Medication for Opioid Use Disorder After Nonfatal Opioid Overdose and Association With Mortality

Larochelle, Marc R.; Bernson, Dana; Land, Thomas; Stopka, Thomas J.; Wang, Na; Xuan, Ziming; Bagley, Sarah M.; Liebschutz, Jane M.; Walley, Alexander Y.

doi:10.7326/m17-3107

Cited by 718 publications

(565 citation statements)

References 34 publications

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“…Consistent with this work, this study found that long-term opioid use (3+ months) is associated with more than double the risk of incident OUD and opioid-related death, while the strength of the initial prescription had only a modest association. Additionally, our findings are consistent with prior studies suggesting that opioid prescribing practices have become more restrictive in recent years [51], with a reduction in overall opioid prescription strength as well as number of overlapping benzodiazepine prescriptions [33,52]. The present study extends this prior work by examining multiple outcomes, including mortality, using several data sources at the height of the recent opioid epidemic for up to 4 years after the initial prescription and specifically examining trends over time after taking changes in opioid prescribing into account.…”

Section: Discussionsupporting

confidence: 91%

Trends in opioid use disorder and overdose among opioid‐naive individuals receiving an opioid prescription in Massachusetts from 2011 to 2014

et al. 2019

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Aims To examine how the risks of incident opioid use disorder (OUD), non‐fatal and fatal overdose have changed over time among opioid‐naive individuals receiving an initial opioid prescription. Design Retrospective, longitudinal study using the Massachusetts Chapter 55 data set, which linked multiple administrative data sets to study the opioid epidemic. We identified the cumulative incidence of OUD, non‐fatal and fatal overdose among the opioid‐naive initiating opioid treatment in Massachusetts from 2011 to 2014 and estimated rates of these outcomes at 6 months and at 1, 2, 3 and 4 years to 2015. We used Cox regression to examine the association between characteristics of the initial prescription and risk of these outcomes. Setting Massachusetts, USA. Participants Massachusetts residents aged ≥ 11 years in 2011–15 who were opioid‐naive (no opioid prescriptions or evidence of OUD in the 6 months prior to the index prescription) (n = 2 154 426). The mean age was 49.1 years, 55.3% were female and 47.3% had commercial insurance. Measurements Opioid prescriptions were identified in the Prescription Monitoring Program (PMP) database, as were the characteristics of the initial prescription database. The outcomes of OUD and non‐fatal overdose were identified from claims in the All Payer Claims Database (APCD) and hospital encounters in the acute hospital case mix files. Fatal overdoses were identified using Registry of Vital Records and Statistics (RVRS) death certificates and the Office of the Chief Medical Examiner (OCME) circumstances of death and toxicology reports. Findings Among opioid‐naive individuals receiving an initial opioid prescription, the risk of incident OUD appears to have declined between 2011 and 2014, while rates of overdose were largely unchanged. For example, the 1‐year OUD rate was 1.18% in 2011, 1.11% in 2012, 1.26% in 2013 and 0.94% in 2014. Longer therapy duration was associated with higher risk of OUD [hazard ratio (HR) = 2.24, 95% confidence interval (CI) = 2.19–2.29 for duration of 3 or more months], non‐fatal (HR = 1.67, 95% CI = 1.53–1.82) and fatal opioid overdose (HR = 2.24, 95% CI = 1.91–2.61). Concurrent benzodiazepine treatment was also associated with higher risk of OUD (HR = 1.14, 95% CI = 1.12–1.17), non‐fatal (HR = 1.20, 95% CI = 1.10–1.30) and fatal overdose (HR = 1.86, 95% CI = 1.61–2.16). Conclusions Among opioid‐naive individuals in Massachusetts receiving an initial opioid prescription, the risk of incident opioid use disorder appears to have declined between 2011 and 2014, while rates of overdose were largely unchanged. Longer therapy duration and concurrent benzodiazepines were associated with higher rates of opioid use disorder and opioid overdose.

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Section: Discussionsupporting

confidence: 91%

Trends in opioid use disorder and overdose among opioid‐naive individuals receiving an opioid prescription in Massachusetts from 2011 to 2014

et al. 2019

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“…The mortality‐reducing standard of care for opioid use disorder includes treatment with medications such as methadone and buprenorphine . Buprenorphine is particularly vital because of its availability in office‐based settings and unique safety profile due to a “ceiling” effect on respiratory depression .…”

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Transitioning Hospitalized Patients with Opioid Use Disorder from Methadone to Buprenorphine without a Period of Opioid Abstinence Using a Microdosing Protocol

2019

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Study Objective Buprenorphine, a partial μ‐opioid agonist, is an effective treatment for opioid use disorder that conventionally requires symptoms of withdrawal before initiation to avoid precipitating withdrawal. Our institution implemented a microdosing approach to transition patients from full μ‐opioid agonists to buprenorphine without requiring patients to undergo a period of opioid abstinence. Little has been published about this strategy in the inpatient setting in the United States, and even less has been published dealing with the transition from methadone to buprenorphine. Our objective was to demonstrate that a microdosing protocol to transition patients from methadone to buprenorphine can be feasibly implemented in a U.S. hospital setting. Design Case series. Patients Three hospitalized adults with opioid use disorder who received a 1‐week buprenorphine microdosing protocol. Measurements and Main Results In January 2019, we implemented a 1‐week buprenorphine microdosing protocol for hospitalized adult patients with opioid use disorder who were initially stabilized on methadone and wished to start buprenorphine. We gave low‐dose buprenorphine concurrently with each patient's full dose of methadone, and the buprenorphine dose was gradually titrated up over 7 days. On day 8, methadone was abruptly discontinued. The buprenorphine dose was further increased based on clinical judgment. All three patients were successfully transitioned from methadone 40–100 mg/day to buprenorphine 12–16 mg/day with minimal symptoms of opioid withdrawal. One patient relapsed and was lost to follow‐up; two remained in treatment. Conclusion A protocol using microdosing of buprenorphine can successfully transition patients receiving full μ‐opioid agonist therapy, including methadone, to buprenorphine without the need for a period of opioid abstinence.

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“…A 2014 Cochrane systematic review showed that, at flexible doses, methadone retains patients in treatment significantly longer, when compared to buprenorphine . Risk of death after a nonfatal opioid overdose is substantially less likely for those with OUD when in treatment with methadone, as opposed to no treatment . There was a significant decrease in criminal behavior when patients were treated with methadone …”

Section: Treatment Of Oud In Older Adultsmentioning

confidence: 99%

“…11 Risk of death after a nonfatal opioid overdose is substantially less likely for those with OUD when in treatment with methadone, as opposed to no treatment. 12 There was a significant decrease in criminal behavior when patients were treated with methadone. 13 Methadone has a long elimination half-life, with its metabolism through CYP450 pathways, leading to some variability in its bioavailability.…”

Section: Methadonementioning

confidence: 99%

“…Risk of death after a nonfatal opioid overdose was significantly less likely for those with OUD when in treatment with buprenorphine, as opposed to no treatment. 12 A recent retrospective cohort study showed an association of buprenorphine therapy with significantly reduced opioid overdose, when compared to no treatment. 18 There is an association between buprenorphine and reduced arrest rate for all crime categories.…”

Section: Buprenorphinementioning

confidence: 99%

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Help Is on the Way: Medicare Coverage of Opioid Treatment Programs

Felix

Sharfstein

Olsen

2019

J American Geriatrics Society

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Opioid use disorder (OUD) among older adults has been increasing, yet evidence still remains scarce for age‐specific treatment. We discuss the three US Food and Drug Administration–approved medications used to treat OUD (methadone, buprenorphine, and naltrexone) and consider evidence gaps in OUD treatment in older adults. Legislation passed in 2018 (the Substance Use Disorder Prevention That Promotes Opioid Recovery and Treatment for Patients and Communities Act [also known as the SUPPORT Act]) expanded Medicare coverage to include bundled payment for OUD treatment through opioid treatment programs, permitting coverage of methadone treatment for the first time. Since the policy change will take effect in January 2020, healthcare providers need to be aware of new opportunities for treatment when caring for older adult patients with OUD. J Am Geriatr Soc 68:637–640, 2020

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Medication for Opioid Use Disorder After Nonfatal Opioid Overdose and Association With Mortality

Abstract: National Center for Advancing Translational Sciences of the National Institutes of Health.

Cited by 718 publications

References 34 publications

Trends in opioid use disorder and overdose among opioid‐naive individuals receiving an opioid prescription in Massachusetts from 2011 to 2014

Trends in opioid use disorder and overdose among opioid‐naive individuals receiving an opioid prescription in Massachusetts from 2011 to 2014

Transitioning Hospitalized Patients with Opioid Use Disorder from Methadone to Buprenorphine without a Period of Opioid Abstinence Using a Microdosing Protocol

Help Is on the Way: Medicare Coverage of Opioid Treatment Programs

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