REVIEW OF: Larochelle MR et al, Ann Intern Med 2018;169(3):137–145

We are in the middle of an opioid crisis in the US, with many lives lost daily to opioid-related deaths. Pharmacotherapy with methadone, buprenorphine, or naltrexone represents an important tool for clinicians during this crisis. But just how good are these medications in saving lives? A recent retrospective cohort study evaluated the effects of methadone, buprenorphine, and naltrexone on all-cause and opioid-related mortality in the 12 months after an opioid overdose.

This analysis used data from Massachusetts government and hospital records from 2012 to 2014 to identify adults who survived an opioid overdose, then looked at the 12 months after that overdose. If an individual had multiple overdoses during that period, the first overdose was used for the data collection. A total of 17,568 cases were identified. In the 12 months after the index overdose, 11% (2,040) were on methadone for a median of 5 months, 17% (3,022) were on buprenorphine for a median of 4 months, and 6% (1,099) were on naltrexone for a median of 1 month.

All-cause mortality over 12 months was significantly reduced in those receiving methadone (adjusted hazard ratio [AHR] 0.47 [CI 0.32–0.71]) and buprenorphine (AHR 0.63 [CI 0.46–0.87]), but not those on naltrexone (AHR 1.44 [CI 0.84–2.46]). Similarly, opioid-related mortality was significantly decreased for patients on methadone (AHR 0.41 [CI 0.24–0.70]) and buprenorphine (AHR 0.62 [CI 0.41–0.92]), but not those on naltrexone (AHR 1.42 [CI 0.73–2.79]).

CATR’s Take
This study represents real-world population data linking treatment with methadone or buprenorphine after an opioid overdose to a decrease in all-cause and opioid-related mortality in the following year. Remember, these results were tallied over a 1-year period even though most patients discontinued treatment within 6 months. Naltrexone failed to show a significant difference in mortality, perhaps because most people stopped it after 1 month, or because the researchers could not distinguish between the oral and extended release injectable formulations (unlike oral naltrexone, extended release naltrexone has shown treatment efficacy). Another takeaway from this article is that only about a third of those who had an opioid overdose were ever prescribed any form of opioid use disorder pharmacotherapy. Much work remains to be done to provide better access to life-saving treatment for opioid use disorder.