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PSYCHOPHARMACOLOGY
Overdose Risk High Following Buprenorphine Discontinuation
December 13, 2019   

Opioid use disorder is a considerable issue in the United States. Medication assisted treatment (MAT) involves replacing opioids (such as hydrocodone or heroin) with agents that bind to the mu opioid receptor but do not elicit euphoria; methadone, buprenorphine, and naltrexone are the 3 approved MAT agents for opioid use disorder. Buprenorphine, a mu opioid receptor partial agonist, is the most commonly employed MAT strategy for opioid use disorder. Given that opioid use disorder is a chronic condition, most expert recommendations suggest maintenance on MAT for extended periods of time. Unfortunately, many patients (50-80%) who are initiated on buprenorphine discontinue use all-too-soon due to a variety of reasons, including stigma and limits on insurance coverage. In this study, involving data from 8,996 individuals with US Medicaid claims, the authors investigated the effects of the duration of use of buprenorphine on various outcomes after discontinuation. Use of inpatient services, emergency services, opioid prescriptions, and overdose were compared during the 6 months following discontinuation in individuals who had used buprenorphine for 6-9 months, 9-12 months, 12-15 months, and 15-18 months. The authors found that individuals who had maintained buprenorphine treatment for 15-18 months had significantly improved outcomes during the 6 month following buprenorphine discontinuation compared to individuals who had only maintained buprenorphine for 6-9 months (Figure). The data also showed a trend towards improving outcomes correlated with increased duration of buprenorphine use prior to discontinuation. One very serious outcome that did not seem to be affected by duration of buprenorphine use was overdose. Thus, regardless of whether an individual had maintained buprenorphine MAT for 6 months or 18 months, the risk of overdose during the 6 months following discontinuation of buprenorphine was still approximately 5%. However, these data collectively imply that longer duration of buprenorphine MAT prior to discontinuation greatly improves patient outcomes and encourages policy changes and clinical practices that reflect a longer duration of MAT therapy.

Figure. Duration of Buprenorphine Use Affects Outcomes After 6-months Discontinuation.


Compared to individuals who used buprenorphine for 6-9 months before discontinuation, those who maintained buprenorphine use for 15-18 months had better outcomes in terms of inpatient service use, emergency service use, and opioid prescriptions. Unfortunately, duration of buprenorphine use did not change the risk of overdose after discontinuation.


Reference:

Williams AR et al. AJP in Advance 2019; Epub ahead of print. Abstract


For more information:

Keeping Up with Clinical Advances: Opioid Use Disorder
CME credit: 1.00
32-Year-Old Teacher With Opioid Use Disorder
CME credit: 0.5
This Month in Psychopharmacology: Addiction/Reward
Independence Day: Medication-Assisted Treatment of Opioid Dependence
CME credit: 0.75