In the 12-month period ending in April, more than 100,000 people in the U.S. died from drug overdoses -- the most recorded in a year-long span. Most of those overdoses involved opioids. Public health experts and addiction researchers agree that wider utilization of effective medications to treat opioid use disorder (OUD) is critical to bringing the crisis under control. As it now stands, with OUD receive medications for treatment.
Buprenorphine is a partial opioid agonist that was originally developed to treat pain -- but it's also a highly effective medication to treat OUD. Yet, like other drugs that activate mu opioid receptors, it has the potential to be misused -- taken in some other way than the doctor prescribed (such as at a higher dose or for longer duration) or taken without one's own prescription (i.e., via diversion). This concern led to safety restrictions, including the requirement of a waiver to prescribe buprenorphine for OUD and limits on the number of patients whom providers can treat using it. Such restrictions don't exist when using buprenorphine for the treatment of pain.
With widespread efforts to increase the numbers of people with OUD in medication treatment, we badly need empirical evidence about buprenorphine misuse: its extent, whether it is increasing, and why people misuse the drug. Our group at the National Institute on Drug Abuse (NIDA) along with a CDC colleague utilized data from the Substance Abuse and Mental Health Services Administration's (NSDUH) to help answer these questions. We recently published our findings in .
We found that nearly three quarters of U.S. adults who reported buprenorphine use in 2019 did not report misusing buprenorphine during the previous 12 months and that misuse of buprenorphine by people with OUD declined during 2015-2019. Buprenorphine misuse among people without OUD remained stable. We also found that, consistent with previous studies, hydrocodone and oxycodone were far more commonly misused than buprenorphine. Importantly, the survey also showed that using prescription opioids without a prescription was more frequently reported among respondents who misused buprenorphine than among those who misused other prescription opioids without a prescription.
The reasons most often cited by those with OUD who did misuse buprenorphine were "because I am hooked" and "to relieve physical pain." This is important. It indicates that when buprenorphine is misused by people with OUD, the reason tends to be self-medication of withdrawal symptoms and pain, not to get high. In contrast, those without OUD who had misused buprenorphine most commonly reported doing so "to relieve physical pain" and "to feel good or to get high."
In our view, these data paint a clear picture of a too-little-prescribed medication being sought and used by people with OUD principally to self-treat their addiction symptoms. It points to the need for greater buprenorphine availability and prescribing by physicians to treat patients who have OUD, while ensuring measures are in place to monitor and prevent misuse and diversion.
Earlier this year, some of the restrictions on buprenorphine prescribing were relaxed: Eligible practitioners who wish to treat less than 30 patients with buprenorphine were exempted from certain X-waiver requirements. But the waiver requirement itself remains in place, along with limits on the number of patients waivered providers can treat. While exempting providers from some of the X-waiver requirements is expected to expand the use of buprenorphine by certain prescribers, other impediments remain, including concerns about reimbursement and stigma.
More than half of primary care physicians surveyed in a recent study of people with OUD. Those views are associated with lower willingness to use medications to treat OUD, despite clear evidence for their effectiveness. Even physicians who are waivered and willing to prescribe buprenorphine may be reluctant to accept patients with OUD due to from their practice partners.
Treatment of OUD, and buprenorphine treatment specifically, reflect racial and socioeconomic healthcare disparities. White people with OUD are to receive buprenorphine treatment than Black or Hispanic people, even though the latter groups have seen in deaths from opioids. also are more likely to receive buprenorphine even though people who are uninsured or on Medicaid are to have OUD. Prescribing differences may be rooted in beliefs that those minority groups and poorer people are more likely to misuse buprenorphine, but our study found no differences in buprenorphine misuse by race and ethnicity or by health insurance status.
A factor that we did find to be associated with buprenorphine misuse, specifically among people with OUD, was whether they lived in a city. Those living in more rural areas were more likely than their urban counterparts to misuse buprenorphine. Given the and the slower increase in waivered clinicians in rural areas, this doesn't come as a surprise -- and again, it suggests the need for improving access to this effective OUD treatment in rural communities. Besides the recent relaxation of training and other certification requirements, developing and enhancing technologies and services needed for expanding access to telehealth could help achieve this goal.
It is crucial to overcome infrastructural barriers to wider utilization of medications for OUD and to break down the surrounding stigma, not only within the healthcare system but also within the justice system, where of all people incarcerated in the U.S. have a substance use disorder, often OUD.
Buprenorphine has enabled thousands of people with OUD to lead healthy lives and recover from addiction, but many more could benefit. Despite concerns about safety and diversion risk in media reports about buprenorphine, previous research has generally shown that diversion of this drug is much less of a concern than lack of access to it. Also, because it is a partial rather than full agonist at the mu opioid receptor, there is a ceiling effect that makes overdose relatively less likely with buprenorphine than with other opioid drugs. Compared to other prescription opioids, when buprenorphine is misused by people with OUD, it is likely to be misused to self-treat the craving and withdrawal symptoms that otherwise may drive them to seek far more dangerous illicit opioids.
Our results highlight the urgent need to expand access to buprenorphine treatment for OUD and to improve pain management, while continuing to monitor and reduce buprenorphine misuse. Misuse is not a reason to withhold or avoid treatment with buprenorphine. Buprenorphine treatment for OUD needs to be expanded.
is the Deputy Director of the National Institute on Drug Abuse at NIH.