Treatment gaps with buprenorphine linked to increased opioid overdose risk and higher health care spending: JAMA

USA: According to a new study gaps in treatment with buprenorphine were associated with increased risk of opioid overdose and higher health care spending.

The results of original investigation have been published in JAMA Psychiatry. 

Opioid abuse and dependence contribute to excessive mortality, disability, and economic costs. Buprenorphine (at low doses) was first used in the 1970s. High-dose Buprenorphine (0.4mg, 2.0mg, and 8.0mg doses) was introduced in 1980 to treat opioid dependency. Buprenorphine has activity as a partial opioid agonist.

Many trials and reviews suggest Buprenorphine is safe and effective for opioid dependency, but it can potentially be a drug of abuse. Therefore it is crucial to assess the risk (opioid overdose and drug abuse) and benefits of Buprenorphine (licit and illicit) use as it is "unclear." A trial was conducted to add data on the role of Buprenorphine on the risk of opioid overuse and economic cost.

Dr. Jason B. Gibbons et al., the primary researcher from the Department of Health Policy & Managemen at Johns Hopkins University Bloomberg School of Public Health, with his fellow researchers, answered the question, "Whether treatment gaps with Buprenorphine increase the risk of opioid overdose and is associated with higher health care spending or not?

The current longitudinal case-control study was designed to compare patient opioid overdose and health care spending (in buprenorphine-treated months with treatment gap months). The analysis took place between January 2010 and December 2017. The Buprenorphine treatment gap in a month was more than 15 consecutive days.

The critical points of the study are:

• 34 505 Medicare beneficiaries, with a mean age of 49.5 years, were included in the study.

• The participants were 17 927 males and 16 578 females.

• 33.4 % of beneficiaries experienced one or more buprenorphine treatment gaps.

• The comparison was made between treatment gap and nontreatment gap beneficiaries.

• Opioid overdose and total medical and drug spending were the primary outcomes measured in the study.

• Beneficiaries were 2.89 times more likely to experience opioid overdose in treatment gap months compared to the treated months.

• Spending was $196.41 more during treatment gap months than in treated months.

• Patients with buprenorphine dosages greater than 8 mg/d and 16 mg/d were 2.61 and 2.84 times more likely to be associated with overdose in a treatment gap month.

• Patients on buprenorphine dosages of 8 mg/d or less were 3.62 times more likely to overdose in a treatment gap month.

• With maintenance of >16 mg/d, > 8mg/dl and ≤ 8 mg/dl, hazard ratio (HR) was 2.64, 2.84 and 3.62 respectively.

• Buprenorphine monotherapy leads to a greater risk of overdose and higher spending during treatment gaps compared to buprenorphine/naloxone.

Jeffrey S. McCullough from the Department of Health Management and Policy at the University of Michigan School of Public Health said that the main finding of our case-control study was patients in buprenorphine treatment gap months had a higher risk of opioid overdosage and had higher healthcare spending in Medicare when compared to patients with treated months.

The researchers concluded that treatment gaps with buprenorphine were associated with increased risk of opioid overdose and higher health care spending. The impact of the findings should be quantified so that the clinicians are updated on practice and policy.

Further reading:

• Gibbons JB, McCullough JS, Zivin K, Brown ZY, Norton EC. Association Between Buprenorphine Treatment Gaps, Opioid Overdose, and Health Care Spending in US Medicare Beneficiaries With Opioid Use Disorder. JAMA Psychiatry.

• Yokell MA, Zaller ND, Green TC, Rich JD. Buprenorphine and buprenorphine/naloxone diversion, misuse, and illicit use: an international review. Curr Drug Abuse Rev. 2011 Mar;4(1):28-41.