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Medication for Opioid Use Disorder After Nonfatal Opioid Overdose and Mortality

TO THE EDITOR: I appreciate Larochelle and colleagues' (1) efforts to address the association between opioid agonist therapy and subsequent mortality in opioid overdose survivors. The authors propose that enrollment in an opioid agonist program is associated with a decreased risk for mortality from both opioids and any cause. The participants were persons who had a nonfatal drug overdose, and fewer deaths occurred in those who subsequently elected to enter an opioid maintenance program. However, the authors did not address an inherent factor that predicts success in recovery: patient motivation. It is logical to conclude that patients who are motivated to recover from addiction are more likely to both enter and remain in an opioid maintenance program than those not motivated to recover. The latter group is more likely to return to their addictive behavior pattern after their recovery. That such behavior is more likely to have an adverse effect in these patients can thus be expected. In 2006, Lee and associates (2) reported on a group of patients who had been incarcerated. One half of these patients was randomly assigned to naltrexone; the other half was assigned to usual care, which consisted of counseling and referral to outreach centers. Even in this more motivated population, which was aware that relapse might increase their risk for reincarceration, the average time to relapse was only 10 weeks with naltrexone and 5 weeks in the control population. However, Kinlock and coworkers (3) found that the rate of returning to opioids in a prison population was lower among those who began methadone therapy while incarcerated than in those who did not. In my community in rural Kentucky, the county jail has implemented a naltrexone program in which testing positive for drugs is considered a probation violation that warrants a return to jail. The hope is that this system will result in a cohort of persons motivated to stay out of jail. The success rate remains to be determined. No firm conclusions can be drawn from Larochelle and colleagues' study other than that patients motivated to recover do better than those who are less motivated. We cannot conclude that an intervention with an opioid agonist had any effect on this outcome any more than we can deny that such an intervention may have been effective. Performing a randomized study in this patient population is difficult; however, an observational study such as theirs is always subject to inherent flaws.