Thursday, December 5, 2019

Discontinuation of Buprenorphine Too Soon May Increase Risk of Adverse Outcomes

People who are treated with buprenorphine for more than 15 months appear to have superior clinical outcomes in the six months following buprenorphine discontinuation compared with those receiving the medication for shorter periods, according to a study published this week in AJP in Advance. However, there was no difference between the groups in rates of overdoses requiring medical treatment during this period.

“Although the study design cannot establish a causal relationship between longer retention and clinical outcomes, the results suggest that postdiscontinuation benefits may not begin to accrue until well after the six-month mark,” wrote Arthur Robin Williams, M.D., M.B.E., of the Columbia University Medical Center and colleagues. “[T]he results are consistent with a growing literature underscoring the protective effects of long-term pharmacotherapy for opioid use disorder as opposed to short-term use or brief detoxification.”

The researchers analyzed Medicaid claims data from 2013 to 2017 of patients who were 18 to 64 years old when they initiated buprenorphine treatment, were continuously retained on the treatment for at least six months, and maintained Medicaid enrollment for at least six months after discontinuing buprenorphine. The data included health information such as medication prescriptions and use of emergency services and inpatient and outpatient services.

The researchers separated these patients into four groups based on when they discontinued buprenorphine treatment (defined as a gap of more than 60 days after the last filled buprenorphine prescription): after 6 to 9 months (n=4,126), 9 to 12 months (n=2,440), 12 to 15 months (n=1,499), or 15 to 18 months (n=931).

The 15 to 18 months group had significantly lower rates of adverse events compared with the 6 to 9 months group, including fewer emergency department visits (41.2% compared with 48.6%), inpatient hospitalizations (11.3% compared with 13.9%), and opioid prescription claims (19.1% compared with 25.9%).

The rates of medically treated overdoses after discontinuation were about 5% for all groups, the authors wrote, “suggesting that overdose events in the subacute period following buprenorphine discontinuation remain common irrespective of treatment duration.” In fact, the six-month period following buprenorphine discontinuation was a “high-risk period for adverse events, especially among patients with comorbid mental illness,” they added.

They concluded, “Given high rates of early treatment discontinuation among patients who initiate buprenorphine treatment, often exceeding 50% within three to six months, greater efforts at the clinical and systems levels are needed to improve patient retention. Priority should be given to redesigning systems of care to emphasize chronic disease management models under collaborative care teams with emergency response capabilities for reaching patients who discontinue medication or disengage from care.”

For related information, see the Psychiatric Services study “Three-Year Retention in Buprenorphine Treatment for Opioid Use Disorder Among Privately Insured Adults.”

(Image: iStock/Moussa81)

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