Patients who received a higher daily dose of buprenorphine (24 mg) were significantly more likely to remain in treatment over six months compared with those who received a lower dose (16 mg), according to a study published this week in JAMA Network Open.
“The U.S. Food and Drug Administration recommends a target dose of 16 mg for buprenorphine maintenance treatment, with an upper limit of 24 mg,” wrote Laura Chambers, Ph.D., M.P.H., of Brown University and colleagues. The authors noted that this recommendation was established prior to the emergence of fentanyl in the illicit drug supply. “Some physicians have suggested that the current daily maintenance target dose of buprenorphine (16 mg) may be inadequate to control withdrawal and cravings in patients who used fentanyl and that a higher daily dose may better suppress withdrawal and cravings.”
Chambers and colleagues conducted a retrospective study using data from the Rhode Island Prescription Drug Monitoring Program. They included patients who initiated buprenorphine treatment for opioid use disorder for the first time between October 2016 and September 2020. Each patient was followed for 180 days after initiation. The authors categorized patients as having discontinued treatment if they had a gap in treatment of more than 27 days based on prescription fill dates and days’ supply. To account for slight variations in prescribing, the authors categorized patients who received daily doses in the 14-18 mg range in the 16 mg group, and patients who received doses in the 22-26 mg range in the 24 mg group.
A total of 6,499 patients were included in the study, 57% of whom were 25 to 44 years old and 61% of whom were male. The initial daily dose for most patients was 8 mg (21%) or 16 mg (50%), and only 10% were initially prescribed a 24 mg dose. In total, 58% of patients discontinued buprenorphine treatment within 180 days. Of those who received 16 mg, 59% discontinued treatment compared with 53% of those prescribed 24 mg—a statistically significant difference, according to Chambers and colleagues.
“Effective treatment can save lives, but our proven treatments for opioid use disorders must evolve to match the challenges posed by the fentanyl crisis,” National Institute on Drug Abuse (NIDA) Director Nora Volkow, M.D., said in a news release. NIDA funded the study by Chambers and colleagues. “If science continues to demonstrate that a higher dosage of buprenorphine increases treatment retention, we must re-evaluate clinical guidelines to optimize treatment and help people achieve recovery.”
The authors noted that future research should examine outcomes for patients who are prescribed doses higher than 24 mg, “as it is uncertain where the ceiling is on the treatment effect in the era of fentanyl.”
For related information, see the Psychiatric News article “VA, DoD Recommend Buprenorphine for Chronic Pain.”
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