Stimulants Plus Buprenorphine for Opioid Addiction a Double-Edge Sword?

Megan Brooks

May 12, 2022

For patients with opioid use disorder (OUD) taking buprenorphine, prescribing a stimulant medication may be a double-edged sword.

Stimulants may lead to better engagement and retention in buprenorphine treatment, which is associated with a host of health benefits, but this may come at a cost of a modest increase in drug-related overdose risk, new research suggests.

"It's important for clinicians to weigh both the potential risks and benefits of prescribing stimulants to people with opioid use disorder," co-first author Carrie Mintz, MD, assistant professor of psychiatry, Washington University School of Medicine, St. Louis, Missouri, told Medscape Medical News.

The study was published online May 11 in JAMA Network Open.

Common Dilemma

Stimulant medications are often prescribed for people taking buprenorphine for OUD, but there is a lack of evidence on risks and benefits to guide decision-making.

Using large insurance claims databases, Mintz and colleagues examined associations between prescription stimulant use and two clinically relevant OUD-related outcomes: drug-related poisonings and buprenorphine treatment retention.

The cohort included 22,946 individuals (mean age, 32.8 years; 49.7% women) with OUD who were receiving buprenorphine treatment and had a history of at least one drug-related poisoning.

Prescription stimulant use was associated with a modest 19% increased odds of drug-related overdose (odds ratio [OR], 1.19; 95% CI, 1.06 - 1.34) compared with nonuse.

However, this risk was offset by a 36% decreased odds of buprenorphine treatment attrition (OR, 0.64; 95% CI, 0.59 - 0.70), which itself was strongly protective against drug poisoning (OR, 0.62; 95% CI, 0.59 - 0.65).

Filling an Important Research Gap

In a linked editorial, Judith Tsui, MD, MPH, with the University of Washington, Seattle, writes that it's not uncommon for clinicians who prescribe buprenorphine to get requests to prescribe stimulant medications and, to date, there has been a lack of evidence on risks and benefits to guide clinical decision-making.

The study by Mintz et al "addresses this important gap in the literature," Tsui writes.

For clinicians who prescribe stimulants to patients who are stably retained in buprenorphine treatment, the results "should provide some reassurance of the net benefits to continued prescribing," Tsui adds.

For those who prescribe buprenorphine in settings where there is a high prevalence of co-use of methamphetamine, the results "might also serve as an opportunity to question existing treatment paradigms, particularly considering the increasing harms due to fentanyl contamination and methamphetamine-related drug poisonings," Tsui writes.

This study, Tsui concludes, "represents an important step toward understanding the trade-offs of prescribed stimulant medication for patients with OUD receiving buprenorphine, which should stimulate conversations among clinicians, patients, researchers, and policymakers alike."

The study was supported in part by grants from the National Institutes of Health (NIH), the Saint Louis University Research Institute, the Substance Abuse and Mental Health Services Administration (SAMHSA) and the National Center for Advancing Translational Sciences (NCATS). Mintz and Tsui have disclosed no relevant financial relationships.

JAMA Netw Open. 2022;5:e2211634, e2211641. Full text, Editorial

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