Outpatient opioid addiction treatment with sublingual buprenorphine pharmacotherapy has rapidly expanded in the United States and abroad, and, with this increase in medication availability, there have been increasing concerns about its diversion, misuse, and related harms. This narrative review defines the behaviors of diversion and misuse, examines how the pharmacology of buprenorphine alone and in combination with naloxone influence its abuse liability, and describes the epidemiological data on buprenorphine diversion and intravenous misuse, risk factors for its intravenous misuse, and the unintended consequences of misuse and diversion. Physician practices to prevent, screen for, and therapeutically respond to these behaviors, which are a form of medication nonadherence, are discussed, and gaps in knowledge are identified. Outpatient opioid addiction treatment with sublingual buprenorphine pharmacotherapy experiences from other countries that have varied health care systems, public policies, and access to addiction treatment are shared to make clear that diversion and misuse occur across the world in various contexts, for many different reasons, and are not limited to buprenorphine. Comparisons are made with other opioids with known abuse liability and medications with no known abuse. The objective was to facilitate understanding of diversion and misuse so that all factors influencing their expression (patient and provider characteristics and public policy) can be appreciated within a framework that also recognizes the benefits of addiction treatment. With this comprehensive perspective, further careful work can help determine how to minimize these behaviors without eroding the current benefits realized through improved addiction treatment access and expansion.
From the Center on Drug and Alcohol Research (MRL, SLW), the College of Medicine Departments of Behavioral Science (MRL, SLW), Psychiatry (MRL, SLW), and Pharmacology (SLW), and the College of Pharmacy Department of Pharmaceutical Sciences (SLW), University of Kentucky, Lexington.
Send correspondence and reprint requests to Michelle R. Lofwall, MD, Departments of Behavioral Science and Psychiatry, Center on Drug and Alcohol Research, University of Kentucky College of Medicine, 515 Oldham Ct, Lexington, KY 40502. E-mail: firstname.lastname@example.org.
Supported by, in part, National Institute on Drug Abuse grant R01DA016718 and R01DA033932 (SLW). Drs Lofwall and Walsh are on the steering committee for the European Quality Patient Care Network that is part of PCM Scientific (a British educational company) and have received payment from PCM Scientific for developing educational materials and giving educational talks. In addition, Dr Walsh has received payment for chairing and organizing a 3-day conference supported by PCM Scientific through an unrestricted grant from Reckitt Benckiser. Dr Lofwall has been a consultant for Orexo Pharmaceuticals and has had research contract funding from CRS Associates in the past. Dr Walsh has received payment for service on a Safety Advisory Board for MEDA Pharmaceuticals and for service on the American Society of Addiction Medicine Board Exam Committee. She has served as a consultant for DemeRx, Eli Lilly and Co, KSI Consulting, MedSignals, and Cephalon. She has received honoraria and travel reimbursement for participating in educational meetings for physicians through Real Science Communications and the University of Kentucky.
The authors declare no conflicts of interest.
Received November 26, 2013
Accepted March 30, 2014