Characteristics and experiences of buprenorphine-naloxone use among polysubstance users

Postmortem toxicology findings from the Camden Opioid Research Initiative

The United States continues to be impacted by decades of an opioid misuse epidemic, worsened by the COVID-19 pandemic and by the growing prevalence of highly potent synthetic opioids (HPSO) such as fentanyl. In instances of a toxicity event, first-response administration of reversal medications such as naloxone can be insufficient to fully counteract the effects of HPSO, particularly when there is co-occurring substance use. In an effort to characterize and study this multi-faceted problem, the Camden Opioid Research Initiative (CORI) has been formed. The CORI study has collected and analyzed post-mortem toxicology data from 42 cases of decedents who expired from opioid-related toxicity in the South New Jersey region to characterize substance use profiles. Co-occurring substance use, whether by intent or through possible contamination of the illicit opioid supply, is pervasive among deaths due to opioid toxicity, and evidence of medication-assisted treatment is scarce. Nearly all (98%) of the toxicology cases show the presence of the HPSO, fentanyl, and very few (7%) results detected evidence of medication-assisted treatment for opioid use disorder, such as buprenorphine or methadone, at the time of death. The opioid toxicity reversal drug, naloxone, was detected in 19% of cases, but 100% of cases expressed one or more stimulants, and sedatives including xylazine were detected in 48% of cases. These results showing complex substance use profiles indicate that efforts at mitigating the opioid misuse epidemic must address the complications presented by co-occurring stimulant and other substance use, and reduce barriers to and stigmas of seeking effective medication-assisted treatments.

Scope of, Motivations for, and Outcomes Associated with Buprenorphine Diversion in the United States: A Scoping Review

BACKGROUND

Expanding access to medications to treat opioid use disorder (OUD), such as buprenorphine, is an evidence-based response to the mounting drug overdose crisis. However, concerns about buprenorphine diversion persist and contribute to limited access.

METHODS

To inform decisions about expanding access, a scoping review was conducted on publications describing the scope of, motivations for, and outcomes associated with diverted buprenorphine in the U.S.

RESULTS

In the 57 included studies, definitions for diversion were inconsistent. Most studied use of illicitly-obtained buprenorphine. Across studies, the scope of buprenorphine diversion ranged from 0% to 100%, varying by sample type and recall period. Among samples of people receiving buprenorphine for OUD treatment, diversion peaked at 4.8%. Motivations for using diverted buprenorphine were self-treatment, management of drug use, to get high, and when drug of choice was unavailable. Associated outcomes examined trended toward positive or neutral, including improved attitudes toward and retention in MOUD.

CONCLUSIONS

Despite inconsistent definitions of diversion, studies reported a low scope of diversion among people receiving MOUD, with inability to access treatment as a motivating factor for using diverted buprenorphine, and increased retention in MOUD as an outcome associated with use of diverted buprenorphine. Future research should explore reasons for diverted buprenorphine use in the context of expanded treatment availability to address persistent barriers to evidence-based treatment for OUD.

Increasing rates of buprenorphine diversion in the United States, 2002 to 2019

PURPOSE

Recent reports suggest that buprenorphine is being diverted and used non-medically. However, no apparent studies have reported national-level data on buprenorphine diversion.

METHODS

Case report data were drawn from a quarterly survey of prescription drug diversion completed by a national sample of law enforcement and regulatory agencies who engage in drug diversion investigations. Quarterly rates of buprenorphine diversion per 100 000 population and 100 000 prescriptions dispensed were calculated for the period 2002 through 2019. Population-based diversion rates were also calculated by U.S. region.

RESULTS

In total, 9670 cases of diverted buprenorphine were reported across all 50 states and the District of Columbia during the study period. Buprenorphine diversion rates, per 100 000 population, were characterized by an accelerating increase over time; increases in diversion rates from 1st quarter 2002 through 4th quarter 2006 were not statistically significant, yet from 1st quarter 2007 through 4th quarter 2019, the rate of diversion cases increased by 0.0067 cases per 100 000 per quarter (p < 0.001). Buprenorphine diversion rates per 100 000 prescriptions dispensed indicated a gradual increase over time; from 3rd quarter 2010 through 4th quarter 2019, diversion rates showed a statistically significant increase of 0.28 cases (p = 0.037) per quarter on average. The Northeast was the only region that did not observe an increase in the average quarterly change in buprenorphine diversion rates after 2006.

CONCLUSIONS

Findings from this study illustrate longitudinal national trends of increasing buprenorphine diversion. Continued systematic surveillance of this phenomenon is needed.

Endogenous Opiates and Behavior: 2018

This paper is the forty-first consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2018 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (2), the roles of these opioid peptides and receptors in pain and analgesia in animals (3) and humans (4), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (5), opioid peptide and receptor involvement in tolerance and dependence (6), stress and social status (7), learning and memory (8), eating and drinking (9), drug abuse and alcohol (10), sexual activity and hormones, pregnancy, development and endocrinology (11), mental illness and mood (12), seizures and neurologic disorders (13), electrical-related activity and neurophysiology (14), general activity and locomotion (15), gastrointestinal, renal and hepatic functions (16), cardiovascular responses (17), respiration and thermoregulation (18), and immunological responses (19).

Examining Recovery Program Participants by Gender: Program Completion, Relapse, and Multidimensional Status 12 Months After Program Entry

This study examined individual-level characteristics and factors associated with program completion, relapse, and multidimensional status at follow-up for 213 men and 248 women who entered one of 17 peer-led recovery programs and who completed a follow-up interview 12 months later. Study results found that although there were some significant gender differences at program entry among participants entering Recovery Kentucky, there were few gender differences at follow-up. In addition, although participants had significant psychosocial problems, polysubstance use patterns, and severe substance use disorder (SUD), the majority of both men and women reported completing the program (80.3%), a small minority reported relapse (9.5%), and about one third had worse multidimensional status about 12 months after program entry. Lower quality of life rating at program entry was associated with program completion and with better multidimensional status at follow-up. Study results suggest the recovery program provides an important option for some of the most vulnerable individuals with SUD.

Classics in Chemical Neuroscience: Buprenorphine

Buprenorphine has not only had an interdisciplinary impact on our understanding of key neuroscience topics like opioid pharmacology, pain signaling, and reward processing but has also been a key influence in changing the way that substance use disorders are approached in modern medical systems. From its leading role in expanding outpatient treatment of opioid use disorders to its continued influence on research into next-generation analgesics, buprenorphine has been a continuous player in the ever-evolving societal perception of opioids and substance use disorder. To provide a multifaceted account on the enormous diversity of areas where this molecule has made an impact, this article discusses buprenorphine's chemical properties, synthesis and development, pharmacology, adverse effects, manufacturing information, and historical place in the field of chemical neuroscience.

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.

Patterns of non-prescribed buprenorphine and other opioid use among individuals with opioid use disorder: A latent class analysis

AIM

Non-prescribed buprenorphine (NPB) use increased in the US. This study aims to characterize heterogeneity in patterns of NPB and other opioid use among individuals with current opioid use disorder.

METHODS

The study recruited 356 participants in Dayton (Montgomery County), Ohio, area in 2017-2018 using targeted and Respondent Driven Sampling. Participants met the following criteria: 1) 18 years or older, 2) current moderate/severe opioid use disorder (DSM-5), 3) past 6-month NPB use. Latent class analysis (LCA) was conducted to identify subgroups based on past 6-month (days of NPB and heroin/fentanyl use; use of NPB to get high; use of non-prescribed and prescribed pharmaceutical opioids; participation in formal treatment) and lifetime (years since first NPB and other illicit opioid use) characteristics. Selected auxiliary variables were compared across classes using Asparouhov and Muthén's 3-step approach.

RESULTS

49.7% were female, and 88.8% were non-Hispanic whites. 89% used NPB to self-treat withdrawal. LCA resulted in three classes: "Heavy Heroin/Fentanyl Use" (61%), "More Formal Treatment Use" (29%) and "Intense NPB Use" (10%). After adjusting for multiple testing, the following past 6-month variables differed significantly between classes: injection as a primary route of heroin/fentanyl administration (p < 0.001), cocaine use (p = 0.044), unintentional drug overdose (p = 0.023), and homelessness (p = 0.044), with the "Intense NPB Use" class having the lowest prevalences.

CONCLUSION

Predominance of self-treatment goals and the association between more intense NPB use and lower risks of adverse consequences suggest potential harm minimization benefits of NPB use. More research is needed to understand consequences of NPB use over time.

Buprenorphine Treatment for Opioid Use Disorder: An Overview

Opioid use disorder affects over 26 million individuals worldwide. There are currently three World Health Organization-recommended and US Food and Drug Administration-approved medication treatments for opioid use disorder: the full opioid agonist methadone, the opioid partial agonist buprenorphine, and the opioid receptor antagonist naltrexone. We provide a review of the use of buprenorphine for the treatment of opioid use disorder and discuss the barriers, challenges, risks, and efficacy of buprenorphine treatment vs. other treatments. Although evidence from numerous studies has shown buprenorphine to be effective for the treatment of opioid use disorder, a majority of patients with opioid use disorder do not receive buprenorphine, or any other medical treatment. We review the different formulations of buprenorphine, including newer long-acting injectable formulations that may decrease the risk of diversion and improve adherence.

Non-Prescribed Buprenorphine Use Mediates the Relationship between Heroin Use and Kratom Use among a Sample of Polysubstance Users

In Asia, Mitragyna speciosa (e.g., "kratom") has been used to mitigate alcohol and drug dependence. Some preliminary findings suggest kratom's potential use as an informal harm-reduction method in the United States, such as an opioid substitute or as a means of lessening opioid withdrawal symptoms. To determine correlates of past-year kratom use among a sample of polysubstance users enrolled in residential recovery programs in Kentucky, an anonymous survey was completed by clients in April 2017. Logistic regression was used to identify significant associations with past-year kratom use. Of the final sample (N = 478), 10.4% reported past-year kratom use. Past-year heroin use, but not past-year prescription opioid (e.g., oxycodone, hydrocodone) use, was significantly associated with kratom use, such that individuals who reported past-year heroin use were 2.5 times more likely to also report past-year kratom use. Non-prescribed buprenorphine (i.e., Suboxone) use partially mediated the relationship between past-year heroin and kratom use by explaining 36% of the association between the two drugs. Though amphetamines were highly preferred, past-year use was negatively correlated with past-year kratom use. Rates of past-year kratom use were lower than rates of alcohol and illicit drug use. Kratom was not preferred over heroin or prescription opioids.