Is Buprenorphine Diversion a Risk?

Many people—providers and patients alike—may be concerned about the risk of buprenorphine diversion and misuse. However, buprenorphine diversion is uncommon, and the rate of diversion went down once treatment access was expanded through telemedicine. Plus, the benefits of buprenorphine, especially in its ability to combat the opioid epidemic, greatly outweigh the risks.

What is Buprenorphine Diversion?

Diversion is the unauthorized or illegal rerouting of a prescription drug, such as buprenorphine, to someone for whom the medication was not intended.

This can happen voluntarily or involuntarily, and it can happen with or without the exchange of money or other services. For example, someone may give their friend a Suboxone pill to deal with their withdrawal symptoms or someone may sell their Suboxone strips on the street.

What is Buprenorphine Misuse?

Misuse involves taking medication like buprenorphine in a way that wasn’t prescribed by a healthcare professional.

For example, taking more than the prescribed dose, or injecting/smoking/snorting a medication intended for oral use.

Certain substances and prescription drugs in the US are “controlled” because of the concern around diversion and misuse. Buprenorphine is designated as a Schedule III Controlled Substance, meaning it can be misused and abused.

Consequently, anytime there is buprenorphine diversion, there is also misuse because the end-consumer is taking a medication that was not prescribed to them.

Are Buprenorphine Misuse and Diversion Significant Risks?

Well, it’s a nuanced answer, and the relative context matters.

When it comes to diversion, generally, prescription medications—not just buprenorphine—are frequently diverted. Most commonly, allergy medications, antibiotics, and pain relievers are the medications that are diverted.

Millions of people in the US report taking a medication that was not prescribed to them–whether it was shared, borrowed, or bought. In fact, studies generally show that 25% of people have taken medications that were not prescribed to them. So to be clear, diversion of prescribed medications is not just an issue for people with substance use disorders or addictions.

Now let’s talk about buprenorphine. Yes, buprenorphine can be diverted and misused. Someone could take a higher dose than prescribed. They could take it via another route like swallowing it, snorting it, smoking it, or injecting it since it’s a sublingual medication. And of course, someone could take buprenorphine that wasn’t prescribed to them.

What the Research Says

Regarding buprenorphine diversion, studies show that non-prescribed use of buprenorphine is often done due to gaps in addiction treatment services, not to misuse or abuse the drug. 

Non-prescribed buprenorphine use is most often taken not “to get high” but to stop opioid withdrawal symptoms, to self-taper, or to self-treat their opioid use disorder because they couldn’t get seen by a provider to get a legal prescription. 

In fact, there was one study out of Ohio showing that increased diversion of buprenorphine actually decreased overdoses. Essentially, the more non-prescribed buprenorphine was used, the less fentanyl or heroin was being used, leading to fewer overdoses. 

Another study showed that using non-prescribed buprenorphine actually increased people’s willingness to start and remain in opioid addiction treatment because after trying it, they realized how helpful it was so they got into a formal treatment program.

Buprenorphine Helps Combat the Fentanyl Epidemic

Buprenorphine is an opioid agonist, also known as an opioid receptor activator, and it could cause overdose and death in the wrong hands. When combined with other sedatives and respiratory depressants, there is always the risk of adverse events like overdose. 

But this is why context matters. And the context is the fentanyl epidemic. The alternative is often illicit opioid use. The fact is buprenorphine is a partial opioid agonist, unlike all the dangerous full opioid agonists available on the street. It has much less sedating and respiratory depressing effects. It is far less likely to overdose on buprenorphine than heroin, hydrocodone, oxycodone, morphine, fentanyl, and methadone.

At the end of the day, one of the most important goals for us in the healthcare profession is to do no harm. We don’t want to contribute to people dying. We don’t want to worsen an opioid epidemic that was already caused by greedy drug companies, ignorant or unethical prescribers, pharmacies, criminal organizations and beyond. We don’t want to contribute to criminal activity on the black market, nor do we condone it. And the bottom line is that buprenorphine (prescribed or not) is safer for people with opioid addiction.

The Main Takeaways

Ok, let’s recap:

1. Buprenorphine diversion and misuse do happen, just like for other prescription medications.
2. When it’s diverted and misused, it’s typically not for its euphoric effects–it’s for managing withdrawal or self-treating opioid use disorder. 
3. The dangers of diverted buprenorphine are overstated —buprenorphine-related deaths usually have other risky medications on board and one study showed diversion actually reduces overdoses and deaths.
4. Buprenorphine diversion is also related to the lack of access to addiction treatment in the health care system. (If it was more available, there would be less diversion.)
5. Buprenorphine’s euphoric effects are exaggerated. (It’s analogous to the stimulant effects of a giant energy drink or a quadruple espresso to a small cup of green tea.)

Contextualizing the Risk and Concern

I am not condoning the illegal diversion or nonprescribed use or misuse of buprenorphine. But from my experience working with my patients, and the myriad research out there, our concern for buprenorphine diversion has gotten out of hand.

We are making access to this life-saving medication way too difficult. I think about all the pharmacies that have refused to fill buprenorphine prescriptions I’ve sent, my patients telling me about all the pharmacists and pharmacy techs who have treated them with stigmatizing disdain and prejudice and the health insurance companies that make them fill out prior authorizations or refuse to fill buprenorphine monoproduct. It is deeply upsetting that there are laws in certain states restricting how healthcare professionals can prescribe buprenorphine, when these legislators haven’t spent all the years that we have spent training in clinics and hospitals, studying the science and research literature, and all the exams and certifications we’ve completed to do what we do.

At the end of the day, only 10% to 15% of people with OUD are actually getting medication for opioid use disorder (MOUD). This isn’t because 85% to 90% of people don’t want treatment. Part of it is that it’s so hard to access buprenorphine. And one major reason for that is this fear of diversion and misuse. 

I hope you can now see that by helping people access this medication with less fear and more compassion, you can be doing your part in helping someone start and sustain their recovery journeys.