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

Abstract 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.

[1]  S. Kurtz,et al.  Increasing rates of buprenorphine diversion in the United States, 2002 to 2019 , 2021, Pharmacoepidemiology and drug safety.

[2]  J. Gryczynski,et al.  Exploring nonprescribed use of buprenorphine in the criminal justice system through qualitative interviews among individuals recently released from incarceration. , 2021, Journal of substance abuse treatment.

[3]  J. Gryczynski,et al.  Use of non-prescribed buprenorphine in the criminal justice system: Perspectives of individuals recently released from incarceration. , 2021, Journal of substance abuse treatment.

[4]  S. Wakeman,et al.  Removing One Barrier to Opioid Use Disorder Treatment: Is It Enough? , 2021, JAMA.

[5]  B. Tofighi,et al.  A Telemedicine Buprenorphine Clinic to Serve New York City: Initial Evaluation of the NYC Public Hospital System's Initiative to Expand Treatment Access During the COVID-19 Pandemic , 2021, Journal of addiction medicine.

[6]  Nazila Jamshidi, MBBS, FRACP, FAChAM, BPharm (hons), PhD,et al.  Buprenorphine not detected on urine drug screening in supervised treatment. , 2021, Journal of opioid management.

[7]  H. Surratt,et al.  Factors Associated with Gabapentin Misuse among People Who Inject Drugs in Appalachian Kentucky , 2020, Substance use & misuse.

[8]  C. Davis,et al.  Continuing increased access to buprenorphine in the United States via telemedicine after COVID-19 , 2020, International Journal of Drug Policy.

[9]  Philip R. Kavanaugh,et al.  Motivations for Diverted Buprenorphine Use in a Multisite Qualitative Study , 2020 .

[10]  H. Surratt,et al.  Examining Factors Associated with Non-Fatal Overdose among People Who Inject Drugs in Rural Appalachia , 2020, Substance use & misuse.

[11]  Brandon del Pozo,et al.  Decriminalization of Diverted Buprenorphine in Burlington, Vermont and Philadelphia: An Intervention to Reduce Opioid Overdose Deaths , 2020, Journal of Law, Medicine & Ethics.

[12]  S. Wakeman,et al.  An overdose surge will compound the COVID-19 pandemic if urgent action is not taken , 2020, Nature Medicine.

[13]  S. Wakeman,et al.  Use of promethazine, gabapentin and clonidine in combination with opioids or opioid agonist therapies among individuals attending a syringe service program. , 2020, The International journal on drug policy.

[14]  Ramzi W. Nahhas,et al.  Unintentional drug overdose: Is more frequent use of non-prescribed buprenorphine associated with lower risk of overdose? , 2020, The International journal on drug policy.

[15]  H. Cooper,et al.  Buprenorphine dispensing in an epicenter of the U.S. opioid epidemic: A case study of the rural risk environment in Appalachian Kentucky. , 2020, The International journal on drug policy.

[16]  S. Martins,et al.  On my own terms: Motivations for self-treating opioid-use disorder with non-prescribed buprenorphine. , 2020, Drug and alcohol dependence.

[17]  K. Breuel,et al.  High Prevalence of Buprenorphine in Prenatal Drug Screens in an Appalachian City , 2020, Southern medical journal.

[18]  M. Staton,et al.  Characterization of diverted buprenorphine use among adults entering corrections-based drug treatment in Kentucky. , 2020, Drug and alcohol dependence.

[19]  J. Duchin,et al.  Engaging an Unstably Housed Population with Low-Barrier Buprenorphine Treatment at a Syringe Services Program: Lessons Learned from Seattle, Washington , 2019, Substance abuse.

[20]  R. Bluthenthal,et al.  Characteristics Associated with Nonmedical Methadone Use among People Who Inject Drugs in California , 2020, Substance use & misuse.

[21]  S. Martins,et al.  "Everything is not right anymore": Buprenorphine experiences in an era of illicit fentanyl. , 2019, The International journal on drug policy.

[22]  Ramzi W. Nahhas,et al.  Patterns of non-prescribed buprenorphine and other opioid use among individuals with opioid use disorder: A latent class analysis. , 2019, Drug and alcohol dependence.

[23]  T. Land,et al.  The Contribution of Prescribed and Illicit Opioids to Fatal Overdoses in Massachusetts, 2013-2015 , 2019, Public health reports.

[24]  Philip R. Kavanaugh,et al.  "They're making it so hard for people to get help:" Motivations for non-prescribed buprenorphine use in a time of treatment expansion. , 2019, The International journal on drug policy.

[25]  Kelly E. Dunn,et al.  Buprenorphine in the United States: Motives for abuse, misuse, and diversion. , 2019, Journal of substance abuse treatment.

[26]  R. Silverman,et al.  Court personnel attitudes towards medication-assisted treatment: A state-wide survey. , 2019, Journal of substance abuse treatment.

[27]  B. Tofighi,et al.  Patient Barriers and Facilitators to Medications for Opioid Use Disorder in Primary Care , 2019, Substance use & misuse.

[28]  A. Bohnert,et al.  Characteristics of US Counties With High Opioid Overdose Mortality and Low Capacity to Deliver Medications for Opioid Use Disorder , 2019, JAMA network open.

[29]  M. Fingerhood,et al.  Article Commentary: Demystifying Buprenorphine Misuse: Has Fear of Diversion Gotten in the Way of Addressing the Opioid Crisis? , 2019, Substance abuse.

[30]  Martin T. Hall,et al.  Non-Prescribed Buprenorphine Use Mediates the Relationship between Heroin Use and Kratom Use among a Sample of Polysubstance Users , 2019, Journal of psychoactive drugs.

[31]  W. Ling,et al.  Remission from chronic opioid use-Studying environmental and socio-economic factors on recovery (RECOVER): Study design and participant characteristics. , 2019, Contemporary clinical trials.

[32]  T. Cicero,et al.  Understanding the use of diverted buprenorphine. , 2018, Drug and alcohol dependence.

[33]  Zachary Munn,et al.  Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach , 2018, BMC Medical Research Methodology.

[34]  J. Rich,et al.  The More Things Change: Buprenorphine/naloxone Diversion Continues While Treatment Remains Inaccessible , 2018, Journal of addiction medicine.

[35]  M. Stein,et al.  Buprenorphine treatment formulations: Preferences among persons in opioid withdrawal management. , 2018, Journal of substance abuse treatment.

[36]  C. Beyrer,et al.  A Public Health Strategy for the Opioid Crisis , 2018, Public health reports.

[37]  J. McGowan,et al.  PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation , 2018, Annals of Internal Medicine.

[38]  S. Allen,et al.  Fentanyl-contaminated drugs and non-fatal overdose among people who inject drugs in Baltimore, MD , 2018, Harm Reduction Journal.

[39]  A. Bohnert,et al.  Policy Pathways to Address Provider Workforce Barriers to Buprenorphine Treatment. , 2018, American journal of preventive medicine.

[40]  R. Walker,et al.  Characteristics and experiences of buprenorphine-naloxone use among polysubstance users , 2018, The American journal of drug and alcohol abuse.

[41]  J. M. Webster,et al.  Patterns of buprenorphine use and risk for re-arrest among highly vulnerable opioid-involved women released from jails in rural Appalachia , 2018, Journal of addictive diseases.

[42]  M. Bachhuber,et al.  Description and Outcomes of A Buprenorphine Maintenance Treatment Program Integrated within Prevention Point Philadelphia, An Urban Syringe Exchange Program , 2018, Substance abuse.

[43]  B. Andraka-Christou,et al.  A qualitative study comparing physician-reported barriers to treating addiction using buprenorphine and extended-release naltrexone in U.S. office-based practices. , 2018, The International journal on drug policy.

[44]  H. Thiede,et al.  Utilization of Buprenorphine and Methadone among Opioid users who Inject Drugs , 2018, Substance abuse.

[45]  S. Butler,et al.  Understanding abuse of buprenorphine/naloxone film versus tablet products using data from ASI-MV® substance use disorder treatment centers and RADARS® System Poison Centers. , 2018, Journal of substance abuse treatment.

[46]  J. Suzuki,et al.  Quantitative Testing of Buprenorphine and Norbuprenorphine to Identify Urine Sample Spiking during Office-Based Opioid Treatment , 2017, Substance abuse.

[47]  M. Stein,et al.  The relationship between diversion-related attitudes and sharing and selling buprenorphine. , 2017, Journal of substance abuse treatment.

[48]  He Zhu,et al.  Treatment utilization among persons with opioid use disorder in the United States. , 2016, Drug and alcohol dependence.

[49]  Alex Harocopos,et al.  Non-Prescribed Buprenorphine in New York City: Motivations for Use, Practices of Diversion, and Experiences of Stigma. , 2016, Journal of substance abuse treatment.

[50]  M. Sullivan,et al.  Patterns of opioid use and co-morbidity in non-treatment-seeking individuals with opioid use disorder , 2015 .

[51]  K. O’grady,et al.  Prior Experience with Non-Prescribed Buprenorphine: Role in Treatment Entry and Retention. , 2015, Journal of substance abuse treatment.

[52]  Amit Sheth,et al.  "Sub is a weird drug:" A web-based study of lay attitudes about use of buprenorphine to self-treat opioid withdrawal symptoms. , 2015, The American journal on addictions.

[53]  K. O’grady,et al.  Changes in Quality of Life following Buprenorphine Treatment: Relationship with Treatment Retention and Illicit Opioid Use , 2015, Journal of psychoactive drugs.

[54]  B. DiPaula,et al.  Physician-pharmacist collaborative care model for buprenorphine-maintained opioid-dependent patients. , 2015, Journal of the American Pharmacists Association : JAPhA.

[55]  C. Cunningham,et al.  Release from incarceration, relapse to opioid use and the potential for buprenorphine maintenance treatment: a qualitative study of the perceptions of former inmates with opioid use disorder , 2015, Addiction Science & Clinical Practice.

[56]  H. Surratt,et al.  Factors contributing to the rise of buprenorphine misuse: 2008-2013. , 2014, Drug and alcohol dependence.

[57]  S. Walsh,et al.  A Review of Buprenorphine Diversion and Misuse: The Current Evidence Base and Experiences From Around the World , 2014, Journal of addiction medicine.

[58]  B. B. Bartelson,et al.  Nonmedical Use of Tapentadol Immediate Release by College Students , 2014, The Clinical journal of pain.

[59]  F. Altice,et al.  Self-Management of Buprenorphine/Naloxone Among Online Discussion Board Users , 2014, Substance use & misuse.

[60]  C. Cunningham,et al.  I Heard about it from a Friend: Assessing Interest in Buprenorphine Treatment , 2014, Substance abuse.

[61]  D. Vlahov,et al.  Prevalence and correlates of street-obtained buprenorphine use among current and former injectors in Baltimore, Maryland. , 2013, Addictive behaviors.

[62]  Joseph D. Ma,et al.  Urine specimen detection of concurrent nonprescribed medicinal and illicit drug use in patients prescribed buprenorphine. , 2013, Journal of analytical toxicology.

[63]  C. Cunningham,et al.  Prior Buprenorphine Experience Is Associated With Office-Based Buprenorphine Treatment Outcomes , 2013, Journal of addiction medicine.

[64]  K. O’grady,et al.  Patient perspectives on choosing buprenorphine over methadone in an urban, equal-access system. , 2013, The American journal on addictions.

[65]  C. Cunningham,et al.  Consumer attitudes about opioid addiction treatment: a focus group study in New York City. , 2013, Journal of opioid management.

[66]  J. Havens,et al.  Inability to access buprenorphine treatment as a risk factor for using diverted buprenorphine. , 2012, Drug and alcohol dependence.

[67]  Raminta Daniulaityte,et al.  Illicit use of buprenorphine in a community sample of young adult non-medical users of pharmaceutical opioids. , 2012, Drug and alcohol dependence.

[68]  N. Campbell,et al.  The history of the development of buprenorphine as an addiction therapeutic , 2012, Annals of the New York Academy of Sciences.

[69]  Robert L DuPont,et al.  The Emerging Buprenorphine Epidemic in the United States , 2012, Journal of addictive diseases.

[70]  J. Astemborski,et al.  Correlates of non-medical prescription drug use among a cohort of injection drug users in Baltimore City. , 2011, Addictive behaviors.

[71]  J. Rich,et al.  Illicit Use of Buprenorphine/Naloxone Among Injecting and Noninjecting Opioid Users , 2011, Journal of addiction medicine.

[72]  Albert Dahan,et al.  Current Knowledge of Buprenorphine and Its Unique Pharmacological Profile , 2010, Pain practice : the official journal of World Institute of Pain.

[73]  Sarah E. Nelson,et al.  Self-treatment: illicit buprenorphine use by opioid-dependent treatment seekers. , 2010, Journal of substance abuse treatment.

[74]  N. Petry,et al.  Methadone Deaths: Risk Factors in Pain and Addicted Populations , 2010, Journal of General Internal Medicine.

[75]  M. Agar,et al.  Uses of diverted methadone and buprenorphine by opioid-addicted individuals in Baltimore, Maryland. , 2009, The American journal on addictions.

[76]  Edward W Boyer,et al.  Diversion of Buprenorphine/Naloxone Coformulated Tablets in a Region with High Prescribing Prevalence , 2009, Journal of addictive diseases.

[77]  K. O’grady,et al.  A randomized clinical trial of methadone maintenance for prisoners: results at 1-month post-release. , 2007, Drug and alcohol dependence.

[78]  J. Inciardi,et al.  Use and misuse of buprenorphine in the management of opioid addiction. , 2007, Journal of opioid management.

[79]  P. Doering,et al.  Buprenorphine for the treatment of opioid dependence. , 2007, American journal of health-system pharmacy : AJHP : official journal of the American Society of Health-System Pharmacists.

[80]  E. Richter,et al.  Relationship between conflicts of interest and research results , 2007, Journal of General Internal Medicine.

[81]  R P Mattick,et al.  Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. , 2008, The Cochrane database of systematic reviews.