A Review of Buprenorphine Diversion and Misuse

Abstract

Outpatient opioid addiction treatment with sublingual buprenorphine pharmacotherapy (OBOT) has rapidly expanded in the United States and abroad, and, with this increase in medication availability, there have been increasing concerns about its diversion, misuse and related harms. This narrative review defines the behaviors of diversion and misuse, examines how the pharmacology of buprenorphine alone and in combination with naloxone influence its abuse liability, and describes the epidemiological data on buprenorphine diversion and intravenous misuse, risk factors for its intravenous misuse and the unintended consequences of misuse and diversion. Physician practices to prevent, screen for, and therapeutically respond to these behaviors, which are a form of medication non-adherence, are discussed and gaps in knowledge are identified. OBOT experiences from other countries that have varied health care systems, public policies, and access to addiction treatment are shared in order to make clear that diversion and misuse occur across the world in various contexts, for many different reasons, and are not limited to buprenorphine. Comparisons are made with other opioids with known abuse liability as well as medications with no known abuse. The objective is to facilitate understanding of diversion and misuse so that all factors influencing their expression (patient and provider characteristics and public policy) can be appreciated within a framework that also recognizes the benefits of addiction treatment. With this comprehensive perspective, further careful work can help determine how to minimize these behaviors without eroding the current benefits realized through improved addiction treatment access and expansion.

Buprenorphine Treatment and 12-step Meeting Attendance: Conflicts, Compatibilities, and Patient Outcomes

“…Two opioid agonist medications (methadone and buprenorphine) are approved by the FDA for the treatment of opioid dependence and their efficacy has considerable empirical support (Amato et al, 2005; Mattick, Breen, Kimber, & Davoli, 2014). Since buprenorphine became available in the US in early 2003, its utilization has dramatically increased (Lofwall & Walsh, 2014). …”

Management of moderate to severe chronic low back pain with buprenorphine buccal film using novel bioerodible mucoadhesive technology

“…Unlike other opioids, buprenorphine has been associated with antihyperalgesia36 and has a ceiling effect for both gastrointestinal side effects and respiratory depression 24. Buprenorphine is associated with less abuse liability than many other opioid agents 37. This may be due to the fact that it acts as an agonist at the opioid receptor-like 1 (NOP) receptor, which has been associated with attenuating the rewarding effect common with other opioids 25,38…”

Intranasal buprenorphine alone and in combination with naloxone: Abuse liability and reinforcing efficacy in physically dependent opioid abusers

“…Reports indicate that BUP tablets with and without naloxone are being crushed (and sublingual films dissolved) and subsequently injection or insufflated intranasally (Alho et al, 2007; Bruce et al, 2009; Horyniak et al, 2011; Jenkinson et al, 2005; Lofwall and Walsh, 2014; Nordmann et al, 2012; Young et al, 2010). For instance, two studies report that up to 30% of patients enrolled in BUP therapy were snorting their medication (Barrau et al, 2001; Roux et al, 2008).…”