Center to Improve Veteran Involvement in Care (CIVIC)
Don't Hold Up; Management of Buprenorphine Treatment
Written by Chris Larsen
As part of ongoing research by Dr. Jessica Wyse and her team regarding buprenorphine treatments and practices, they conducted a national retrospective cohort study investigating how VA clinicians were managing patients’ buprenorphine prescriptions over the course of their hospital visit for surgery (perioperative period). They wanted to understand how VA clinical practice aligned with an emerging clinical consensus recommending maintaining buprenorphine perioperatively. Holds, or temporarily stopping medications around the time of surgery, create a risk for Veterans relapsing during necessary perioperative and postoperative pain management.
In her paper, titled “Perioperative Management of Buprenorphine/Naloxone in a Large, National Health Care System: A Retrospective Cohort Study,” Dr. Wyse collaborated with CIVIC colleagues Anders Herreid O’Neill, Jacob Dougherty, Sarah Shull, and Travis Lovejoy to identify high rates of buprenorphine holds (66% of patients) during the perioperative period. High rates of buprenorphine discontinuation (33%) 12-months post operation and frequent adverse events (relapse, overdose) were also identified. The authors suggest that educational campaigns or provider targeted interventions may be needed to ensure patients receive guideline-concordant care.
Barriers to buprenorphine maintenance identified in this study align with access barriers Dr. Wyse has seen more generally, “There are many multi-level barriers to expanding access to medications, including providers who think recovery using a medication isn’t ‘real’ recovery, and clinicians who think using the medication is replacing one opioid for another,” she said. Other barriers include stigma associated with opioid use disorder (OUD), concerns over patient medical history and other substance use, or patient barriers like transportation (buprenorphine requires a clinic visit) and not wanting to continue medications. Dr. Wyse “wants to lower barriers to people accessing buprenorphine” and prefers a systemic harm reduction approach to treatment of OUD. Harm reduction focuses on enabling patients to change their behavior by setting their own goals and addressing broader health and social issues.
For OUD, normalizing buprenorphine treatment in inpatient and outpatient settings could help to create a support system for patients. Additional measures like utilizing telehealth and clinical pharmacists would eliminate critical access barriers to rural patients that are out of reach of the system. Dr. Wyse hopes to continue identifying barriers and potential points of intervention to improve patient health and reform patient and provider perspectives of OUD.
