Opioid agonist treatment and risk of mortality during opioid overdose public health emergency: population based retrospective cohort study

Abstract

Objective To compare the risk of mortality among people with opioid use disorder on and off opioid agonist treatment (OAT) in a setting with a high prevalence of illicitly manufactured fentanyl and other potent synthetic opioids in the illicit drug supply. Design Population based retrospective cohort study. Setting Individual level linkage of five health administrative datasets capturing drug dispensations, hospital admissions, physician billing records, ambulatory care reports, and deaths in British Columbia, Canada. Participants 55 347 people with opioid use disorder who received OAT between 1 January 1996 and 30 September 2018. Main outcome measures All cause and cause specific crude mortality rates (per 1000 person years) to determine absolute risk of mortality and all cause age and sex standardised mortality ratios to determine relative risk of mortality compared with the general population. Mortality risk was calculated according to treatment status (on OAT, off OAT), time since starting and stopping treatment (1, 2, 3-4, 5-12, >12 weeks), and medication type (methadone, buprenorphine/naloxone). Adjusted risk ratios compared the relative risk of mortality on and off OAT over time as fentanyl became more prevalent in the illicit drug supply. Results 7030 (12.7%) of 55 347 OAT recipients died during follow-up. The all cause standardised mortality ratio was substantially lower on OAT (4.6, 95% confidence interval 4.4 to 4.8) than off OAT (9.7, 9.5 to 10.0). In a period of increasing prevalence of fentanyl, the relative risk of mortality off OAT was 2.1 (95% confidence interval 1.8 to 2.4) times higher than on OAT before the introduction of fentanyl, increasing to 3.4 (2.8 to 4.3) at the end of the study period (65% increase in relative risk). Conclusions Retention on OAT is associated with substantial reductions in the risk of mortality for people with opioid use disorder. The protective effect of OAT on mortality increased as fentanyl and other synthetic opioids became common in the illicit drug supply, whereas the risk of mortality remained high off OAT. As fentanyl becomes more widespread globally, these findings highlight the importance of interventions that improve retention on opioid agonist treatment and prevent recipients from stopping treatment.

Commentary on Krawczyk et al. (2020): Reinforcing the case for evidence‐based treatment of opioid use disorder

“…In British Columbia, Canada, we recently reported a >2-fold increase in the relative risk of mortality following the introduction of fentanyl to the illicit drug supply; however, this increase was only recorded for individuals off of OAT. We found no change in the risk of mortality for individuals continuously engaged in OAT [13]. Our findings and the findings of Krawczyk et al highlight that even with changes to the drug supply, OAT remains an essential medication [1,17].…”

“…[1,11,12] There is a need for improved evidence on when, how, and for whom non-medication treatments can benefit people with OUD. More importantly, however, there is a need to rapidly scale up the evidence-based approaches that we already know work [1,12,13].…”

Integrating Buprenorphine Treatment Into Family Medicine Resident Clinic

“…Patients with OUD are known to have increased risk for mental health disorders, hepatitis C and HIV infection. 6 Older patients with OUD have been shown to have increased rates of hypertension, cardiovascular disease, and polypharmacy, 7 and patients with OUD and diabetes mellitus have been shown to have more diabetic complications. 8 Our literature review did not locate any data on comorbidities among MAT patients specifically in family medicine residencies.…”

The Opioid-overdose Reduction Continuum of Care Approach (ORCCA): Evidence-based practices in the HEALing Communities Study

“…Methadone and buprenorphine, two of the three FDA-approved medications for treating opioid use disorder (OUD), decrease all-cause and overdose mortality for persons with OUD ( Larochelle et al, 2018 ; Pearce et al, 2020 ; Sordo et al, 2017 ). There is insufficient evidence to draw conclusions about the impact of naltrexone (specifically, extended-release naltrexone), the third FDA-approved medication for treating OUD, on mortality reduction ( Jarvis et al, 2018 ; Larochelle et al, 2018 ).…”