Payer-Mandated Buprenorphine Dose Decreases Result in Worse Patient Outcomes

Despite a lack of evidence supporting specific limits to FDA-approved buprenorphine doses for the treatment of opioid use disorder, payer mandates in some areas have imposed plan limits on dosing for patients initiating or already receiving buprenorphine. In this natural experiment, the authors performed a retrospective analysis of urine toxicology results among patients receiving higher doses of buprenorphine who were forced to limit their daily dose to 16 mg per day. Urine toxicology results were compared between the 6 months before and 4 months after the policy change. To control for other temporal factors, comparison groups were formed among patients from the same practice with the same insurance receiving buprenorphine doses of ≤16 mg per day, patients with different insurance receiving ≤16 mg per day, and patients with different insurance receiving >16 mg per day.

• Rates of aberrant urine toxicology results rose from 28% to 34% among those patients who were mandated to decrease their dose. No other group experienced this increase in aberrant findings.
• Groups receiving >16 mg per day had lower rates of aberrant toxicology findings and greater treatment retention.

Comments:

These data suggest that an arbitrary dose decrease imposed by payer mandates results in an increase in aberrant urine toxicology findings. Despite the single site study design with relatively short follow-up after the mandated decrease and lack of investigation into buprenorphine diversion at higher doses, this study suggests that involuntary dose decreases may result in patient destabilization.

Jeanette M. Tetrault, MD

Reference:

Accurso AJ, Rastegar DA. The effect of a payer-mandated decrease in buprenorphine dose on aberrant drug tests and treatment retention among patients with opioid dependence. J Subst Abuse Treat. 2015 [Epub ahead of print]. doi: 10.1016/j.jsat.2015.09.004.