Criminal justice outcomes over 5 years after randomization to buprenorphine-naloxone or methadone treatment for opioid use disorder.

A critical strategy to address the opioid epidemic is increasing access to pharmacotherapy, particularly buprenorphine/naloxone (BUP). BUP is a partial agonist that has a superior safety profile than methadone (MET), a full agonist, in terms of overdose risk. Few studies have compared the long-term outcomes of participants randomized to BUP or MET treatment for opioid use disorder (OUD), however, and differences in treatment retention by medication type may translate into variation in criminal justice outcomes.

This study aimed to compare long-term criminal justice outcomes among opioid dependent individuals randomized to receive buprenorphine or methadone. Five-year follow-up was conducted in 2011-2014 of 303 opioid-dependent participants entering three opioid treatment programs in California in 2006-2009 (as part of CTN-0050, “Starting Treatment with Agonist Replacement Therapy (START)”) and randomized to receive either buprenorphine/naloxone or methadone.

Participants received BUP (n=179) or MET (n=124) for 24 weeks and then were tapered off their treatment over 8 weeks or less or referred for ongoing clinical treatment. Midway through the study, the randomization scheme was switched from 1:1 BUP:MET to 2:1 because of higher drop out in the BUP arm.

Study outcomes included arrests and self-reported incarceration. Predictors included randomization condition (BUP vs. MET), age, gender, race/ethnicity, use of cocaine, drug injection in the 30 days prior to baseline, and study site. Treatment status (BUP, MET, none) during follow-up was included as a time-varying covariate.

There was no significant difference by randomization condition in the proportion arrested (BUP: 55.3%, MET: 54%) or incarcerated (40.9%, 47.3%) during follow-up. Among methadone-randomized individuals, arrest was less likely with methadone treatment (0.50, 0.35-0.72) during follow-up (relative to no treatment) and switching to buprenorphine had a lower likely likelihood of arrest than those receiving no treatment (0.39, 0.18-0.87). Among buprenorphine-randomized individuals, arrest was less likely with receipt of buprenorphine (0.49, 0.33-0.75) during follow-up and switching to methadone had a similar likelihood of arrest as methadone-randomized individuals receiving no treatment. Likelihood of arrest was also negatively associated with older age (0.98, 0.96-1.00); it was positively associated with Hispanic ethnicity (1.63, 1.04-2.56), cocaine use (2.00, 1.33-3.03), injection drug use (2.19, 1.26-3.83), and study site.

Conclusions: In a US sample of people treated for opioid use disorder, continued treatment with either buprenorphine or methadone was associated with a reduction in arrests relative to no treatment. Cocaine use, injection drug use, Hispanic ethnicity, and younger age were associated with higher likelihood of arrest.

Related protocols: CTN-0050