Physicians Key in Appropriate Buprenorphine Use

Buprenorphine misuse is a hot topic in Addiction Medicine, as seen by the large audience at Saturday's symposium, "Buprenorphine: Enhancing Access While Preventing Diversion."

Buprenorphine misuse is a hot topic in Addiction Medicine, as seen by the large audience at Saturday’s symposium, “Buprenorphine: Enhancing Access While Preventing Diversion.”

Misconceptions—yes or no? Buprenorphine diversion and misuse are signs that my patient is “bad” and should be kicked out of treatment. Buprenorphine is the lesser evil than using street drugs. Diversion and misuse are inevitable, so it is OK to ignore it. The answer is “no” to these misconceptions, says Michelle R. Lofwall, M.D., Assistant Professor of Psychiatry, Center on Drug and Alcohol Research, University of Kentucky College of Medicine, Lexington, Ky., who addressed Saturday’s Symposium 6, “Buprenorphine: Enhancing Access While Preventing Diversion.”

“As for the first myth that the patients are bad and we need to fire them, the truth is the misusing and diversion are common behaviors among addicted patients,” she says. “They take opioids in non-medically intended ways for non-medical reasons. It’s part of the essence of addiction. These patients deserve treatment.”

Nevertheless, it goes too far to just ignore buprenorphine diversion and misuse, regarding it a lesser evil than injecting heroin.

“We don’t want to look like we have that attitude,” Dr. Lofwall says. “If we don’t try to address it, it could damage our treatment reputation and harm patients. Lack of attempts to prevent or decrease misuse and diversion could threaten the treatment’s availability. Individual states could decide to re-schedule buprenorphine to a more restrictive drug class and it won’t be available for office-based treatment any more.”

Buprenorphine misuse has been associated with liver damage, pancreatitis, fungal endophthalmitis, pulmonary granulomatosis, abscesses at the injection site, and death—when combined with central nervous system depressants. She also reports on the increased incidence of injecting buprenorphine tablets, which presents the unwanted potential for harming individuals, not only from the buprenorphine itself, but also from the excipients within the tablets.

To prevent inappropriate buprenorphine use, Dr. Lofwall recommends evaluating circumstances surrounding these behaviors and addressing them in treatment plans.

“We have an open conversation with our patients,” she says. “We let them know we are here to help them and not harm them. We ask them to let us know everything they are doing with their medications. If they tell us they are misusing and diverting, we have answers for that.”

She also advises weekly visits from her patients being treated with buprenorphine until they are stable.

“A therapeutic dose decreases withdrawal, craving, and illicit drug use and provides opiate blockade,” Dr. Lofwall says. “Think carefully when you are going above 16 milligrams a day. If they continue craving, think about what is going on psychosocially because lots of things can affect craving.”

Symposium 6 also featured Jody Rich, M.D., M.P.H., Professor of Medicine and Community Health, Division of Biology and Medicine, Brown University, Providence, R.I., who studied the use, procurement, and motivations for use of diverted buprenorphine/naloxone among injecting and non-injecting opioid users in Providence, R.I. Participants were recruited from a fixed-site syringe exchange program.

Of 51 injecting opioid users and 49 non-injecting opioid users in the study, 76 percent reported having obtained buprenorphine/naloxone illicitly, with 41 percent having done so in the previous month. Participants reported reasons for using buprenorphine/naloxone: 74 percent to treat opioid withdrawal symptoms, 66 percent to stop using other opioids, and 64 percent because they could not afford drug treatment.

“Diverted buprenorphine/naloxone was common among our sample,” Dr. Rich says. “Many opioid users, particularly in intravenous drug users, were using diverted buprenorphine/naloxone for reasons consistent with its therapeutic purpose, such as alleviating opioid withdrawal symptoms and reducing the use of other opioids. These findings highlight the need to explore the impact of buprenorphine/naloxone diversion, as well as improve accessibility of  buprenorphine/naloxone through licensed treatment providers.”

In addressing buprenorphine trends, Richard C. Dart, M.D., Ph.D., Executive Director, Researched Abuse, Diversion, and Addiction-Related Surveillance (RADARS) System, Denver, reports conclusions from its Opioid Treatment Program tracking and Survey of Key Informants’ Patients.

“The treatment population seems to be appreciating the fact the single ingredient (buprenorphine) is more available, it doesn’t have naloxone, and abuse of it is going up,” he says. “If you ask them how they abuse those drugs, the single-ingredient versions are endorsed much more frequently in terms of intravenous abuse. Not only are we seeing more of that, but this population has a high proportion of a high-risk route of abuse.”