How can opioid deaths be reduced?

It is no revelation that death rates among people with opioid dependence is higher than that of the general population.
 
In Australia, opioids were present in three in five (60%) drug-induced deaths in 2019. In the same year, 25% of the 1865 drug-induced deaths were attributed to heroin – the highest since 1997.
 
Misuse of prescription medicine is also an ongoing global concern; with 3.3% of Australia’s adult population using opioids, while recent reports of organised criminal activity designed to deceive GPs into prescribing highly potent fentanyl patches and other opioids also point to an ongoing issue.
 
However, new international research has provided hope by confirming the effectiveness of ‘game-changing’ opioid agonist therapy (OAT), such as buprenorphine and methadone.
 
It found that receiving OAT is associated with lower risk of multiple causes of death among people with opioid dependence, suggesting that increasing access to, and retaining treatment of OAT are ‘critical’ for reducing death rates.
 
‘We looked at trial evidence, but so few studies were powered to examine mortality, which is why we need to rely on cohort studies of people in treatment around the world,’ lead author Thomas Santo said.
 
To estimate the association of time receiving OAT with mortality, the researchers conducted 15 randomised clinical trials of 3852 participants and 36 primary cohort studies, including analysing 749,634 participants.
 
They found that people with opioid dependence who receive either buprenorphine or methadone as OAT are not only at lower risk of overdose than those not on OAT, but at ‘significantly lower’ risk of suicide and other causes of death, such as cancer, and cardiovascular- and alcohol-related disease.
 
Buprenorphine was added to the Pharmaceutical Benefits Scheme in September 2019 following advocacy from RACGP addiction medicine specialists, making it available to people with an opioid dependency through a prescription from their GP.
 
The RACGP has long-recognised the vital role of GPs in supporting patients with opioid dependence and assisting them with access to, and retention of, OAT treatments.
 
In Australia, methadone is the most commonly prescribed OAT, with 58% of people treated on a ‘snapshot day’ in 2020. This is followed by 21% of people on buprenorphine-naloxone, and sublingual buprenorphine at 19%. More than 53,000 people received OAT at 3084 dosing points across the country on that same day.
 
According to Mr Santo, the study showed that the benefits of OAT were consistent across region, age, sex, and comorbidity status, and were not impacted by patient HIV or hepatitis C status, nor whether drugs were taken through injection.
 
Meanwhile, in the month following OAT cessation, participants were at a six times higher risk of all-cause mortality, including overdose and suicide, remaining double the rate for the remainder of time not receiving OAT.
 
Mr Santo said these findings underline the importance of continuing treatment, as well as the need for ‘more detailed investigation and intervention development’ to minimise mortality risk during induction onto OAT.
 
For participants on methadone, there was an elevated risk in the first four weeks of treatment, with rates of all-cause mortality and drug-related poisoning almost double the rates than during the remainder of OAT.
 
This risk was not identified for those on buprenorphine.
 
Monash University addiction medicine researcher, Associate Professor Suzanne Nielsen, previously told newsGP that buprenorphine has less risk of causing overdose as it is a partial opioid agonist, whereas methadone is a full agonist.

‘In the first two weeks of methadone treatment, there are higher rates of mortality because people are overshooting their dose,’ she said. ‘Buprenorphine has a ceiling on its respiratory depressant effect, so it doesn’t lead to an overdose state when used on its own.’
 
Despite the research findings confirming that OAT is associated with lower rates of mortality, the authors say that the population-level benefits may not be fully realised, and further work is needed to improve global access, increase engagement and prevent cessation of OAT.
 
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