The link titled, “Ultra-Low-Dose Buprenorphine as a Time-Limited Treatment for Severe Suicidal Ideation: A Randomized Controlled Trial,” below, by Yoram Yovell et al., is a May, 2016 article that cautiously suggests a role for opioid agonists in management of suicidality in conjunction with mood disorders. It brings into focus at least one other consideration, beyond the role of the endogenous opioid system in maintaining mood balance. The use of buprenorphine is not exclusively within the province of the addiction specialist, despite its being principally deployed in the management of opioid use disorders. The brain’s functions exist in a complex ecological balance. To view any one pharmaceutical as serving just one disorder ignores the effect on psychological equilibrium that any one disorder may have, in inducing or altering the course of another. In the Yovell study, investigators were careful both to use a dose of buprenorphine at the lower level of that used for analgesia, and 20-fold below that used to initiate opioid substitution therapy for opioid use disorder. They looked for and found no indication of opioid withdrawal in the subjects (57 active arm of 88 total), a level of caution that was well-justified by this country’s tendency to employ dependence-inducing pharmaceuticals in the management of any number of disorders (insomnia, ADHD, pain). But given the inductive effect of any degree of opioid use on the development of opioid use disorder, the modifier, “Ultra-Low Dose” should be taken in context; it is not the same as “benign,” “homeopathic,” or “harmless.” To be fair to the authors, neither do they suggest any conclusion of harmlessness. But a much longer-term, if not larger study population, should be the next step.
Editor-in-Chief: William Haning, MD, DFAPA, DFASAM