Risk of opioid overdose rises after de-addiction treatment completion

By Dr. Ananya Mandal, MDDec 2 2019

A study from Columbia University reveals that patients, who have been successfully treated with buprenorphine for opioid addiction, are at a greater risk of overdose after completion of the treatment. The study was titled, “Acute care, prescription opioid use, and overdose following discontinuation of long-term buprenorphine treatment for opioid use disorder”, and was published in the latest issue of The American Journal of Psychiatry. This study was funded and supported by the National Institute on Drug Abuse (NIDA) and the Agency for Healthcare Research and Quality.

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Researchers from the Columbia University Vagelos College of Physicians and Surgeons reveal that even after a treatment that lasts for 18 months, this theory holds true. Buprenorphine when used in individuals for 6 to 18 months continuously has been shown to be effective in opioid de-addiction treatment. Results from this study reveal that 5 percent of those who have thus been treated require treatment for opioid overdose within 6 months of ending treatment with buprenorphine. The authors of the study warn that these figures may be the tip of the iceberg because all overdose events that did not warrant healthcare setup visits may have been missed. Researcher Arthur Robin Williams, assistant professor of clinical psychiatry at Columbia University explained, “The rate at which individuals relapsed and overdosed after ending treatment was alarmingly high, suggesting that discontinuing buprenorphine is a life-threatening event.”

In fact the study authors reveal that the longer a person was on therapy with buprenorphine, the lower is their risk of poor outcomes in a person with opioid dependence. This means that at present buprenorphine therapy for de-addiction of opioid users may be the best choice. Researchers and other experts reveal that there is an opioid dependence crisis worldwide at present with opioid use disorder affecting over 2.1 million individuals. Buprenorphine was approved for opioid dependence in 2002 and is being prescribed and dispensed to over one million persons per year. The treatment however is discontinued by around 50 to 80 percent patients within a few weeks or months of use. There have been no guidelines that outline the duration of use of this agent for de-addiction. Insurance plans allow use of the agent for six months and there is requirement of periodic reauthorization, if it is to be continued further.

Williams said, “Many clinicians think they should prescribe buprenorphine only for time-limited periods, due to stigma and outdated beliefs that patients using medications for opioid use disorder are not in 'true recovery'. Our paper is one of the first to look at the effect of long-term durations of buprenorphine treatment on subsequent outcomes.”

For this study the team of researchers looked at the Medicaid claims data of around 9,000 persons aged between 18 and 64 years. These patients were on buprenorphine therapy for at least 6 months and as long as 18 months. Buprenorphine is one of the standard therapies for opioid de-addiction wrote the researchers. Experts have said that opioid addiction does not involve only heroin addiction as previous believed but also other opioids such as prescription drugs including oxycodone, codeine, morphine etc. there has been a serious rise in number of patients admitted or dying due to opioid overdose. Over the last few years, say reports from the CDC, between 1999 and 2016, there have been 350,000 deaths due to opioid overdose in United States and Canada. Reports also say that this “opioid epidemic” also known as the opioid crisis began in the nineties. One of the reasons for this rise in opioid use was the extended release low dose pain relief preparations that were being manufactured and prescribed during that time. Street drug use has given way to prescription opioid overuse.

Notwithstanding the duration of treatment, the team noted that 1 in 20 individuals had to be treated for opioid overdose at least once, 6 months after completion of buprenorphine treatment. Results also showed that around 25 percent had to be prescribed new opioids and around 45 percent presented to the emergency room, 6 months after buprenorphine treatment. The rate was high for those with pre-existing mental illness. The results also show that those who stopped therapy after 6 months of buprenorphine had higher risk of opioid overdose compared to those who were having the medication for 15-18 months.

The authors wrote that there have been studies that show that opioid overdose deaths reduce by 70 percent among those who are treated with buprenorphine. The dependence and addiction however has a risk of relapsing in most patients after the drug is discontinued. This study shows that those being treated for de-addiction may require years of therapy before they can be free of the risk of overdose. Williams said, “Patients and families need guidance, social support, and better coordination of care to help facilitate long-term maintenance with buprenorphrine for opioid use disorder.”