Journal of Substance Abuse Treatment 46 (2014) 356–361

Contents lists available at ScienceDirect

Journal of Substance Abuse Treatment

Leaving buprenorphine treatment: Patients' reasons for cessation of care

Jan Gryczynski, Ph.D. a,⁎, Shannon Gwin Mitchell, Ph.D. a, Jerome H. Jaffe, M.D. a,b, Kevin E. O’Grady, Ph.D. c,Yngvild K. Olsen, M.D. d, Robert P. Schwartz, M.D. a

a Friends Research Institute, Inc., 1040 Park Avenue, Suite 103, Baltimore, MD 21201, USAb University of Maryland School of Medicine, Department of Psychiatry, Baltimore, MD 21201, USAc University of Maryland, College Park, Department of Psychology, College Park, MD 20742, USAd Institutes for Behavior Resources, Inc., REACH Health Services, Baltimore, MD 21218, USA

a b s t r a c ta r t i c l e i n f o

⁎ Corresponding author. Tel.: +1 410 837 3977x246;E-mail address: jgryczynski@friendsresearch.org (J. G

0740-5472/$ – see front matter © 2014 Elsevier Inc. Alhttp://dx.doi.org/10.1016/j.jsat.2013.10.004

Article history:Received 14 May 2013Received in revised forms 19 September 2013Accepted 4 October 2013

Keywords:BuprenorphineOpioid dependenceRetentionDropoutPatient intentions

Many opioid-dependent patients leave treatment prematurely. This study is a planned secondary analysisfrom a randomized trial of counseling for African Americans (N = 297) entering buprenorphine treatment atone of two outpatient programs. This study examines: (1) whether patients’ initial treatment durationintentions prospectively predict retention; and (2) patients’ reasons for leaving treatment. Participants werequeried about their treatment duration intentions at treatment entry, and their reasons for leaving treatmentat 6-month follow-up. At baseline, 28.0% reported wanting to stay in buprenorphine treatment less than6 months, while 42.1% actually left buprenorphine treatment within 6 months. However, participantsintending short-term buprenorphine at the outset were not at elevated risk of early treatment discontinuation(OR = 1.15; p = .65). Participants attributed treatment cessation predominantly to conflicts with staff,involuntary discharge, and perceived inflexibility of the program. Future research should examine patient-centered models of buprenorphine treatment that could improve retention.

fax: +1 410 752 4218.ryczynski).

l rights reserved.

© 2014 Elsevier Inc. All rights reserved.

1. Introduction

Opioid agonistmedications likemethadone and buprenorphine areeffective treatments for opioid dependence (Amato et al., 2005;Mattick, Kimber, Breen, & Davoli, 2008). However, some opioid-dependent individuals view such medications negatively (Hunt,Lipton, Goldsmith, Strug, & Spunt, 1985–1986; Peterson et al., 2010;Rosenblum, Magura, & Joseph, 1991), which could prompt earlydiscontinuation of treatment. Long-term abstinence following discon-tinuation of maintenance treatment is possible for some patients, butis not a typical outcome (Kornør & Waal, 2005; Maddux & Desmond,1992; Stimmel, Goldberg, Rotkopf, & Cohen, 1977; Waal & Kornor,2004). In a review of 14 studies examining abstinence prognosisfollowing cessation of agonist maintenance treatment, Kornør andWaal (2005) determined that, on average, 33% of patients could beclassified as abstinent at follow-up. Abstinence rates were twice ashigh for patients completing a voluntary “therapeutic detoxification”compared to those leaving treatment involuntarily (Kornør & Waal,2005). A study in a time-limited, 9-month buprenorphine treatmentprogram found that only 12% of patients were abstinent from allopioids at 2-year follow-up (Kornør, Waal, & Sandvik, 2007).

Thus, although some individuals may remain abstinent after ter-minating maintenance treatment, the typical prognosis after leavingmaintenance treatment is poor (Magura & Rosenblum, 2001).

Discontinuation of maintenance treatment has not only been linkedwith resumption of opioid use (Kornør et al., 2007; Stimmel & Rabin,1974; Stimmel et al., 1977), but elevated risk of death as well(Caplehorn, Dalton, Cluff, & Petrenas, 1994; Clausen, Waal, Thoresen,& Gossop, 2009; Degenhardt et al., 2011; Gibson et al., 2008; Woody,Kane, Lewis, & Thompson, 2007). For example, Caplehorn et al. (1994)found that heroin addicts were almost 3 times more likely to diewhile not enrolled in methadone treatment than while actively en-rolled. A study comparing patients who remained in methadonetreatment to those who were discharged found that the latter grouphad 2.8 times higher rates of death (Woody et al., 2007). Likewise, ameta-analysis of studies examining mortality risk among opioid usersfound that, compared to periods of active enrollment in treatment,the overall pooled mortality rate was 2.4 times higher during out-of-treatment periods, while mortality due to overdose was 3.5 timeshigher during out-of-treatment periods (Degenhardt et al., 2011).

Despite these risks, many of those who enter agonist maintenancetreatment end up leaving treatment prematurely (Reisinger et al.,2009; Winstock, Lintzeris, & Lea, 2011). Research with patients inmethadone maintenance treatment suggests that major life events,desire for abstinence, periods of incarceration, conflicts with staff, andnon-compliance with program rules contribute to early treatmentdiscontinuation (Mitchell et al., 2009, 2011; Reisinger et al., 2009).Moreover, many patients express a desire to stop taking maintenancemedication and initiate attempts to withdrawal on their own(Winstock et al., 2011). Thus, patient intentions regarding treatmentduration may play an important role in outcomes.

357J. Gryczynski et al. / Journal of Substance Abuse Treatment 46 (2014) 356–361

Patient preferences for shorter treatment duration pose a chal-lenge for clinicians, because the provision of patient-centered caremay conflict with the provision of evidence-based care. This issue isparticularly salient now given the continuing expansion of bupre-norphine treatment. Several studies have found that patients treatedwith buprenorphine have somewhat higher rates of treatmentdiscontinuation than those treated with methadone (Gryczynskiet al., 2013; Mattick et al., 2008; Pinto et al., 2010). A meta-analysisof randomized trials comparing methadone and buprenorphinefound that, among the trials with flexible-dosing regimens, meth-adone was better able to retain patients in treatment through theend of each study (relative risk = .85; Mattick et al., 2008). Somestudies with samples entering community treatment programs havedocumented even greater retention differences between these medi-cations within 6 months of admission, with elevated risk of earlydiscontinuation in buprenorphine treatment (hazard ratios N 2;Gryczynski et al., 2013; Pinto et al., 2010). However, less is knownabout why patients leave buprenorphine treatment, or the extent towhich their initial treatment duration intentions are related to theiractual retention in treatment.

The aims of the present study were to: (1) examine whetherbuprenorphine patients' intentions regarding medication mainte-nance duration prospectively predict retention and length of stay intreatment, and (2) characterize reported reasons for leaving bupre-norphine treatment from the patient perspective. We hypothesizedthat participants' intended length of stay would be associated withtheir actual length of stay, and that participants intending shorterbuprenorphine treatment duration would discontinue the medica-tion sooner than those who preferred a longer maintenance periodat the outset.

2. Methods

2.1. Parent Study

This study used data gathered as part of a randomized clinical trialof two levels of counseling intensity for 300 opioid-dependent AfricanAmerican male and female adults newly admitted to buprenorphinetreatment. The study was conducted at two formerly “drug-free”outpatient substance abuse treatment programs that had adoptedbuprenorphine as part of a larger city-wide initiative to expand theavailability of buprenorphine treatment in the local substance abuseservice system (Agency for Healthcare Research and Quality, 2011).One of the programs was an outpatient buprenorphine treatmentprogram co-located in a large urban community health center. Thesecond site was a free-standing outpatient buprenorphine treatmentprogram located adjacent to a large outpatient community mentalhealth clinic.

Exclusion criteria were pregnancy and an acute medical orpsychiatric problem beyond the capacity of the clinic physician tomanage (under which circumstances patients would not have beenadmitted to the programs). Participants in the parent study wererandomly assigned to either a standard outpatient (OP) or intensiveoutpatient (IOP) level of care as normally delivered by each clinic. Theconditions varied based on the content, frequency, and duration ofcounseling services, but there were no differences in buprenorphinedoses between conditions. Moreover, no significant differences werefound between the conditions on a range of outcomes, includingtreatment retention (Mitchell et al., 2013).

Participants were interviewed by a research assistant at treatmentadmission and at 3- and 6-months thereafter. Follow-up interviewswere conducted by a trained research interviewer using a battery ofmeasures. Follow-up rates were 96% and 93% at 3 and 6 months,respectively. Over half of those who could not be interviewed atfollow-up were determined to be incarcerated using public databases(at 3 months, 5 incarcerated out of 13 not interviewed; at 6 months,

13 incarcerated out of 21 not interviewed). Treatment data, such asbuprenorphine dosing records and attendance, were obtained fromclinic records. The study was approved by the Friends ResearchInstitute Institutional Review Board (IRB), as well as the IRB of oneof the treatment sites. All participants provided written informedconsent. Additional details about the design and findings of the parentstudy can be found elsewhere (Mitchell et al., 2013).

2.2. Participants

Of the 300 African American participants enrolled in the parentstudy, two participants had missing baseline cocaine urine data, andone participant had missing buprenorphine dosing data and wereexcluded from the analyses, leaving n = 297. The mean age of theanalysis sample was 46.6 years (SD = 6.5), and 38.1% were women.Injection drug use was reported by 23.2%, and 48.8% had a urine drugscreening test at baseline that was positive for cocaine. Heroin wasthe primary opiate of abuse for all participants, and half of the sam-ple had previous experience with buprenorphine treatment (50.5%).There was good balance across the two program sites, with 52.5% ofthe sample recruited at the community health center.

2.3. Variables and Measures

2.3.1. Aim 1 – Role of Patients' Intended Treatment Duration inPredicting Actual Retention

The variables and corresponding measures used in the inferentialanalysis of treatment dropout (either as outcome, focal explanatory,or control variables) are described below.

2.3.1.1. Retention in Buprenorphine Treatment (Outcome Variable). Thenumber of days in buprenorphine treatment was obtained from clinicrecords (1–180 days, after which observations were censored).Because the aim of the buprenorphine treatment programs was toeventually transfer patients to ongoing office-based buprenorphinetreatment under the care of a physician, such transfers were classifiedas remaining in treatment through 180 days if the participant re-ported successful transfer and enrollment in buprenorphine treat-ment through the 6-month follow-up. Eight participants who couldnot be located at 6 month follow-up were assumed to no longer bein treatment.

2.3.1.2. Patients' Intended Treatment Duration (Focal ExplanatoryVariable). No validated instruments were available to captureintended length of stay in treatment. Instead, a single question withhigh face validity was developed by our internal panel of experts. Thisitem was included in a study-specific supplemental questionnaireadministered at the baseline assessment, and simply asked partici-pants: “How long do you intend to stay in buprenorphine treatment?”The interviewer recorded responses in weeks (up to 1 year, with acode of 53 to signify responses of more than 1 year or indefinitely).For the purposes of the present analysis, values were truncated at26 weeks to match the 6-month observation period of the study.[We confirmed that the findings were not sensitive to the coding ofthis variable].

2.3.1.3. Background and Treatment Characteristics (Control Variables).Control variables included gender, age (in years), injection drug usestatus (yes vs. no), baseline cocaine urine status (negative vs. posi-tive), program site (site 1 vs. site 2), assigned condition in the parentstudy (intensive outpatient vs. standard outpatient), and buprenor-phine maintenance dose (in milligrams). Participant characteristics,including gender, age, and injection drug use status, were derivedfrom the Addiction Severity Index (5th edition) administered at studyentry (McLellan et al., 1992). The modal buprenorphine dose was

Table 1Participant characteristics (N = 297).

Percent Mean (SD)

Baseline characteristicsAge (in years) 46.6 (6.5)Female gender 38.1% (n = 113)Injection drug user 23.2% (n = 69)Cocaine + urine at baseline 48.8% (n = 145)Previous buprenorphinetreatment experience

50.5% (n = 150)

Buprenorphine doseModal buprenorphine dose 13.6 (4.5)

Expected treatment durationExpected treatment duration(weeks)

23.9 (5.0)

Wants to stay onbuprenorphine b 6 m.

28.0% (n = 83)

Actual treatment durationDays in treatment (days upto 180)

127.0 (68.9) [in weeks:18.3 (10.0)]

Left treatment within6 months

42.1% (n = 125)

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obtained from clinic records. Cocaine use was determined by theresults of the urine drug screening test administered at study entry.

2.3.2. Aim 2 – Patients' Reasons for Leaving Treatment

2.3.2.1. Reasons for Treatment Discontinuation. A study-specificquestionnaire was developed to capture reasons for treatmentdiscontinuation. At the 6-month follow-up, participants were askedwhether they were still in treatment at their original program. If theyindicated no, participants were asked their reasons for leavingtreatment: “I’d like to ask you about why you left treatment at[CLINIC]. I’m going to read some reasons that people leave treatment.Please let me know if each reason I read applies to you or not. You canjust answer ‘yes’ or ‘no’ for each one.” The list of reasons wasassembled by the study team based on previous research on dropoutfrom methadone treatment (Mitchell et al., 2009, 2011; Reisingeret al., 2009), and underwent multiple rounds of internal developmentand refinement. The list contained 14 possible reasons for leavingtreatment, as well as an additional open-ended “other” category inwhich the research assistant recorded participants' responses. Theseitems covered reasons such as: “you finished your treatmentsuccessfully”, “you didn’t like the effects of the medication”, “youleft because the treatment was too expensive”, “you were dischargedbecause you had a disagreement with the staff”, and “you weredischarged because you missed too many days”. Participants werepermitted to select more than one reason. The full list of reasons canbe found in Results. Information regarding reasons for leavingtreatment was collected for the 139 participants who had discon-tinued treatment at their original program within 6 months andcompleted their follow-up interview.

2.4. Statistical Analysis

Reasons for treatment discontinuation are presented descriptive-ly. The linear relationship between intended length of stay and actuallength of stay was first examined using a Pearson correlation. For theinferential analysis of the effect of patients' intended treatmentduration on retention, two analyses were conducted using differentoperationalizations of retention in treatment: (1) treatment status at6 months (in-treatment vs. out-of-treatment), and (2) number ofdays in treatment. For the first analysis, logistic regression was usedto predict treatment discontinuation by 6 months. Control variablesin the model included gender, age (in years), injection drug use status(yes vs. no), baseline cocaine urine status (negative vs. positive),treatment site, assigned condition in the parent study, and bupre-norphine maintenance dose. The explanatory variable of interest waswhether the participant intended to remain in buprenorphinetreatment less than 6 months (b 6 months vs. ≥ 6 months). Thus,participants' treatment duration intention was coded with a cut-point to match the dichotomous outcome of the 6-month analysistime frame.

The second analysis used Cox regression tomodel time-to-dropoutfrom buprenorphine treatment. Participants remaining in treatmentthrough 180 days were considered censored. In this analysis,consistent with the dependent variable of time-to-treatment discon-tinuation, participants' intended treatment duration at baseline wasleft as a continuous variable (number of weeks the participant wishedto remain in buprenorphine treatment). Diagnostics for the propor-tional hazards assumption revealed departures from this assumptionfor age, buprenorphine dose, and program site. Thus, an “extended”Cox model was fit, stratifying on site and interacting age and dosewith analysis time (Cleves, Gould, Guitierrez, & Marchenko, 2008;Kleinbaum, 2005). This improved overall model fit but had minimalimpact on the findings. The results from the extended Cox model arepresented here. The analyses were conducted using Stata software,version SE/12.

3. Results

3.1. Intended Treatment Duration and Actual Retention

Descriptive statistics on participant characteristics, baselinetreatment duration intentions, and retention in treatment arepresented in Table 1. Short-term treatment less than 6 months induration was preferred by a sizable minority of the sample (28.0%).The actual treatment discontinuation rate at 6 months was 42.1%. Onaverage, participants intended to remain in buprenorphine in23.9 weeks, but the actual mean length of stay in treatment wasonly 18.3 weeks. The raw correlation between participants' intendedlength of stay at baseline and actual length of stay was weak and notstatistically significant (Pearson's r = .07; p = .24).

Results of the inferential analyses are presented in Table 2. Thelogistic regression model shows that the odds of remaining intreatment through 6 months were not significantly different forthose who initially intended to remain on buprenorphine less than6 months vs. those who intended to stay in treatment 6 months orlonger (odds ratio [OR] = 1.15; 95% confidence interval [CI] = 0.63–2.10; p = .65). The survival analysis using a continuous metric oftime-to-dropout echoed these findings. Participants' desired treat-ment duration with buprenorphine had no significant relationshipwith time-to-leaving treatment (hazard ratio [HR] = 1.00; 95% CI =0.97–1.04; p = .81). Thus, in the current sample, baseline partici-pant intentions for treatment duration appear to play no substantiverole in predicting actual retention in buprenorphine treatment.

Of the control variables included in the models, participants with abaseline positive cocaine urine test were more likely to leave treat-ment earlier (HR = 1.71; 95% CI = 1.18–2.48; p = .004) and todiscontinue treatment within 6 months (OR = 2.05; 95% CI =1.25–3.35; p = .004). Older age was related to lower risk of early dis-continuation in the Cox regression (HR = .95; 95% CI = .91–.997;p = .04). Finally, higher buprenorphine dosewas related to lower riskof leaving treatment (HR = .84; 95% CI = .78–.89; p b .001) and ofdiscontinuing treatment within 6 months (OR = .91; 95% CI =.86–.96; p b .001). On average, the modal (i.e., maintenance) dosewas 12.56 mg among those who discontinued treatment within6 months, and 14.31 mg among those who remained in treatment(independent samples t-test: t = 3.35; p b .001).

The extended Cox model revealed time-varying effects on re-tention for buprenorphine dose and age, such that the protectiveeffects of older age and higher buprenorphine doses against treatment

Table 2Statistical models examining the relationship between intended treatment duration and retention.

Days-to-dropout–Cox regression p 6 month dropout–Logistic regression p

Hazard ratio (95% CI) Odds ratio (95% CI)

Predictor variables of interestIntended treatment duration (weeks) 1.004 (.97–1.04) .81 –

Expects to take buprenorphine b 6 months – 1.15 (.63–2.10) .65

Control variablesFemale gender .91 (.63–1.32) .62 .99 (.60–1.64) .97Age (years) .95 (.91–.997) .04 .99 (.96–1.03) .68Injection drug user 1.42 (.94–2.13) .10 1.60 (.90–2.86) .11Baseline cocaine + urine 1.71 (1.18–2.48) .004 2.05 (1.25–3.35) .004Program site 2 (ref = program site 1) (stratified) 1.01 (.62–1.66) .97IOP (ref = standard outpatient) .96 (.67–1.38) .82 1.01 (.62–1.65) .96Buprenorphine dose (in mg) .84 (.78–1.89) b .001 .91 (.86–.96) b .001

Time-varying covariatesBuprenorphine dose (in mg) 1.002 (1.0008–1.0027) b .001 –

Age (years) 1.0006 (1.00002–1.0012) .04 –

Note: CI = confidence interval; IOP = intensive outpatient. Hazard ratios and odds ratios are adjusted for the independent variables in each model. To address violations of theproportional hazards assumption, the Cox model is stratified on program site and specified with time-varying covariates for age and buprenorphine dose.

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discontinuation diminish the longer a participant remains intreatment. In the earlier segments of the treatment episode, olderparticipants and those on higher doses were less likely to be the nextto leave treatment. However, as participants accumulated more timein treatment, these factors played a diminished role in predictingsubsequent risk of treatment discontinuation. Thus, higher dosingearly on may help to reduce dropout, but once the patient is stabilizedthe dose does not matter as much (presumably because patients havereached a therapeutic maintenance dose).

3.2. Reasons for Leaving Treatment

Reasons for discontinuing buprenorphine treatment from theperspective of 139 participants who left treatment within the 6-month study window are shown in Table 3. Although participantswere able to select as many reasons as they felt applied to them, themajority attributed their treatment discontinuation to a single reason(84.9%). The single most commonly endorsed reason for treatment

Table 3Reasons for leaving buprenorphine treatment from the patient perspective.

Percent endorsing reason

Discharged involuntarily due to disagreement withprogram staff

24% (n = 33)

Discharged involuntarily for missing too many daysat the program

17% (n = 24)

Program conflicted too much with life, work, orschool obligations

17% (n = 23)

Left to get treatment at another provider 14% (n = 20)Discharged involuntarily due to too manypositive urines

9% (n = 12)

Incarcerated and did not return after release 7% (n = 9)Did not like the medication 4% (n = 6)Financial (discharged for not paying fees; insuranceended; too costly)

4% (n = 6)

Left because the provider was too strict 4% (n = 6)Left because wanted to keep using drugs 4% (n = 6)Finished treatment successfully 4% (n = 6)Discharged for breaking program rules 4% (n = 5)Moved out of town 3% (n = 4)Did not have transportation to get to the program 3% (n = 4)Felt addiction recovery was not possible whiletaking medication

1% (n = 2)

Notes: Data from 139 participants who had dropped out of treatment at their originalprogram and were interviewed at 6 month follow-up. Percentages do not sum to 100because participants could select multiple reasons. Program interference with life,transportation/distance, and moving were tabulated from responses to the open-ended “other” item.

discontinuation was a disagreement with the program staff, whichwas reported by 24% of participants. Discharge following insufficientattendance at the program was cited by 17% as a reason for leavingtreatment. Participants also reported leaving treatment because itinterfered with life obligations such as employment, education,healthcare, or caring for family members (17%). Only 4% reportedthat they left the program because they felt they had finished theirbuprenorphine treatment successfully, whereas 14% left their originaltreatment program to receive treatment at another provider [andmayhave continued buprenorphine treatment]. Taken together, the mostcommon reasons for leaving treatment could be considered as somesort of conflict, either with program staff, policies, or expectations.Excluding discharge for missing too many days at the program, 30.2%reported being discharged involuntarily from treatment (whendischarge for insufficient attendance is included, the rate ofinvoluntary discharge was 44.6%).

4. Discussion

Opioid-dependent individuals seek help for diverse reasons andenter treatment programswith a variety of preconceived expectations,preferences, and intentions regarding their care. Paying attention topatient preferences is an important aspect of patient-centeredtreatment and quality medical care (Institute of Medicine, 2001).Yet, sometimes patient preferences can run counter to evidence-basedpractices. Agonist treatment with methadone or buprenorphine canimprove outcomes for opioid-dependent individuals (Amato et al.,2005; Mattick et al., 2008), and premature discontinuation of suchtreatment can be perilous to patient health (Caplehorn et al., 1994;Clausen et al., 2009; Magura & Rosenblum, 2001).

The current study provides some encouraging evidence thatpatients' baseline intentions regarding buprenorphine maintenanceduration do not necessarily constrain their ability to remain intreatment, at least over the first 6 months. The lack of a relationshipbetween patients' intended treatment duration and actual length ofstay has important clinical implications for addiction medicine.Patients who are reluctant to commit to longer-term buprenorphinemaintenance treatment should not be dismissed as being overlyambivalent or at especially high risk of early dropout. Such patientsare no less likely to remain in treatment than those who, at theoutset, expect to stay in treatment longer. However, the fact thatpatients' treatment duration intentions do not prospectively predictretention does not mean that patient intentions or preferences areinconsequential. It is possible that 6 months is too short a time

360 J. Gryczynski et al. / Journal of Substance Abuse Treatment 46 (2014) 356–361

frame in which to study the impact of patients' intended treatmentduration on retention. However, a substantial number of patientsdiscontinue treatment within the first 6 months, over 40% in thecurrent sample. It is also possible that patients recalibrated theirtreatment duration intentions after experiencing improvements infunctioning across a range of domains following enrollment inbuprenorphine treatment (Mitchell et al., 2013).

An alternative explanation is that other factors overshadowedpatient treatment duration intentions and were more importantcontributors to treatment discontinuation. The descriptive dataregarding patients' stated reasons for dropout support this argument.Conflicts and disagreements with staff, and involuntary dischargefor missing too many days, breaking program rules, or continueddrug use – were by far the most commonly cited reasons for treat-ment discontinuation. These findings are consistent with earlierresearch conducted in methadone treatment programs (Reisingeret al., 2009). Importantly, many of the problems that patients cited ascontributing to their early departure from treatment may be, at leastto some extent, preventable.

This study has several limitations. An important limitation is thatwe did not ascertain reasons for participants' intended treatmentduration. Often, the underlying reasons for self-imposed time limitson treatment may not be readily apparent at the outset of care, evento the patients themselves. When patients first enter treatment, theirinitial treatment duration expectations and intentions can beinfluenced by a range of factors, including motivation for abstinence,ambivalence about treatment, external pressure, or a combination offactors. Some patients may prefer short-term treatment because theyseek only a brief respite from drug use or are enrolling in treatment atthe behest of family members or the criminal justice system. Othersmay prefer short-term treatment because they are highly motivatedto cease their drug use and desire to be abstinent from all opioids,including medications. Some studies support motivation as a pros-pective correlate of retention (Booth, Corsi, & Mikulich-Gilbertson,2004; Simpson & Joe, 1993), while others have not found this rela-tionship (Gryczynski, Schwartz, O’Grady, & Jaffe, 2009; Gryczynskiet al., 2012). Unfortunately, the parent study did not include instru-ments measuring patient motivation. Even though it is unknownwhy some patients preferred shorter treatment, the fact that ini-tial intentions had no bearing on actual length of stay remains anoteworthy finding. Future research should consider the basis oftreatment duration intentions and track how such intentions, expec-tations, and preferences change during the course of treatment.

Another limitation is that the findings may not be widely gene-ralizable given the patient population (low-income African Ameri-cans) and buprenorphine service model (formerly drug-freetreatment programs that adopted buprenorphine) in one US city.Replication in other populations and service settings (e.g., primarycare-based buprenorphine) is warranted. Even at a standard out-patient level of care, the buprenorphine treatment programs offeredand expected patients to attend drug abuse counseling services at arelatively high frequency (Mitchell et al., 2013). This service struc-ture may have elevated participants' perceived treatment burdenand created more opportunities for conflicts with the program andstaff than may have been the case in other models of buprenor-phine treatment delivery. However, participants did not reportfeeling overly burdened by the requirements of treatment, and per-ceived burden was actually low (Mitchell et al., 2013). Anotherlimitation is that the stated reasons for leaving treatment representthe participants' perspectives only, and may not reflect all relevantconsiderations. For example, continued drug use may haveprompted clinic personnel to suggest or require additional servicesor buprenorphine dose adjustments. A routine and clinically prudentresponse by the service provider may have been perceived by theparticipant as a disagreement with program staff that prompteddeparture from treatment.

Many patients leave buprenorphine treatment prematurely andcould benefit from remaining in treatment longer. The current studyfound that most patients leaving buprenorphine treatment withinthe first 6 months did so involuntarily or due to perceived incom-patibility between life obligations and the requirements of treat-ment. The relatively high rates of dropout from opioid agonisttreatment reduce the likelihood that such treatment reaches its fullpublic health potential. Additional research is needed to identifypatient-centered models of service delivery that could reduce pre-mature discontinuation of treatment. Our findings indicate thatclinicians should not be discouraged by patients who indicate thatthey do not intend to remain in treatment for more than a briefperiod of time. Such patients just might surprise their providers, andthemselves, after experiencing the benefits of treatment.

Acknowledgments

The authors acknowledge research support by the NationalInstitute on Drug Abuse (NIDA) Award Number 1RC1DA028407 (PI:S. G. Mitchell). The content is solely the responsibility of the authorsand does not necessarily represent the official views of NIDA or theNational Institutes of Health. NIDA had no role in the study design orthe decision to publish the paper. We would like to thank WendyMerrick of Total Health Care and Yvette Jefferson of Partners inRecovery for their collaboration, and toWill Aklin, Ph.D. fromNIDA forhis support. We would also like to thank Ms. Kyra Walls and Ms.Melissa Irwin for their assistance with manuscript preparation.

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