Bret A. Moore, PsyD, ABPP
Board-Certified Clinical Psychologist, San Antonio, TX
Dr. Moore has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
Subject: (Yovell Y et al, Am J Psychiatry 2016;173:491–498)
Short Description: When patients become severely suicidal, we have few good treatment options. These include close monitoring (often in a locked unit), intensive psychotherapy, antidepressants (which, while effective, take weeks to work), a variety of medications to treat symptoms such as agitation and insomnia, and more recently, the experimental treatment ketamine (which requires repeated infusions under medical supervision). In addition, lithium reduces suicidality in bipolar disorder, and clozapine does so in schizophrenia—but both are long-term treatments.
Recognizing the need for more options, Israeli researchers studied the use of very low doses of buprenorphine in suicidal patients. Patients with suicidal ideation were recruited from four medical centers. The participants were severely suicidal, with an average score of 19.7 on the Beck Scale for Suicidal Ideation; 64% of them had made at least one suicide attempt. They were randomly assigned to either buprenorphine (n = 40) or placebo (n = 22). Buprenorphine was started at 0.1 mg once or twice a day and gradually titrated up to a max dose of 0.8 mg/day (average dose was 0.44 mg/day). No changes to the regular psychiatric treatment were made. Most of the patients’ from both groups were on medication, including over 70% who were taking antidepressants. The primary outcome measure was change from baseline on the Beck scale, which was assessed weekly for 4 weeks.
The buprenorphine seemed to work. After 2 weeks, suicide severity dropped by an average of 4.3 points more in the buprenorphine group than the placebo group, and after 4 weeks, the difference was 7.1 points; both values were statistically significant. Adverse events occurred in 77.2% of the buprenorphine patients, and in 54.8% of the placebo patients. The most common buprenorphine-related side effects were fatigue (49.1%), nausea (36.8%), and constipation (26.3%). After 4 weeks, the medication was stopped without a taper, and no patients reported any withdrawal symptoms over the ensuing week, nor was there any exacerbation in suicidality.
TCPR’s Take: This was a small study and of short duration, but the results were encouraging. A brief course of ultra-low-dose buprenorphine may be worth trying in your patients with severe suicidal ideation. Keeping the dose low and limiting the duration to around 4 weeks are likely crucial for preventing opioid addiction in these patients.