenorphine. There were no differences for patients with hazardous alcohol use.

Conclusions: PWH with OUD spend relatively little time receiving buprenorphine in their HIV primary care clinic. Concurrent cocaine use at buprenorphine initiation negatively impact time on buprenorphine.

Keywords: Buprenorphine; Opioid use disorder; Polysubstance use; Retention.

Fig. 1

Depiction of buprenorphine treatment stages and direction of possible transitions. By definition, all participants start follow up when they initiate buprenorphine and are therefore in box 1. If the treatment episode duration is above the retention threshold (e.g., 90 or 180 days), they move to box 2. If they are in box 1 or 2 and stop buprenorphine and are lost to follow up, they move to box 3. If they are in box 1 or 2 and stop buprenorphine and are retained in HIV clinic they are in box 4. Participants can move between being lost to follow up (box 3) and retained in care (4). If after stopping buprenorphine (box 3 or 4) they restart buprenorphine they would return to box 1. Death (box 5) is a competing (terminal) event

Fig. 2

Proportion of participants with HIV and opioid use disorder who initiated clinic-based buprenorphine in each opioid use disorder treatment stage in the Johns Hopkins HIV Clinical Cohort restricted to 4-year follow-up, with retention defined as ≥ 180 days of treatment without a > 7-day gap