Alleviation of Opioid Withdrawal Symptoms Primary Driver of Illicit Buprenorphine Use

Nancy A. Melville

December 10, 2009

December 10, 2009 (Los Angeles, California) — Illicit use of the opioid treatment drug buprenorphine is believed by some to be driven by a desire for a euphoric high, but the much more common motivation behind illicit use of the drug is to self-treat for opioid withdrawal symptoms and cravings, according to a study presented here at the American Academy of Addiction Psychiatry 20th Annual Meeting & Symposium.

Reports of increasing illicit use of buprenorphine have raised concerns of diversion of the drug for euphoria-seeking purposes and have even prompted some to label Suboxone — a combination of buprenorphine and naloxone — a "street drug."

However, lead author Zev Schuman-Olivier, MD, a clinical fellow in psychiatry at the Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, said he is skeptical of the assessment and suspects that the reasons for the illicit use are not recreational.

"I question whether the street abuse is as bad as some suggest it is,” Dr. Schuman-Olivier said. “There have been some overdoses, but they usually are in combination with other drugs and IV [intravenous] use," he told Medscape Psychiatry.

He speculated that the drug’s primary value in illicit use is for substance abusers in the self-treatment of issues ranging from withdrawal symptoms to pain.

"Self-treatment is not a term that’s in the literature right now in regard to buprenorphine," he said. "But we define it as any attempt to provide an appropriate therapeutic strategy to oneself in the absence of professional advice or consent."

With illicit buprenorphine use, self-treatment is likely addressing 3 broad categories, said Dr. Shuman-Olivier. The first is to treat opiate-dependent withdrawal symptoms and eliminate cravings; the second, to treat psychiatric symptoms associated with the dependency, including anxiety, depression, anger, or restlessness; and the third, to address physical pain.

To evaluate the issue, 78 patients were enrolled in an outpatient-based opioid treatment program sequential admission study, with 56% of the patients being new intakes who were enrolled before receiving a buprenorphine prescription and 44% already receiving a prescription.

All subjects underwent regular urine screening. In addition, at intake and 3-month follow-up, participants completed an illicit buprenorphine use questionnaire, a buprenorphine beliefs and behaviors questionnaire, and the Beck Depression Inventory.

Few Use Drug to Get High

At 90 days 49% of participants reported illicit buprenorphine use, including 61% of the new intakes and 32% of existing patients.

As many as 92% of the group as a whole reported using buprenorphine to reduce cravings, with 78% using the drug to prevent withdrawal symptoms and just 3.8% reporting that they used the drug to get high.

Responses from illicit users of the drug differed significantly from licit users. Ninety percent of illicit users reported that they used the drug to prevent withdrawal symptoms compared with 68% of licit users (P < .05).

Among illicit users, 47% reported using the drug to reduce pain vs 15% of licit users (P < .01), 40% of illicit users took the drug to treat depression vs 20% among licit users (P = .05), and 29% of illicit users took the drug to save money compared with 8% of licit users (P < .05).

By the end of the 3-month follow-up assessment, illicit buprenorphine use decreased by 70% (P < .05), and those who reported illicit use of the drug were more likely than licit users to report using it to reduce pain or to treat depression. However, illicit users were not more likely than licit users to use the drug to treat symptoms of anxiety.

"We found that illicit buprenorphine users reported using the drug to prevent withdrawal symptoms even more than licit users," said Dr. Shuman-Olivier. "What this says to me is that people are potentially self-treating their opiate-dependent symptoms, and the longer they are in treatment with a legal prescription, the more their illicit use declines."

Compelling Findings

The findings regarding illicit use to treat depression and pain were particularly compelling, he added.

"The illicit users were nearly 3 times more likely to report using the drug to control pain than nonillicit users, and 2 times as many illicit users reported that they used it to treat depression than nonillicit users."

"The results make sense considering the pharmacologic mechanisms of buprenorphine, which was originally developed for pain and was only later tested for treatment of depression and opioid dependence," Dr. Schuman-Olivier noted.

The findings should help clear up misconceptions about illicit buprenorphine and help prevent misdirected treatment of such users.

"The demand for illicit buprenorphine is driven primarily by people trying to avoid withdrawal and reduce cravings and not to obtain euphoric effect," Dr. Schuman-Olivier said. “And it therefore can and should be distinguished from illegally prescribed buprenorphine diversion, which is a criminal activity.

"Discussion of self-treatment issues for opioid withdrawal symptoms, depression, and pain is very important at patient intake."

Concerns Unfounded?

John Renner, MD, associate chief of psychiatry at the VA Boston Health Care System in Massachusetts, says the findings are particularly important as concerns — and apparent misconceptions — about illicit buprenorphine increase.

"The question of diversion around buprenorphine has been a growing concern, and I think some people, probably more on the law enforcement side, are suggesting there’s a problem in terms of people using the drug to get high.

"But these data suggest that very few people are looking for buprenorphine for a euphoric effect, and that’s certainly consistent with what I’ve been hearing, anecdotally, from my patients," he told Medscape Psychiatry.

Dr. Renner added that the data help explain an issue that has largely been overlooked with buprenorphine use.

"This is the first paper that I have ever seen that really attempted to look at what was really going on and what the behavior and motivation of the individuals using the buprenorphine really is," he said.

"The bottom line, from my perspective, is that when we talk about diversion with buprenorphine, for the vast amount of patients, what’s going on is either self-medication for withdrawal symptoms or efforts to control their own urges and avoid using more harmful or dangerous drugs. Buprenorphine is simply not a drug you would choose to use if you wanted to get high."

Dr. Schuman-Olivier and Dr. Renner have disclosed no relevant financial relationships.

American Academy of Addiction Psychiatry (AAAP) 20th Annual Meeting & Symposium: Abstract. Presented December 6, 2009.

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