Higher buprenorphine doses for opioid use disorder may lower risk for ED, inpatient visits

Key takeaways:

• Patients who received buprenorphine doses above 16 mg and 24 mg experienced longer times to ED or inpatient visit.
• Higher doses of buprenorphine may be beneficial for patients using fentanyl.

Higher doses of buprenorphine were associated with significantly lower rates of acute care utilization among adults with opioid use disorder compared with the FDA’s recommended dose, according to a study published in JAMA Network Open.

Concerns have been raised regarding whether the FDA’s recommended target dose of 16 mg buprenorphine is sufficient for individuals with opioid use disorder given the rise in use of fentanyl, according to the researchers.

“As the overdose crisis evolves, particularly with the rise of fentanyl, it is crucial to investigate how to best adapt and deliver the lifesaving and evidence-based treatments for opioid use disorder that we have available,” Nora D. Volkow, MD, director of the NIH’s National Institute on Drug Abuse, said in an NIH press release. “The findings [of this study] add to the growing evidence that higher doses of buprenorphine may have meaningful health impacts for people with opioid use disorder.”

To examine the association between higher buprenorphine doses and subsequent ED or inpatient service use, Sarah Axeen, PhD, director of data and analytics at USC Schaeffer Center and assistant professor in the division of emergency medicine research at Keck School of Medicine of USC, and colleagues retrospectively analyzed commercial claims data from Optum’s deidentified Clinformatics Data Mart between 2016 and 2021 on 35,451 adults (mean age, 46.2 years; 59.2% men; 75.3% white) with opioid use disorder who initiated buprenorphine treatment at least 90 days after enrollment.

The researchers categorized patients into the following buprenorphine daily dosage tiers based on their highest sustained dose after at least 14 days: more than 24 mg (1.8%), more than 16 mg to 24 mg (29%), more than 8 mg to 16 mg (42.9%), and 1 mg to 8 mg (27.3%).

The main outcome was the number of days from initiation of a patient’s highest buprenorphine dose to any behavioral health-related ED or inpatient visit.

Overall, 12.5% of the patients experienced an ED or inpatient visit.

The researchers conducted a survival analysis with an accelerated failure time model controlled for patient demographics, comorbidities, time to reaching maximum dose, discontinuation of buprenorphine and prior health care use. The results showed that patients in the tiers receiving more than 24 mg (69.5 days slower, 95% CI, 49.2-89.8; time ratio [TR] = 1.37; 95% CI, 1.04-1.81) and more than 16 mg to 24 mg (57.6 days slower; 95% CI, 50.8-64.3; TR = 1.11; 95% CI, 1.02-1.2) experienced longer times to a behavioral health-related ED or inpatient visit than those in the tier receiving more than 8 mg to 16 mg.

Additionally, they found that patients in the tiers receiving more than 24 mg and more than 16 mg to 24 mg experienced significantly longer times to ED or inpatient visit 1 year after buprenorphine initiation.

“The findings support AMA policy calling for flexibility in buprenorphine dosing, allowing patients to receive doses exceeding FDA-approved limits when clinically recommended by their prescriber,” Bobby Mukkamala, MD, president-elect of the AMA and chair of the AMA Substance Use and Pain Care Task Force, said in a statement. “Policymakers must take note of these findings and the growing body of evidence that further affirm buprenorphine as a safe, effective, and lifesaving tool in the fight against the illicit fentanyl overdose pandemic.”

References:

• AMA statement on NIH buprenorphine study. https://www.ama-assn.org/press-center/press-releases/ama-statement-nih-buprenorphine-study. Published Sep. 30, 2024. Accessed Oct. 4, 2024.
• Higher doses of buprenorphine may improve treatment outcomes for people with opioid use disorder. https://www.nih.gov/news-events/news-releases/higher-doses-buprenorphine-may-improve-treatment-outcomes-people-opioid-use-disorder. Published Sep. 25, 2024. Accessed Oct. 4, 2024.