In the JournalsPerspective

Discontinuing buprenorphine results in adverse outcomes

Arthur Robin Williams

Risk for overdose and acute care service use were significant following buprenorphine discontinuation regardless of treatment duration, according to results of a retrospective longitudinal cohort analysis published in American Journal of Psychiatry.

“Currently, our systems of care and payment strategies are fragmented and onerous, which undermines long-term retention,” Arthur Robin Williams, MD, MBE, assistant professor of psychiatry at Columbia University, told Healio Psychiatry. “There is also an ideological bias, that is not empirically based, by many prescribers and systems to limit buprenorphine treatment to just a few weeks or months. Our study suggests that these are major liabilities for patient outcomes.”

According to Williams and colleagues, buprenorphine treatment reduces risk for death and overdose among patients with opioid use disorder, yet most discontinue it within weeks or months. The researchers conducted the analysis between 2013 and 2017 using the MarketScan multistate Medicaid claims database, which covers 12 million beneficiaries annually, they noted. They included 8,996 adults aged 18 to 64 years who received buprenorphine continuously for 6 months or more, and these patients were partitioned into four cohorts based on duration of treatment — 6 to 9 months, 9 to 12 months, 12 to 15 months and 15 to 18 months. The researchers considered all-cause ED visits, all-cause inpatient hospitalizations, opioid prescriptions and opioid or nonopioid drug overdose as primary adverse outcomes.

Williams and colleagues found that adverse events were common in all cohorts, with nearly half (42.1% to 49.9%) of patients seen in the ED at least once. Patients retained on buprenorphine for 15 to 18 months (n = 931) had significantly lower odds of ED visits than those retained for 6 to 9 months (OR = 0.75; 95% CI, 0.65-0.86). They also had lower odds of inpatient hospitalizations (OR = 0.79; 95% CI, 0.64-0.99) and filling opioid prescriptions (OR = 0.67; 95% CI, 0.56-0.8) in the 6 months after discontinuation. Across all cohorts, approximately 5% of patients experienced one or more medically treated overdoses.

“These findings suggest that patients need much longer courses of treatment with buprenorphine and that discontinuation is a life-threatening event,” Williams said. “Systems of care need to be coordinated from the outset to promote and fund long-term treatment, if not indefinite treatment.” – by Joe Gramigna

Disclosures: Williams reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

Arthur Robin Williams

Risk for overdose and acute care service use were significant following buprenorphine discontinuation regardless of treatment duration, according to results of a retrospective longitudinal cohort analysis published in American Journal of Psychiatry.

“Currently, our systems of care and payment strategies are fragmented and onerous, which undermines long-term retention,” Arthur Robin Williams, MD, MBE, assistant professor of psychiatry at Columbia University, told Healio Psychiatry. “There is also an ideological bias, that is not empirically based, by many prescribers and systems to limit buprenorphine treatment to just a few weeks or months. Our study suggests that these are major liabilities for patient outcomes.”

According to Williams and colleagues, buprenorphine treatment reduces risk for death and overdose among patients with opioid use disorder, yet most discontinue it within weeks or months. The researchers conducted the analysis between 2013 and 2017 using the MarketScan multistate Medicaid claims database, which covers 12 million beneficiaries annually, they noted. They included 8,996 adults aged 18 to 64 years who received buprenorphine continuously for 6 months or more, and these patients were partitioned into four cohorts based on duration of treatment — 6 to 9 months, 9 to 12 months, 12 to 15 months and 15 to 18 months. The researchers considered all-cause ED visits, all-cause inpatient hospitalizations, opioid prescriptions and opioid or nonopioid drug overdose as primary adverse outcomes.

Williams and colleagues found that adverse events were common in all cohorts, with nearly half (42.1% to 49.9%) of patients seen in the ED at least once. Patients retained on buprenorphine for 15 to 18 months (n = 931) had significantly lower odds of ED visits than those retained for 6 to 9 months (OR = 0.75; 95% CI, 0.65-0.86). They also had lower odds of inpatient hospitalizations (OR = 0.79; 95% CI, 0.64-0.99) and filling opioid prescriptions (OR = 0.67; 95% CI, 0.56-0.8) in the 6 months after discontinuation. Across all cohorts, approximately 5% of patients experienced one or more medically treated overdoses.

“These findings suggest that patients need much longer courses of treatment with buprenorphine and that discontinuation is a life-threatening event,” Williams said. “Systems of care need to be coordinated from the outset to promote and fund long-term treatment, if not indefinite treatment.” – by Joe Gramigna

Disclosures: Williams reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

    Perspective
    Adam Bisaga

    Adam Bisaga

    Health care executives and some clinicians often believe that 1 to 1.5 years of opioid use disorder treatment with buprenorphine is sufficient to accomplish sustained health benefits and that longer treatment duration may not be needed. This is contradicted by the results of the study by Williams and colleagues who compared adverse health outcomes (ED visits, inpatient admission, relapse to opioid use and overdose) in a cohort of almost 9,000 Medicaid beneficiaries who were treated with buprenorphine for 6, 12, 15 or 18 months but then stopped taking it and could be monitored for 6 months afterwards. Most patients who initiate buprenorphine stop it within 3 to 6 months, and experts consider 6 months to be a minimum length of treatment to be beneficial. The present study shows that even after 6 months of continuing treatment, individuals who stopped buprenorphine continued to experience adverse medical outcomes. For example, half of them visited the ED.

    Although ED admissions and the risk of relapse seem to benefit from extending treatment from 6 to 18 months, the incidence of overdose, the most serious of adverse outcomes, has not benefited from extending treatment up to 18 months and remained at an unacceptably high 5% annual rate. Empirical evidence shown here further underscores the need to educate medical providers and other stakeholders and to organize treatment of [opioid use disorder] around a chronic-disease model of care with the medication and overdose prevention interventions at its center. Without further evidence otherwise, currently there is no rationale for setting an arbitrary limit on medication-treatment duration.

    • Adam Bisaga, MD
    • Healio Psychiatry Peer Perspective Board Member
      Professor of Psychiatry
      Columbia University

    Disclosures: Bisaga reports no relevant financial disclosures.

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