The Buprenorphine Diversion Problem

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The diversion of buprenorphine products has killed thousands of people, right? Or is it hundreds of thousands? Millions? Does it matter?

We live in a big country, and the news media does a poor job of keeping issues in perspective. Headlines decry the number of deaths from one thing or another, emphasizing the dangers that are likely to draw the most interest, rather than the dangers that are likeliest to happen. The media has a narrative, and sometimes it is hard to know how that narrative begins.

Even if we had a perfect news media, our minds struggle with comparisons of risk to the point where we sometimes drop considerations of relative risk completely…-Jeffrey Junig
Even if we had a perfect news media, our minds struggle with comparisons of risk to the point where we sometimes drop considerations of relative risk completely, and decide that ‘even one death is too many.’ That approach is seductively simple, but has no value when arguing public policies that have pluses and minuses on both sides of the debate.

In medical school, doctors learn that a healthy appendix must be removed now and then in order to reduce the number of deaths from peritonitis. Every medical intervention has a cost/benefit ratio. If we aim for better glucose control in order to reduce complications from diabetes, we will increase the number of hypoglycemic episodes. Half of the risk equation holds no value for reasoned decisions about policy. News stories that hype one half of the equation do nothing but titillate and mislead.

Lately, it seems as if every discussion about buprenorphine leads with the diversion problem. Diversion of buprenorphine has apparently become so bad that some policy-makers will choose opioid dependence treatments that have almost no value, over an otherwise-perfect medication for treating the current epidemic of opioid dependence.

Diversion of buprenorphine has apparently become so bad that some policy-makers will choose opioid dependence treatments that have almost no value, over an otherwise-perfect medication…-Jeffrey Junig

U.S. Death Risks by the Numbers

Let’s look at some real numbers. In the U.S., overdose deaths, mostly from opioids, now surpass deaths from motor vehicle accidents. Car accidents are a useful comparator, since most people have a general sense of the risks of driving. Nobody is surprised that car accidents are among the top causes of death, because of the large role of automobiles in the lives of most Americans. That people are found pulseless and blue, dead from drug overdose, in greater numbers than traffic deaths, should command our attention.

Lightning deaths, on the other hand, are uncommon. No politician is running on a platform to reduce lightning strikes. Paramedics don’t refuse to work during thunderstorms. We don’t design public policy around the risk of lightning, other than to delay a football game for an hour or two.

Deaths from buprenorphine occur at the same frequency as deaths from lightning.

The National Oceanic and Atmospheric Administration reports that about 50 people die from lightning each year in the U.S. And in the past 10 years, buprenorphine has been linked to almost 500 overdose deaths. And given that accidental deaths are almost always investigated, it is unlikely that large numbers of buprenorphine deaths go unnoticed.

In the past 10 years, buprenorphine has been linked to almost 500 overdose deaths… Does that amount of risk warrant the concern about buprenorphine diversion?-Jeffrey Junig

Does that amount of risk warrant the concern about buprenorphine diversion? Getting back to the risk equation, I suspect that buprenorphine diversion does, in fact, cause tens of thousands of deaths, but not in the way that most people think. Concern about buprenorphine diversion has contributed to the cap on number of patients doctors can treat with buprenorphine, keeping the life-saving medication from unknown numbers of people. I have no idea the number of lives lost as a consequence, but my small practice turns away several patients seeking help EVERY DAY.

Buprenorphine vs. Naltrexone

Use of naltrexone is based on the fantasy that blocking receptors and forcing ‘counseling’ will result in abstinence…-Jeffrey Junig

Concern about buprenorphine diversion has led many drug courts to instead use monthly injections of naltrexone for mandated treatment. Use of naltrexone is based on the fantasy that blocking receptors and forcing ‘counseling’ will result in abstinence when the block is removed. A pessimist would say that addicts only mark their time until off naltrexone, especially since they know that the $1000/month drug will be used for only a year. Australian studies showed death rates up to 9 times higher in patients who discontinue naltrexone, compared to methadone patients.

Concern about buprenorphine diversion prevents doctors from getting involved in treating opioid dependence, for fear of being associated with a ‘problem drug.’ Concern about buprenorphine diversion causes limited healthcare resources to be used for diversion monitoring programs, including drug testing, that cost several times more than the cost of seeing the doctor. Doctor/patient relationships are colored in indeterminate ways by the diversion issue, as patients are treated as if they are guilty of something just by being on the medication.

The Risks of Buprenorphine

Treatment with buprenorphine has a balance of risks. On one side we have untreated or poorly treated opioid dependence, which is highly associated with personal suffering and societal costs. On the other side we have access to a medication that is sometimes used outside of a doctor/patient relationship. Much of that use consists of patients trying to treat their own addiction, or to take a badly-needed break from opioid agonists. Some may consist of people maintaining an addiction, where the ceiling effect and long half-life of buprenorphine limit the potential for harm.

Given all of the harm caused by the emphasis on buprenorphine diversion, someone should report THAT story.-Jeffrey Junig

The paucity of deaths related to buprenorphine make one thing clear. Whether prescribed or illicit, dying from buprenorphine is as common as being struck by lightning. Given all of the harm caused by the emphasis on buprenorphine diversion, someone should report THAT story.

Photo Source: istock

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of Rehabs.com. We do believe in healthy dialogue on all topics and we welcome the opinions of our professional contributors.

What Are Your Thoughts on this Topic?

  • annemfletcher

    Thank you for this terrific story that puts this important issue into perspective. I’m so tired of hearing about buprenorphine diversion and how monthly naltrexone injections are often favored over more beneficial bupe and methadone treatment. It’s also my understanding that the research support for the value of naltrexone injections for opioid injection is thin.
    Anne Fletcher, MS, RD, Author of Inside Rehab and Sober for Good

  • Med-Tech Rehab

    It is not the overdose deaths caused by buprenorphine diversion that is the real concern, it is the real fact that buprenorphine is quickly becoming the single largest gateway to stronger opiate drugs in many areas. Younger and newer first time opiate users are being told that subutex is a safe party drug to get a buzz without a risk of overdose or addiction, yet two weeks later that young user is either going through withdrawal or switching to a stronger opiate. We should also discuss the tens of millions of dollars that our state medicaid systems are losing to this diversion, which is as you admit, many times nothing more than self guided treatment attempts or a spare tire to prevent withdrawal during times when stronger opiates are unavailable. Let’s all just be honest, buprenorphine and similar physician dispensed drugs are part of a business model that allows largely untrained physicians to take financial advantage of the huge opiate problem we have. We are all being guided by a pharmaceutical industry that created this problem with easy access to opiates through credentialing legislation changes on the use of pain medications and now they are feeling huge multi-billion dollar profits acting like they are cleaning up the mess with easy access to addiction treatment drugs. Nothing has really changed except we are killing our citizens and burning through dollars .

  • J T Junig

    Interesting theory, but there is no evidence that buprenorphine is a gateway drug other than your fantasies. You are suggesting that some people started using opioids by purchasing a 20 or $30 strip of buprenorphine, rather than taking the free hydrocodone in the medicine cabinet or the five dollar Percocet tabs rom by a buddy. Hogwash.

    Ask one of your patients who “used people buprenorphine as a gateway drug”— if you can find one— what happened when they first took buprenorphine . They will inform you that even when they took the smallest possible piece of film, they had severe nausea— that is if they truly were opiate free and using buprenorphine as the gateway drug as you suggest.

    And then ask them about their “transition to a more potent opiate.” They will inform you that buprenorphine is a very potent opioid, much more potent than oxycodone or heroin. But because of the long half life of the drug and the partial agonist ceiling effect, it is impossible to take for a ‘high’ for more than a few days, because after a few days they start feeling normal. Moreover, at that point they can no longer get any effect from other opioids, since buprenorphine blocks receptors so tightly.

    They will tell you that oxycodone or heroin “don’t work” for as long as two weeks after taking one dose of buprenorphine, because of the blocking effects of buprenorphine.

    Ask your patients what happens if they do it a different order, i.e. get high from taking heroin and then go back to buprenorphine. They will explain to you how horribly sick they became from the process.

    Your comment about “us killing our children” baffles me. 50 deaths from buprenorphine each year, compared to 34,000 deaths without buprenorphine. Simply being on buprenorphine clearly has a potent protective effect.

    Listen to your patients without the assumptions. They will teach you some things.

  • J T Junig

    Meant to add… your comment about ‘business models’ and ‘largely untrained physicians’— who are you comparing them to, you? Who made your practice style the gold standard? What makes you so certain that you are smarter than your colleagues? Your smug attitude fuels erroneous media perceptions…. and I wish doctors like you could let go of the pre-med, ‘I’m the smartest’ nonsense.
    People come to addiction treatment by many pathways; many of the “highly trained’, addiction board certified docs were grandfathered in because of limited experience and a brief test. Others are surgeons or dermatologists who for decades spent no time talking to patients, but then did two years of an addiction fellowship after going through their own addictions. I suspect you would see them as more ‘highly trained’ than a family practice doc who has worked with people for decades, treating addiction, chronic pain, and mood disorders.
    All the ‘untrained docs’ you refer to had 4 years of college, 4 years of medical school, and 4 years of residency training. Nobody is ‘untrained’. The important thing for providing good care isn’t training– it is knowing we aren’t always the smartest person in the room. That in turn allows us to drop unchallenged assumptions, and to learn from our patients.

  • Richard Bassett

    I find (as an Addiction Counselor) that those who use buprenophine recreationally usually boost the effects with dangerous amounts of benzodiazepines, thus contributing to a possible fatality. I do not believe it is a ‘gateway’ (which is dubious, at best, these days) drug nor do I believe that addicts think that it is either. As for naltrexone vs buprenorphine, it is an unrealistic comparison as one ‘really’ has nothing chemically to do with the other.

  • J T Junig

    An opioid-naïve person risks overdose if buprenorphine is combined with a benzo, as benzos reduce the ceiling on respiratory depression provided by buprenorphine. But it is impossible to create a scenario for regular, ‘recreational’ buprenorphine use. Regular use results in tolerance, and once tolerant, there is no way to obtain euphoria from buprenorphine– whether taken normally or injected. When I talk to patients, the pattern of use that is almost universally described consists of intermittent attempts at self-treatment during or after binges of opioid agonists. Those who find, and use, buprenorphine learn that heroin will not provide a ‘high’ for days or weeks after taking buprenorphine.

  • Guest

    I may not be a doctor but I am a recovering addict. I am currently in a Methadone treatment program and have been clean for over 4 years. I would just like to put my two cent even if they don’t mean anything. I have had multiple friends who have been in and out of suboxone clinics sometimes two or three times. I am obviously a strong supporter of methadone but I do know that done properly, people on suboxone can do just as good. The biggest problem I’ve seen with Suboxone is that patients are given two weeks and so ermines a months worth of suboxone at a time. In my clinic where I recieve methadone we aren’t instantly “rewarded.” We have to have go everyday except Sundays and we have to earn our take outs. After giving them clean drug tests you eventually earn one takeout after 90 days. Then after another 90 you earn another, the you must have a. Job or be in school to earn any more take outs. If you do everything you are supposed to you earn 6 take outs in 3 years. My clinic is much stricter than some but my point is that hey aren’t handing methadone over to a patient who is recent in recovery. Most if my friends in suboxone would either take half their script for half the month and then sell half their script and use the other half. Once they start getting heir dose lowered they then start borrowing so that they can take more or buy more off the street. I was a addict so I know how we think. Most are going to do what I just described. I think that if you made the patients earn take outs like the methadone clinic does it would minimize the diversion problem. Of course there’s always going to be a problems hen I comes to diverting prescription drugs but the biggest thing is to minimize it.

  • Kate V

    I may not be a doctor but I am a recovering addict. I am currently in a Methadone treatment program and have been clean for over 4 years. I would just like to put my two cent in even if they don’t mean anything. I have had multiple friends who have been in and out of suboxone clinics sometimes two or three times. I am obviously a strong supporter of methadone but I do know that done properly, people on suboxone can do just as good. The biggest problem I’ve seen with Suboxone is that patients are given two weeks and sometimes a months worth of suboxone at a time. In my clinic where I receive methadone we aren’t instantly “rewarded.” We have to have go everyday except Sundays and we have to earn our take outs. After giving them clean drug tests you eventually earn one takeout after 90 days. Then after another 90 days you earn another, then you must have a job or be in school to earn any more take outs. If you do everything you are supposed to you earn 6 take outs in 3 years. My clinic is much stricter than some but my point is that they aren’t handing methadone over to a patient who is recent in recovery. I understand that Suboxone is not a long term treatment plan so it’s obviously it would have to be on a quicker scale. Most of my friends on Suboxone would either take half their script for the last half the month so that it’s in their system and then sell half their script and use heroin or other opiates the other half. Once they start getting their dose lowered they then start borrowing so that they can take more or buy more off the street. I was an addict so I know how we think. Most are going to do what I just described. I think that if you made the patients earn take outs like the methadone clinic does it would minimize the diversion problem. Of course there’s always going to be a problems when it comes to diverting prescription drugs but the biggest thing is to minimize it. I just don’t think that giving an addict that amount of suboxone at once is the smartest thing to do. It’s too much to much for most to handle in the beginning of their sobriety. I know most doctors and counslors what to have faith in us but the reality of it is it puts too much power in he hands of the patient. People always complain about how strict my clinic is but I owe my life to it being that way. I am beyond thankful that they are strict like that because I know myself too well and I don’t know if I would be doing as well as I am if it wasn’t for hem being so strict.

  • Gene

    I’ve be taking Suboxone for about 8 months, I was addicted to Oxycotton for a few years and wanted to get clean. When I switched over to Suboxone, I was really sick for 2 days or so, Then started to feel better and better. I take what was prescribed, and nothing more. The first few weeks I wanted to get high on Oxycotton, but I knew it wouldn’t work because Suboxone is a opiate blocker. My doctor started me on 2 strips a day 16mg and now I’ve cut back to 8mg 1 strip, and soon will be Suboxone free. I started out on the Methadone treatment, That didn’t last, Having to go to a clinic everyday, and sit around with Hereon addicts. Suboxone is the way to go, It doesn’t get you high, but it will make you feel happy, and Normal.

  • kennethanderson

    There were 1500 deaths from Tylenol poisoning in the past 10 years, three times that of Suboxone. Why no hype about that? Because the media thinks opiate users are BAD people and Tylenol users are not. That is all.

    • Counselorchick

      Thank you Ken Anderson!