Deaths from fentanyl-involved drug overdoses soared by 279% from 2016 to 2021, according to the CDC. Buprenorphine has been found to reduce mortality rates of opioid use disorder by 50%, but patients addicted to fentanyl could be missing out on more effective dosages because of outdated FDA guidelines.
Current FDA guidelines for buprenorphine were based on people who used heroin, prior to the emergence of fentanyl in the illicit drug supply. Higher doses of the drug may be more effective at keeping fentanyl-addicted patients in treatment, according to a new study funded by the National Institute on Drug Abuse (NIDA).
The first author of the study, Laura Chambers, lead research scientist of epidemiology at Brown University, told Behavioral Health Business that these higher doses could save lives.
“Clinician observations and case studies have suggested that higher buprenorphine doses are needed than what is currently recommended in order to suppress withdrawal and cravings among patients who use fentanyl,” Chambers said. “We aimed to use statewide data from the prescription drug monitoring program in Rhode Island to really answer the question: Are higher doses of buprenorphine associated with improved retention and treatment when use of fentanyl rather than heroin is more prevalent?”
The short answer, the study found, is yes.
The FDA currently recommends that buprenorphine be prescribed in doses between 4 milligrams to 24 milligrams per day, with a recommended target dose of 16 milligrams. Of patients prescribed the FDA recommended buprenorphine dose of 16, 59% stopped following their treatment plan within 180 days. For those prescribed the high-end of the FDA’s range, 53% discontinued treatment within 180 days.
This data shows that more could be done for patients addicted to fentanyl, which is a “different beast” from drugs used prior to its introduction, such as heroin, Chambers believes.
“Our interventions and our treatments need to adapt based on the drug supply,” she said.
The still-high rate of discontinuation even among patients receiving higher doses means that a variety of approaches will likely be needed to support patients, Chambers said.
Her group is hoping to pursue a randomized control trial to replicate their findings and measure other health outcomes associated with recovery, like risk of overdose and quality of life. Further research could also be done to determine if even higher doses of buprenorphine could be increasingly useful.
Patients, doctors and addiction treatment providers may not be able to wait for the results of a trial, however.
“It’s important for patients, providers and policymakers to be aware of this accumulating evidence that higher doses are likely to be useful for improving retention in the meantime,” Chambers said.
For now, clinicians may already be increasing doses to the high end of the FDA’s recommended range.
“Higher doses were more often prescribed to patients in later years [of the study], which I think makes sense with increasing awareness and observations being shared by providers that higher doses may be useful,” Chambers said.