Author ORCID Identifier

Date Available


Year of Publication


Degree Name

Doctor of Philosophy (PhD)

Document Type

Doctoral Dissertation


Public Health


Epidemiology and Biostatistics

First Advisor

Dr. Svetla Slavova


Opioid use disorder (OUD) is chronic opioid use that results in clinically significant suffering, impairment, or even death. The opioid epidemic in the United States has become a public health and economic crisis, affecting patients' well-being and the nation's overall health and welfare. Eastern Kentucky was among the first regions affected by the opioid crisis, and Kentucky has historically ranked among the top five states for age-adjusted drug overdose mortality rate.

There are three medications (buprenorphine, methadone, naltrexone) approved by the U.S. Food and Drug Administration to treat OUD. As a partial opioid agonist, buprenorphine is a safe medication for OUD (MOUD) because of its ceiling effect, in which higher doses do not increase the risk of respiratory depression in the event of an overdose. While buprenorphine treatment, primarily with the transmucosal (TM) buprenorphine formulations, has increased since its approval in 2002, there are still substantial barriers to the availability and access, with most OUD patients never receiving MOUD. The characteristics of early-stage buprenorphine treatment may affect long-term success. Within the first 30 days of treatment, the discontinuation rate is the highest.

In the dissertation’s studies, we evaluated the utilization of buprenorphine treatment for OUD and associated opioid-related overdose deaths in Kentucky.

The first study, titled “Changes in Transmucosal Buprenorphine Utilization for Opioid Use Disorder Treatment during the COVID-19 Pandemic in Kentucky,” examined the changes in buprenorphine prescribing for OUD treatment following the COVID-19 emergency declaration from 2019 to 2020 in Kentucky, using a segmented regression analysis for an interrupted time series design. The study reported a drop in the TM buprenorphine MOUD utilization in the first weeks of COVID-19 national emergency for both urban and rural residents, followed by gradual increase that may have been facilitated by the relaxed buprenorphine prescribing regulations by federal agencies.

The second study, titled "Characteristics of buprenorphine initiation treatment for opioid use disorder and association with the incidence of opioid-related overdose deaths," explored the associations between characteristics of buprenorphine treatment within the first 30 days of treatment and the incidence of opioid-related overdose deaths in the following 12-month period. To account for the competing risks of deaths from causes other than opioid-related overdose deaths, we utilized Fine and Gray proportional subdistribution hazard models to evaluate the associations. The findings suggest that higher dosages and greater patient compliance (a higher proportion of days covered in treatment) within the first 30 days of treatment were associated with a decreased incidence of opioid-related overdose deaths.

In the context of the rising number of overdose deaths, the results of this dissertation provide information for making data-driven decisions regarding OUD treatment, and it highlights the significance of treatment decisions and patient compliance during the first month of buprenorphine treatment, to inform the design of future studies.

Digital Object Identifier (DOI)