Patients with Opioid Use Disorder and Suicidal Ideation Treated with Buprenorphine

Introduction: There has been an almost six-fold increase in opioid-overdose deaths since 1999, a rise that parallels a 30% increase in the suicide rate between 2000 and 2016.12 Suicides caused by opioid overdose are likely underreported, and many opioid-overdose deaths classified as “undetermined” are likely suicides.3 Treating patients with opioid use disorders(OUD) must involve an assessment of suicidal ideation(SI). The emergency department(ED) may assist in treating patients with OUD by offering buprenorphine. Studies have shown that starting buprenorphine in patients with OUD in the ED decreases opioid use and increases engagement in outpatient substance use treatment.45 A limitation of these studies is that patients with OUD and SI have been excluded. This study presents observational data on 14 patients with OUD who presented to the ED with SI, were initiated on buprenorphine, and were given a referral to outpatient substance use treatment.

Methods: 14 patients meeting criteria for OUD presented to an ED reporting SI. All were evaluated by a psychiatrist and offered buprenorphine with a referral to an outpatient substance use treatment program. Medical records for the 14 patients were reviewed retrospectively for demographics, reasons for ED visit, current substance use, mental health symptoms, buprenorphine use during their ED visit, and engagement in outpatient substance use treatment after ED discharge. Variables collected regarding outpatient substance use treatment included referral to the program during the ED visit, number of days between discharge from the ED and attendance at the first scheduled appointment, attendance at the first scheduled appointment, engagement with the program 30 days after the first scheduled appointment, number of visits to discuss medication and side effects during the 30-day period, and number of visits to discuss issues besides medication and side effects during the 30-day period.

Results: Patients were 86%male and 86%Caucasian with a mean age of 41.36 years(range 26-60 years). Besides opioids, patients reported current cocaine(n=10), cannabis(n=4), and alcohol use(n=7), along with symptoms of mood(n=12) and anxiety(n=6) disorders. Two patients had attempted suicide immediately before presenting to the ED; 12 reported SI as a main reason for their visit. Buprenorphine doses in the ED ranged from 2-16 mg(mean=8.00 mg). None of the patients were hospitalized for SI. All patients were referred to an outpatient substance use treatment program, attended their first scheduled outpatient substance use treatment visit, and remained engaged with the outpatient substance use treatment program 30 days after their first visit. During the 30 days after their first visit, patients attended between one to eight medical visits and seven to 28 support visits at the outpatient substance use treatment program.

Conclusions: This study provides evidence for the feasibility of starting buprenorphine in patients with OUD and SI in the ED, and referring these patients to outpatient substance use treatment. More rigorous studies are needed to determine the effectiveness of starting buprenorphine in the ED on a larger and more diverse sample of patients.

References: 1. Opioid Data Analysis and Resources | Drug Overdose | CDC Injury Center. Published March 19, 2020. Accessed October 18, 2020. https://www.cdc.gov/drugoverdose/data/analysis.html
2. Hedegaard H, Curtin SC, Warner M. Suicide Rates in the United States Continue to Increase. NCHS Data Brief. 2018;(309):1-8.
3. Rockett IRH, Kapusta ND, Coben JH. Beyond suicide: action needed to improve self-injury mortality accounting. JAMA Psychiatry. 2014;71(3):231-232. doi:10.1001/jamapsychiatry.2013.3738
4. D’Onofrio G, O’Connor PG, Pantalon MV, et al. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA. 2015;313(16):1636-1644. doi:10.1001/jama.2015.3474
5. D’Onofrio G, Chawarski MC, O’Connor PG, et al. Emergency Department-Initiated Buprenorphine for Opioid Dependence with Continuation in Primary Care: Outcomes During and After Intervention. J Gen Intern Med. 2017;32(6):660-666. doi:10.1007/s11606-017-3993-2