Speakers
Gregory Simon, MD, MPH
Investigator
Kaiser Permanente Washington Health Research Institute
Susan Shortreed, PhD
Investigator
Kaiser Permanente Washington Health Research Institute
Keywords
Buprenorphine; Self-Harm; Overdose; Target Trial Emulation
Key Points
- There is some overlap between the two public health crises of our time: suicidal behavior and the Opioid Use Disorder (OUD)/opioid overdose crisis.
- The research team looked at whether starting (vs not starting) buprenorphine reduces the subsequent risk of a self-harm event or suicide attempt among people diagnosed with OUD.
- They conducted an observational study with target trial emulation, emulating a randomized trial where people with an OUD diagnosis might be randomly assigned to start or not start buprenorphine during an outpatient visit. They tracked the rates of self-harm, adverse outcomes more broadly, and overdose over 90 days.
- Their analysis found that starting buprenorphine didn’t reduce the risk of self-harm behavior and (surprisingly) had no protective or beneficial effect when it came to opioid poisoning or overdose.
- They found that when they stopped tracking outcomes for those who changed course – i.e. had initiated buprenorphine but stopped or had initially declined but initiated later – they observed protective effects consistent with previous findings. The risk of self-harm for people who stopped or had their treatment interrupted increased four-fold, and the risk of opioid overdose or poisoning increased five- or six-fold.
- These findings reinforce concerns about high risk of adverse outcomes soon after stopping or interrupting buprenorphine treatment.
- These findings also raise questions about the kind of target trials researchers should be emulating and what pragmatic trials might be considered for follow-up. Given these results, the research team is interested in research questions that center on the stopping or interruption of buprenorphine treatment.
Discussion Themes
Given that buprenorphine is often prescribed in shorter supply (7 – 14 days worth), the researchers were able to track the timing of events more accurately than they’d be able to with other chronic conditions. The profit motive of healthcare systems (i.e. billing insurance for treating an overdose) also improved their ascertainment of those events.
One limitation of the study is that they don’t have any way of ascertaining self-harm events or overdoses that never came to medical attention.
At the individual clinician level and at the policy level, the decision to treat OUD with buprenorphine is informed by the knowledge that interruptions in treatment are fairly common and can have adverse effects.
Another study design option is to compare people before and after initiating buprenorphine treatment, as opposed to comparing people who initiate and people who don’t. The tricky thing about that design is that an individual’s state is not consistent; there may have be an initiating event that precipitates the decision to start treatment.