Patients Receiving Medications for Opioid Use Disorder See a Sharp Decrease in Suicidal Ideation in the First Weeks of Treatment

People with opioid use disorder (OUD) have an increased risk of depression and suicidal ideation. Receipt of medications for OUD (MOUD) is associated with an improvement in depressive symptoms, but less is known about the impact on suicidal ideation. In this secondary analysis, researchers investigated changes in suicidal ideation among 570 adults who were randomized 1:1 to receive buprenorphine-naloxone (BUP-NX) or extended-release naltrexone (XR-NTX) for OUD in the X:BOT trial, conducted in eight community-based treatment programs in the US. Participants were assessed for self-reported and clinician-rated suicidal ideation* at baseline and over 24 weeks of outpatient treatment.

• Participants had an average age of 34 years; 70 percent were male, 74 percent were White, and 81 percent had heroin use (67 percent by injection).
• Of the 283 participants randomized to XR-NTX, 79 (28 percent) did not initiate treatment. The primary study outcomes were assessed in the intention-to-treat sample, which included all 570 participants.
• At baseline across both groups, the mean score for self-reported suicidal ideation was 11.2; per the clinician-rated binary measure, 27 participants (4.8 percent) had suicidal ideation.
• Suicidal ideation scores decreased rapidly over the first four weeks of treatment in both groups. At weeks one and three, patients receiving BUP-NX had significantly lower mean self-reported suicidal ideation scores than those receiving XR-NXT.
• At week 24, the prevalence of clinician-rated suicidal ideation had decreased to 1.9 percent and 1.5 percent respectively in the BUP-NX and XR-NTX groups.

* Self-report was assessed via the 16-item Concise Health Risk Tracking–Self Report (authors note that “a score of score of 12 could reflect endorsing ‘disagree’ on the 5-point Likert scale on all six statements about suicidal ideation”); clinician-rated measures were assessed via the Hamilton Depression Rating Scale (suicide item dichotomized to “none” or “any”).

Comments: This study demonstrated a rapid decrease in suicidal ideation after MOUD initiation. An important limitation of the study is that patients with severe suicidal ideation were excluded. Therefore, while initiating MOUD may be sufficient to impact suicidal ideation among people with mild symptoms, these findings may not apply to people at high suicide risk or with severe depression. For these patients, clinicians should closely monitor current and past suicidal ideation to adapt treatment options.

Nicolas Bertholet, MD, MSc

Reference: Rizk MM, Stanley B, Choo TH, et al. Suicidal ideation in adults with opioid use disorder treated with buprenorphine-naloxone versus extended-release naltrexone. Am J Drug Alcohol Abuse. 2025 [Epub ahead of print]. doi:10.1080/00952990.2025.2524110.