Buprenorphine in the United States: Motives for abuse, misuse, and diversion

A Rapid Method for the Determination of Buprenorphine and Norbuprenorphine in Urine by UPLC-MS/MS

Background:

Buprenorphine is quite common in the illicit market. Buprenorphinecontaining drug abuse is frequently encountered in patients. The analysis methods used to determine the abuse of buprenorphine and norbuprenorphine are important for forensic science. Buprenorphine is metabolized to norbuprenorphine by the liver.

Objective:

Therefore, the determination of buprenorphine and norbuprenorphine in urine is one of the methods to determine the abuse of buprenorphine.

Methods:

In this study, we developed a precise, simple, and rapid ultra-performance liquid chromatography- tandem mass spectrometer method for the determination of buprenorphine and norbuprenorphine simultaneously.

Results:

The developed method was validated in terms of selectivity and linearity, which was in the range of 9–1800 ng/mL for both buprenorphine and norbuprenorphine. The intra-assay and inter-assay accuracy and precision were found within acceptable limits of the EMA guideline. Lower limits of quantitation were 9 ng/mL for both buprenorphine and norbuprenorphine.

Conclusion:

The developed method was successfully applied for the determination of both analytes in the proficiency testing samples.

Patient-Reported Outcomes of Treatment of Opioid Dependence With Weekly and Monthly Subcutaneous Depot vs Daily Sublingual Buprenorphine: A Randomized Clinical Trial

IMPORTANCE

Patient-reported outcomes in the treatment of opioid dependence may differ between subcutaneously administered depot buprenorphine and daily sublingual buprenorphine.

OBJECTIVE

To compare patient satisfaction between depot buprenorphine and sublingual buprenorphine in adult outpatients with opioid dependence.

DESIGN, SETTING, AND PARTICIPANTS

This open-label, randomized clinical trial was conducted among adult patients with opioid dependence at 6 outpatient clinical sites in Australia from October 2018 to September 2019. Data analysis was conducted from October 2019 to May 2020.

INTERVENTIONS

Participants were randomized to receive treatment with weekly or monthly depot buprenorphine or daily sublingual buprenorphine over 24 weeks.

MAIN OUTCOMES AND MEASURES

The primary end point was the difference in global treatment satisfaction, assessed by the Treatment Satisfaction Questionnaire for Medication (TSQM) version 1.4 (range, 0-100; higher score indicates greater satisfaction) at week 24. Secondary end points included other patient-reported outcomes, including quality of life, treatment burden, and health-related outcomes, as well as measures of opioid use, retention in treatment, and safety.

RESULTS

A total of 119 participants (70 [58.8%] men; mean [SD] age, 44.4 [10.5] years) were enrolled, randomized to, and received either depot buprenorphine (60 participants [50.4%]) or sublingual buprenorphine (59 participants [49.6%]). From the initial sample of 120, a participant (0.8%) in the sublingual buprenorphine group withdrew consent and did not receive study treatment. All participants were receiving sublingual buprenorphine when enrolled. The mean TSQM global satisfaction score was significantly higher for the depot group compared with the sublingual group at week 24 (mean [SE] score, 82.5 [2.3] vs 74.3 [2.3]; difference, 8.2; 95% CI, 1.7 to 14.6; P = .01). Improved outcomes were also observed for several secondary end points after treatment with depot buprenorphine (eg, mean [SE] treatment burden assessed by the Treatment Burden Questionnaire global score, on which lower scores indicate lower burden: 13.2 [2.6] vs 28.6 [2.5]; difference, -15.4; 95% CI, -22.6 to -8.2; P < .001). Thirty-nine participants (65.0%) in the depot buprenorphine group experienced 117 adverse drug reactions, mainly injection site reactions of mild intensity following subcutaneous administration, and 12 participants (20.3%) in the sublingual buprenorphine group experienced 21 adverse drug reactions. No participants withdrew from the trial medication or the trial due to adverse events.

CONCLUSIONS AND RELEVANCE

In this study, participants receiving depot buprenorphine reported improved treatment satisfaction compared with those receiving sublingual buprenorphine. The results highlight the application of patient-reported outcomes as alternative end points to traditional markers of substance use in addiction treatment outcome studies.

TRIAL REGISTRATION

anzctr.org.au Identifier: ANZCTR12618001759280.

Perceived Ability to Treat Opioid Use Disorder in West Virginia

INTRODUCTION

Medication-assisted treatment (MAT) is an evidence-based therapy for opioid use disorder (OUD) that has not been fully implemented in rural areas due to patient, provider, and logistical barriers. Limited information is available on provider perceptions of barriers to MAT in rural Central Appalachia which has very high rates of OUD compared to the rest the United States.

PURPOSE

Determine perceived barriers for potential prescribers to using MAT, including buprenorphine, as part of treatment for OUD in West Virginia.

METHODS

A 30-question, anonymous survey was sent to physicians, physician assistants and advanced practice registered nurses using an online link. Link was distributed through the WV Medicaid provider list, professional association and institutional contact lists, and social media. Comparisons were made by provider waivered or non-waivered status.

RESULTS

Overall, 84% of waivered providers (n = 77) and only 8% of non-waivered providers (n = 341) indicated ever prescribing a form of MAT for OUD; 73% percent of waivered providers were currently prescribing MAT and accepting new patients with OUD. Only 4% of non-waivered providers were currently prescribing MAT and 21% were currently accepting new patients with OUD. Lack of available mental health and psychosocial support services and concerns about diversion or misuse of medication were the top perceived barriers to implementing MAT programs.

IMPLICATIONS

Implementing strategies to improve access to behavioral health care including telehealth and apps, provider training and addressing stigma around OUD treatment were identified as priorities that would help increase providers' willingness to prescribe medications for OUD treatment.

When an obscurity becomes trend: social-media descriptions of tianeptine use and associated atypical drug use

Background: Originally believed to be an atypical antidepressant acting at serotonin transporters, tianeptine is now known to also be an atypical agonist at mu-opioid receptors. Its nonmedical use may be increasing amidst the broader context of novel drug and supplement use.Objectives: To analyze social-media text from current, former, and prospective tianeptine users for better understanding of their conceptualizations of tianeptine, motives for and patterns of use, and reported benefits and harms.Methods: Reddit posts were obtained and thematically coded; additional quantitative analyses were conducted.Results: A total of 210 posts mentioning tianeptine were made between 2012 and 2020. Eighteen thematic categories were identified, 10 of which were consistent with expected themes. Two independent raters coded all text, generating 1,382 unique codes, of which 1,090 were concordant (78.9% interrater agreement). Tianeptine use was frequently associated with use of other drugs, particularly kratom, phenibut, and racetams. People conceptualized and variously used tianeptine as an opioid, antidepressant, and "nootropic" (cognitive enhancer). Between 2014 and 2020, mentions of positive effects decreased, while mentions of adverse effects and withdrawal increased. Motivations for use included substitution or withdrawal mitigation for other drugs (especially opioids) and for kratom itself; self-treatment for psychiatric symptoms; and improvement of quality of life, mood, or performance. Descriptions of tolerance, withdrawal, and addiction were evident. Intravenous use was rare and strongly discouraged, with detrimental effects described.Conclusion: Tianeptine is recognized as an opioid (though not only an opioid) in online communities. Posts describe benefits, acute risks, and patterns of co-use that warrant greater clinical attention.

Use of non-prescribed buprenorphine in the criminal justice system: Perspectives of individuals recently released from incarceration

Buprenorphine, an effective treatment for opioid use disorder (OUD), remains underutilized in many U.S. jails and prisons. However, use of non-prescribed (i.e., diverted) buprenorphine has been reported in these settings. The current study examined non-prescribed buprenorphine use experiences in correctional and community contexts. The study conducted face-to-face interviews with 300 adults with OUD/opioid misuse and recent incarceration, recruited in Baltimore, MD, and New York, NY (n = 150 each). Illicit/non-prescribed opioid use during incarceration was reported by 63% of participants; 39% reported non-prescribed buprenorphine. Non-prescribed buprenorphine was considered the most widely available opioid in jails/prisons in both states (81% reported "very" or "somewhat" easy to get). The average price of non-prescribed buprenorphine in jail/prison was ~10× higher than in the community (p < 0.001). Participants were more likely to endorse getting high/mood alteration as reasons for using non-prescribed buprenorphine during incarceration, but tended to ascribe therapeutic motives to use in the community (e.g., self-treatment; p < 0.001). Multivariable logistic regression analyses showed that different individual-level characteristics were associated with history of non-prescribed buprenorphine use during incarceration and in the community. Use of non-prescribed buprenorphine during incarceration was associated with younger age (p = 0.006) and longer incarceration history (p < 0.001), while use of non-prescribed buprenorphine in the community was associated with MD recruitment site (p = 0.001), not being married (p < 0.001), prior buprenorphine treatment experience (p < 0.001), and housing situation (p = 0.01). These findings suggest that different dynamics and demand characteristics underlie the use of non-prescribed buprenorphine in community and incarceration contexts, with implications for efforts to expand OUD treatment in correctional settings.

"The Doctor Says You Cannot Have [Buprenorphine]" Autonomy and Use of Prescribed or Non-Prescribed Buprenorphine

BACKGROUND

People may overcome barriers to professional buprenorphine treatment by using non-prescribed buprenorphine (NPB) to manage opioid use disorder (OUD). Little is known about how people perceive NPB differently than formal treatment. This qualitative study investigated how and why people use NPB as an alternative to formal treatment.

METHODS

In-depth, semi-structured interviews were conducted with participants of harm reduction agencies (N = 22) who had used buprenorphine. Investigators independently coded transcribed interviews, generating themes through iterative reading and analysis of transcripts.

RESULTS

Three main factors drove decisions about prescribed and non-prescribed buprenorphine use: 1) autonomy; 2) treatment goals; and 3) negative early experiences with NPB. An overarching theme from our analysis was that participants valued autonomy in seeking to control their substance use. NPB was a valuable tool toward this goal and professional OUD treatment could impede autonomy. Participants mostly used NPB to "self-manage" OUD symptoms. Many participants had concerns about long-term buprenorphine treatment and instead used NPB over short periods of time. Several participants also reported negative experiences with NPB, including symptoms of withdrawal, which then deterred them from seeking out professional treatment.

CONCLUSIONS

These results support prior studies showing that people use NPB to self-manage withdrawal symptoms and to reduce use of illicit opioids. Despite these benefits, participants focused on short-term goals and negative consequences were common. Increasing buprenorphine treatment engagement may require attention to patients' sense of autonomy, and also assurance that long-term treatment is safe, effective, and reliably accessible.

Concomitant drugs with buprenorphine user deaths

BACKGROUND

Buprenorphine is abused in several countries notwithstanding its benefits as an analgesic and as an opioid agonist treatment medication. Benzodiazepines and alcohol have previously been associated with buprenorphine toxicity. This study elucidates the role of emerging concomitant drugs in different groups of buprenorphine user deaths.

METHODS

All cases in the Finnish national post-mortem toxicology database from 2016-2019 in which buprenorphine or norbuprenorphine was a laboratory finding in any post-mortem specimen and age at death of 15-64 years were investigated for cause and manner of death, concurrent drug and alcohol findings, age, and gender.

RESULTS

There were 792 deaths with a buprenorphine finding, of which buprenorphine was implicated in poisoning without other opioids in 271 cases (34 %). In this group of buprenorphine poisoning deaths, concomitant benzodiazepines were found in 94 % (clonazepam 53 %), illicit drugs in 63 %, gabapentinoids in 50 % (pregabalin 41 %), alcohol in 41 %, antidepressants in 32 %, and antipsychotics in 28 % of cases; only three deaths showed no benzodiazepines, alcohol, or gabapentinoids. Polydrug use was common regardless of the cause of death. In the age group 15 to 24 years, concomitant use of benzodiazepines and illicit drugs, and buprenorphine poisoning were more prevalent than in the age group 25-64 years.

CONCLUSIONS

The unprecedentedly high concomitant use of benzodiazepines in buprenorphine user deaths obscures other possible pharmacological risk factors for buprenorphine poisoning that could be relevant for prevention. Higher mortality in the younger age group suggests particularly unsafe drug use patterns that should be addressed.

Motivations for Diverted Buprenorphine Use in a Multisite Qualitative Study

Drawing on a multisite sample of 40 persons who sell, share, or use diverted buprenorphine to manage opioid use disorder, in this study we describe why individuals seek to obtain buprenorphine outside of formal treatment contexts, and between-site variation regarding their motives and means. Findings indicate that both the provision and purchase of diverted buprenorphine support user-defined risk minimization strategies to avoid withdrawal, reduce heroin use, and satiate opioid cravings in periods of lowered tolerance. We also found that a subset of the sample used buprenorphine recreationally, and that it functioned to extend or augment illicit drug use careers. Implications of the findings are discussed in light of federal and state drug control and treatment policies.

Unintentional drug overdose: Is more frequent use of non-prescribed buprenorphine associated with lower risk of overdose?

BACKGROUND

Unintentional drug overdoses have reached epidemic levels in the U.S. This study tests the hypothesis that people who have used non-prescribed buprenorphine more frequently in the past six months were less likely to experience a drug overdose during that same time period.

METHODS

Participants age 18 years or older with opioid use disorder who reported use of non-prescribed buprenorphine in the last six months were recruited from the Dayton, Ohio, area using a combination of targeted and modified respondent-driven sampling. Participants completed a structured interview, including six-month timeline follow-back, after informed consent. Logistic regression was used to test the association between (log-transformed) frequency of non-prescribed buprenorphine use and overdose in the previous six months, adjusted for confounding due to sex, homelessness, incarceration, substance use treatment, previous overdose, heroin/fentanyl injection, psychiatric comorbidity, and (log-transformed) frequencies of other (non-opioid) drug use.

RESULTS

Almost 89% of 356 participants were white, 50.3% were male, and 78.1% had high school or greater education. Over 27% (n = 98) reported experiencing an overdose in the past six months. After adjusting for confounding, greater frequency of non-prescribed buprenorphine use was significantly associated with lower risk of overdose (AOR = 0.81, 95% CI = 0.66, 0.98; p = .0286). Experiencing an overdose more than six months ago (AOR = 2.19, 95% CI = 1.24, 3.97); injection as the most common route of administration of heroin/fentanyl (AOR = 2.49, 95% CI = 1.36, 4.71); and frequency of methamphetamine use (AOR = 1.13, 95% CI = 1.02, 1.27) were strongly associated with increased risk of recent overdose in multivariable analysis.

DISCUSSION

The findings support our hypothesis that higher frequency of non-prescribed buprenorphine use is associated with lower risk of drug overdose, a potential harm reduction consequence of diversion. Improving the availability of buprenorphine though standard substance use disorder treatment, primary care, and other innovative methods is urgently needed.

Risk factors for heroin use following release from jail or prison in adults in a Central Appalachian state between 2012-2017

Background

Corrections-involved adults with a history of opioid use disorder are at elevated risk of opioid overdose following release from correctional settings. Increased opioid prescribing restrictions and monitoring during a time when heroin is becoming cheaper and ubiquitous means that adults who misused prescription opioids prior to incarceration may be reentering communities at greater risk for heroin exposure and use.

Objectives

Determine risk factors of post-release heroin use among a sample of adults who participated in corrections-based drug treatment in Kentucky released between 2012 and 2017.

Methods

Survey data obtained as part of an ongoing evaluation of corrections-based drug treatment were examined.

Results

The final sample (N = 1,563) was majority male (80.9%). Nearly 11.0% reported past-year heroin use following their release. Depressive symptoms, polydrug use, and urban proximity were more common among participants reporting post-release heroin use. Heroin use 30 days prior to incarceration was associated with a 432.1% increase in odds of heroin use subsequent to incarceration. Post-release suicidal ideation increased odds of heroin use by 154.2%, whereas reporting satisfaction from social interactions decreased odds of use by nearly 60%. Post-release use of cocaine and diverted buprenorphine were associated with increased likelihood of heroin use during this time period, increasing odds by 469.1% and 265.9%, respectively. Residing in Central Appalachia subsequent to incarceration was associated with decreased likelihood of use.

Conclusions

In this sample, post-release heroin use was associated with concerning features, such as polydrug use, lack of social satisfaction, and suicidal ideation. These features can serve as clear targets for clinical intervention.

Characterization of diverted buprenorphine use among adults entering corrections-based drug treatment in Kentucky

BACKGROUND

Illicit, medically unsupervised use of buprenorphine (i.e., "diverted use") among vulnerable and underserved populations, such as corrections-involved adults, remains underexplored.

METHODS

Survey data (2016-2017) collected as part of a clinical assessment of incarcerated adults entering corrections-based substance use treatment in Kentucky were analyzed. For years examined, 12,915 completed the survey. Removing cases for participants who did not reside in Kentucky for >6 months during the one-year pre-incarceration period (n = 908) resulted in a final sample size of 12,007.

RESULTS

Over a quarter of the sample reported past-year diverted buprenorphine use prior to incarceration and 21.8 % reported use during the 30-days prior to incarceration, using 6.5 months and 14.3 days on average, respectively. A greater proportion of participants who reported diverted buprenorphine use had previously been engaged with some substance use treatment (77.0 %) and reported greater perceived need for treatment (79.4 %) compared to those who did not report use. Use was more likely among participants who were younger, white, male, and who reported rural or Appalachian residence. Diverted buprenorphine users also evidenced extensive polydrug use and presented with greater substance use disorder severity. Non-medical prescription opioid, heroin, and diverted methadone use were associated with increased odds of diverted buprenorphine use while kratom was not. Diverted methadone use was associated with a 252.9 % increased likelihood of diverted buprenorphine use.

CONCLUSIONS

Diverted buprenorphine use among participants in this sample was associated with concerning high-risk behaviors and may indicate barriers to accessing opioid agonist therapies for corrections-involved Kentucky residents, particularly those in rural Appalachia.