Higher buprenorphine dose may keep patients in treatment longer

Key takeaways:

• Patients prescribed 16 mg buprenorphine were 20% more likely discontinue treatment vs. those prescribed 24 mg.
• However, 53% of patients prescribed a higher dose still discontinued treatment within 180 days.

Patients prescribed buprenorphine at 24 mg for opioid use disorder were more likely to remain in treatment compared with those prescribed a 16 mg dose, a study in JAMA Network Open showed.

“Having a large study that compares the higher dosage to a more typical dosage is very important to guide practice and to provide the rigorous information that we all count on,” Wilson M. Compton, MD, MPE, the deputy director of the National Institute on Drug Abuse, which supported the study, told Healio.

According to Laura C. Chambers, PhD, MD, an assistant professor of the practice of epidemiology at Brown University School of Public Health, and colleagues, some physicians have suggested buprenorphine doses of 16 mg “may be inadequate to control withdrawal and cravings in patients who used fentanyl, and that a higher daily dose may better suppress withdrawal and cravings.”

Chambers and colleagues wanted to know if a higher dose could improve treatment retention, evaluating a sample of 6,499 Rhode Island residents who initiated buprenorphine between Oct. 1, 2016, to Sept. 30, 2020 — a period when unintentional fentanyl-related overdose deaths in the state rose from 59% to 76%.
Of the study’s cohort, 57% were aged 25 to 44 years, and 61% were men.

At the start of treatment, 50% were prescribed a daily buprenorphine dose of 16 mg, whereas just 10% were given a dose of 24 mg.

Chambers and colleagues found that 59% of patients prescribed 16 mg discontinued buprenorphine treatment within 180 days compared with 53% of patients prescribed 24 mg.

Overall, patients prescribed a dose of 16 mg had a 20% greater chance of discontinuing treatment than those prescribed 24 mg (adjusted HR = 1.2; 95% CI, 1.06-1.37).

“Particularly for patients who are using fentanyl... a higher dose than they might have expected is likely to be beneficial,” Compton said. “Instead of aiming for a typical 16 mg dosage, [physicians] may need to be aiming for a 24 mg dosage.”

He added buprenorphine can be a lifesaving medication “if people take it consistently and longer term.”

“Even at the higher dosage, an awful lot of persons dropped out of treatment or stopped their treatment prematurely, so they don’t even reach the 6-month mark as a starting point for long-term recovery,” he said. “I think we have a long way to go toward making treatment more acceptable and successful for the vast majority of our patients.”

Compton said future research should focus on even higher buprenorphine doses.

“Would 32 mg be more beneficial than 24 mg? Would there be more side effects at 32 mg compared to 24 mg?” he asked. “Since so few patients are treated, at least in this study, with higher than 24 mg, we really couldn’t answer that with this project.”

References:

• Chambers L, et al. JAMA Netw Open. 2023;doi:10.1001/jamanetworkopen.2023.34540.
• Higher buprenorphine doses associated with improved retention in treatment for opioid use disorder. https://www.nih.gov/news-events/news-releases/higher-buprenorphine-doses-associated-improved-retention-treatment-opioid-use-disorder/. Published Sept. 18, 2023. Accessed Sept. 18, 2023.