Long-Acting Buprenorphine May Help Patients Initiate Treatment Without Withdrawal

Most patients with opioid use disorder (OUD) and mild withdrawal symptoms can initiate buprenorphine using a 7-day injection without precipitating withdrawal symptoms, according to a study issued in JAMA Network Open.

“To date, there is little evidence for rapid strategies to initiate buprenorphine without the prerequisite withdrawal,” wrote lead author Gail D’Onofrio, M.D., at Yale School of Medicine and colleagues. “Thus, patients are often instructed to initiate buprenorphine on their own after a brief education or are discharged without medication treatment, leaving them at risk for overdose.”

D’Onofrio and colleagues recruited 100 patients at emergency departments (ED) who had screened positive for moderate to severe OUD; all were experiencing minimal to mild withdrawal as measured on the Clinical Opioid Withdrawal Scale (COWS), with 38 scoring 0-3 and 62 scoring 4-7. All received a 7-day injectable 24 mg formulation of extended-release buprenorphine, CAM2038, which is equivalent to 16 mg of buprenorphine daily.

Participants were monitored in the ED for four hours and referred to community-based programs or clinicians for ongoing OUD treatment upon discharge. Over the following week, they provided daily phone and text assessments on their opioid use, cravings, injection pain or other side effects, and engagement with treatment.

Each day, between 33% and 43% of patients reported no cravings, and between 78% and 85% reported no use of opioids. Overall, 60% of participants did not use opioids in the week after buprenorphine administration, and there were also no reported incidences of overdoses. In addition, 73% of patients engaged in OUD treatment within seven days of the injection. Participants rated the improved privacy and not requiring daily medication as extremely important advantages of the long-acting formulation.

Within four hours of receiving the injection, just 10 of the 100 patients experienced a 5-point or greater increase in COWS scores and of those, seven participants transitioned to moderate or greater withdrawal (COWS score of 13 or higher). Participants who had baseline COWS scores of 0 to 3 were more likely to experience significantly increasing withdrawal, so researchers said further study is needed to assess the criteria for using rapid buprenorphine initiation in this subgroup.

“The opportunity to initiate buprenorphine in patients without having to first experience prolonged withdrawal has many clear benefits and could substantially increase the number of patients with OUD able to initiate buprenorphine upon ED presentation,” researchers wrote. “This finding may have a significant public health impact in light of the continued increase in opioid deaths in 2023 driven primarily from fentanyl and the heightened risk of overdose death without medication treatment.”

For more information, see the Psychiatric News article, “OUD Overdose, Suicide Risk in Veterans Four Times Higher Without Buprenorphine.”

(Image: Getty Images/iStock/Kobus Louw)

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Entering Treatment After First Episode of Psychosis May Reduce Risk of Self-Harm

Young people who began treatment within 14 days of being diagnosed with first-episode psychosis (FEP) were less likely to deliberately harm themselves than those who did not initiate treatment, according to a report in Psychiatric Services. The findings were based on data collected from Ohio Medicaid claims for more than 6,300 youth with FEP.

“Given the high rates of suicide in this population, our findings suggest a great need for suicide-specific interventions for individuals in the early course of a psychotic disorder,” wrote Heather Wastler, Ph.D., an assistant professor of psychiatry at the Early Psychosis Intervention Center at Ohio State University Medical Center, and colleagues.

Wastler and colleagues focused their analysis on 6,349 adolescents and young adults aged 15 to 24 years who were enrolled in Ohio Medicaid and were diagnosed with FEP between June 30, 2010, and December 31, 2017. They compared deliberate self-harm among those who did and did not initiate treatment after being diagnosed with FEP and among those who engaged or did not engage in treatment after initiation. Treatment initiation was defined as an inpatient admission or at least one psychotherapy session (individual, family, or group), medication management visit, or partial hospitalization within 14 days of an FEP diagnosis. Treatment engagement was defined as at least two of the same forms of treatment within 90 days of treatment initiation.

A total of 4,419 (69.6%) of the youth initiated treatment within 14 days of their FEP diagnosis; 55% of these youth engaged in treatment during the 90-day period. The researchers tracked the outcomes of the youth up to 365 days from the end of the initiation or engagement period, with follow-up ending at the first deliberate self-harm claim, the end of Medicaid enrollment, death, or the end of the study period (December 31, 2017).

A total of 229 individuals deliberately harmed themselves during the follow-up period. Of the 4,419 youth who initiated treatment, 134 (3.0%) deliberately harmed themselves at least once; among the 1,930 youth who did not initiate treatment, 95 (4.9%) deliberately harmed themselves.

“Given the established relationship between positive symptoms and suicide-related outcomes, it’s possible that this initial contact reduces DSH [deliberate self-harm] through the stabilization of psychotic symptoms with antipsychotic medication,” Wastler told Psychiatric News. “Another potential explanation is that providers might deliver brief evidence-based interventions such as crisis response planning, safety planning, or lethal-means counseling during the first treatment contact.”

Among the 2,431 who continued treatment, 64 (2.6%) deliberately harmed themselves during the follow-up period compared with 42 (2.1%) of those who discontinued treatment.

Wastler said that more sessions may be needed to reduce deliberate self-harm. She also noted that other factors, such as the quality of care received or the patients’ motivation for treatment, may have influenced the findings.

For related information, see the Psychiatric News article “New Network Collects Real-Time Data to Improve Treatment of Early Psychosis.”

(Image: iStock/Dziggyfoto)

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