Which Buprenorphine Taper Characteristics Are Associated with Subsequent Overdose Risk?

This retrospective cohort study assessed the association of buprenorphine taper characteristics* with opioid overdose in Ontario, Canada. Participants were 5774 adults with opioid use disorder treated with buprenorphine for ≥60 days who subsequently underwent a buprenorphine taper and were followed for ≤18 months after buprenorphine discontinuation.

• Lower rates of overdose death were observed among people with:
  • ≥1 year of buprenorphine receipt, compared with people with <1 year (7 versus 10 overdoses per 100 person-years, respectively; adjusted hazard ratio [aHR], 0.69).
  • Lower versus higher taper rates:
    • Patients tapered at the rate of 2 mg per month had 7 overdoses per 100 person years; those tapered >2–4 mg per month had 11 overdoses per 100 person-years; and patients tapered >4 mg per month had 17 overdoses per 100 person-years.
    • 2 mg per month versus >4 mg per month, aHR, 0.65; >2–4mg per month versus >4 mg per month, aHR, 0.69.
  • A smaller proportion of days with dose decreases (1.75 percent days with dose decreases versus >3.50% of days, 6 versus 14 overdoses per 100 person-years, respectively; aHR, 0.64).
• Overall duration of taper was not associated with risk of overdose.

* Taper characteristics included: time to initiation of taper, rate of taper, the proportion of days when the prescribed buprenorphine dose was decreasing, and the duration of the taper.

Comments: Buprenorphine is highly protective against overdose; patients should be encouraged to continue receiving this medication for as long as they need. Patients who want to taper off of buprenorphine should be advised of the risks. This study showed that overall taper duration was not associated with differences in overdose risk, but higher rates of dose reductions, and tapers with a higher proportion of days with dose decreases were associated with increased risk of overdose. If a patient is stopping buprenorphine treatment, risk of opioid overdose may be decreased by waiting until they have had a year of treatment, and tapering at a slower rate with fewer days with a dose decrease.

Elizabeth A. Samuels, MD, MPH, MHS

Reference: Bozinoff N, Men S, Kurdyak P, et al. Prescribing characteristics associated with opioid overdose following buprenorphine taper. JAMA Netw Open. 2022;5(9):e2234168.