The Paradox of Diverted Buprenorphine
By Mark Gold, MD
Buprenorphine, a μ-opioid (pronounced mu-opioid) receptor partial agonist, is a highly effective, evidence-based medication for treating opioid use disorders (OUD). In order to prescribe buprenorphine, qualifying practitioners must obtain a waiver from the Drug Enforcement Agency (DEA), which places strict limits on the number of patients they may treat annually. Previous legislation and regulation meant buprenorphine treatment existed nearly entirely outside the traditional healthcare system. Despite legislation that increases the number of patients a doctor can prescribe to, and allowing individual medical providers to become certified, there is still hesitation among many providers over becoming certified to prescribe the medication, many waivered physicians do not have many patients on buprenorphine - some waivered physicians have none at all.
The unique pharmacological characteristics of buprenorphine inhibit its potential for misuse, reduce the effects of physical dependence on opioids, and decrease the likelihood of severe respiratory depression leading to overdoses. Still, it’s diversion and misuse is commonly reported by patients and law enforcement. Buprenorphine is the most diverted medication used to treat OUD, as methadone is more closely monitored and Naltrexone has no street value. Buprenorphine diversion presents a complex medical and socio-economic issue, and may also contribute to excessive mortality. A recent study by Cicero et al. examined the motivations behind the use of diverted buprenorphine and investigated the role of unmet needs for treatment. The results reveal a paradoxical situation where inaccessibility to treatment may actually be fueling this diversion.
Use of Prescribed Buprenorphine
Of the respondents, 54% reported ever receiving a buprenorphine prescription for the treatment of OUD. Those who ceased receiving buprenorphine through a prescription cited their top reasons as choosing to stop seeing their doctor or losing the ability to attend or pay for doctor’s visits/prescription. Only 19% (one in five) patients reported stopping buprenorphine because of mutual doctor and patient agreement on completion of treatment - in fact, 12% report that their doctor cut off their buprenorphine prescription despite the patient not being ready to end treatment.
Barriers to Accessing Buprenorphine
A majority of respondents said they had limited accessibility to doctors legally able to prescribe buprenorphine - 24% (one quarter) of the respondents didn’t have insurance. High costs were also a significant barrier to access. We also know that the inadequate amount of providers who can prescribe buprenorphine make access to licit buprenorphine very difficult. A little over one-third of people with a prescription, one-third of people using diverted buprenorphine had problems finding a doctor, and 81% of the participants with any history of diverted buprenorphine stated that easier access to a doctor would have encouraged them to get a prescription rather than seek the drug on their own.
Why are People Using Diverted Buprenorphine?
Three of the four most common reasons cited for using diverted buprenorphine were for self-medicating to achieve intended, therapeutic purposes of the medication: avoiding/easing withdrawal symptoms, maintaining abstinence from other substances, and trying to taper off of drugs. The authors also learned that buprenorphine is not many people’s drug of choice. Only 3% of respondents used buprenorphine because it gave “them a better high than other drugs.”
The authors found an overwhelming number of people using diverted buprenorphine, also called bupe, were doing so to ease withdrawals or wean themselves off other drugs. Only 3% of the respondents were using buprenorphine because it was their drug of choice. This indicates a significant shortage in treatment capacity and inaccessibility of existing services, partially due to high treatment costs and a lack of prescribing physicians.
To better understand the use of diverted buprenorphine, the researchers surveyed data collected from adults aged 18 and older that were diagnosed with an OUD while seeking treatment at a treatment center. The survey included closed- and open-ended questions about:
reasons for buprenorphine use with and without a prescription,
how respondents were accessing buprenorphine,
how their buprenorphine was administered,
and the barriers to treatment access.
Resolving the Paradox
More data is necessary to understand how the use of buprenorphine differs from the use of diverted opioid pain medications or heroin. In these cases, as well, opioids are often diverted ostensibly for use in self-treatment of withdrawal symptoms, but it is still not completely clear if buprenorphine is diverted only when other options are not available, or because its relatively low street value makes it affordable to buy illicitly.
Medical practices can often be full, physicians are busy, and many other reasons contribute to prescribers’ hesitation to seek a buprenorphine prescription waiver from the DEA. Some, however, do not apply because they are afraid that the buprenorphine they prescribe might become diverted. It is very important to examine and follow the trends about the motivations for using diverted buprenorphine today, and understand the impact of unmet treatment needs amid an opioid crisis.
The authors called for further research at international levels and emphasized the importance of finding ways to increase access by reducing costs, unavailability of prescribers and social stigma. The team concluded that improving prescriber access is more beneficial than harmful.
Dr. Mark S. Gold is a teacher of the year, translational researcher, author, mentor and inventor best known for his work on the brain systems underlying the effects of opiate drugs, cocaine and food. Read more by Dr. Gold here.