Buprenorphine Treatment Days Linked to Lower Opioid Overdose Risk

Key Takeaways

• In a Rhode Island cohort of 8,676 people initiating buprenorphine for OUD, opioid overdose risk was lower on treatment days than on non-treatment days.
• Starting buprenorphine at 24 mg was associated with better 180-day treatment retention than starting at 16 mg.
• Prescribed buprenorphine doses were similar on days with and without an opioid overdose.
• Most participants were aged 25 to 44 years, and men made up most of the cohort.

Rhode Island residents initiating buprenorphine for opioid use disorder from October 2016 through September 2022 were followed in a retrospective cohort study, which linked statewide controlled substance prescribing, emergency medical services, medical examiner, vital records, and behavioral health treatment databases. Generalized estimating equations compared fatal and non-fatal opioid overdose on treatment versus non-treatment days during the 365 days after initiation, while Cox regression compared 16 mg versus 24 mg initiation doses for treatment discontinuation over 180 days with adjustment for confounding and potential informative censoring.

Among 8,676 patients, most were aged 25 to 44 years and male. Opioid overdose risk was 61% lower on treatment days than on non-treatment days, with an adjusted risk ratio of 0.39 and a 95% confidence interval (CI) of 0.31 to 0.49. Patients prescribed 16 mg at initiation had a 20% higher risk of treatment discontinuation over 180 days than those prescribed 24 mg, with an adjusted hazard ratio of 1.20 (95% CI, 1.06 to 1.37). Prescribed doses on days with and without an opioid overdose were similar (P = 0.261).

Because the data came from linked administrative records, these findings show associations rather than causal effects.

The investigators reported that buprenorphine remained effective for overdose prevention among patients who stayed in treatment during the fentanyl era. They also concluded that doses above current recommendations should be considered for improving retention.

Clinician Questions

How did the Rhode Island analysis define the overdose comparison for buprenorphine treatment in OUD?

The overdose analysis used day-level exposure, comparing days when patients had buprenorphine treatment with days when they did not, and it included both non-fatal and fatal opioid overdose during the year after initiation.

What did the 16 mg versus 24 mg buprenorphine dose comparison measure after OUD treatment initiation?

The dose comparison was defined at treatment initiation, contrasting patients prescribed 16 mg with those prescribed 24 mg and tracking time to treatment discontinuation over 180 days. It addressed retention after treatment start rather than overdose events.