Association between high-threshold practices and buprenorphine treatment termination

•High-threshold practices create additional barriers to buprenorphine treatment.•Required counseling was positively associated with treatment termination.•Drug testing at every visit was positively associated with treatment termination.•State policies should enable low-barrier treatment to retain more patients in care. Regular counseling and frequent drug testing are common requirements for patients with opioid use disorder in buprenorphine treatment. State policies throughout the United States often reinforce these high-threshold practices, as was the case with Michigan, USA. We sought to explore the association between counseling requirements, drug testing practices, and buprenorphine treatment termination rates through administering a survey to buprenorphine prescribers in Michigan. In our sample of 377 prescribers, we found associations between high-threshold practices like drug testing at every clinical visit and requiring counseling and buprenorphine treatment termination rates. Relative to prescribers who randomly drug tested, drug tested at fixed intervals, or did not require any drug testing, prescribers who drug-tested patients at every visit were 38% more likely to terminate treatment. Prescribers who required counseling were 33% more likely to terminate treatment than those who did not require counseling. With the elimination of the USA Drug Enforcement Administration X-waiver in December 2022, state policies need to minimize high-threshold practices that reduce buprenorphine treatment continuity and undermine an effective response to the overdose crisis.