A case of buprenorphine abuse

Patterns of use and adverse events reported among persons who regularly inject buprenorphine: a systematic review

Background and Aims

Given the ongoing opioid crisis, novel interventions to treat severe opioid use disorder (OUD) are urgently needed. Injectable opioid agonist therapy (iOAT) with diacetylmorphine or hydromorphone is effective for the treatment of severe, treatment-refractory OUD, however barriers to implementation persist. Intravenous buprenorphine for the treatment of OUD (BUP iOAT) has several possible advantages over traditional iOAT, including a safety profile that might enable take-home dosing. We aimed to characterize injecting practices among real-world populations of persons who regularly inject buprenorphine, as well as associated adverse events reported in order to inform a possible future BUP iOAT intervention.

Methods

We conducted a systematic review. We searched MEDLINE, EMBASE, and PsycINFO from inception through July 2020 and used backwards citation screening to search for publications reporting on dose, frequency among persons who regularly inject the drug, or adverse events associated with intravenous use of buprenorphine. The review was limited to English language publications and there was no limitation on study type. Study quality and risk of bias was assessed using the Mixed Methods Appraisal Tool. Narrative synthesis was used in reporting the results.

Results

Eighty-eight studies were included in our review. Regular injection of buprenorphine was identified across diverse settings world-wide. Daily dose of oral buprenorphine injected was < 1–12 mg. Frequency of injection was 0–10 times daily. Adverse events could be characterized as known side effects of opioids/buprenorphine or injection-related complications. Most studies were deemed to be of low quality.

Conclusions

Extramedical, intravenous use of buprenorphine, continues to be documented. BUP iOAT may be feasible and results may inform the development of a study to test the efficacy and safety of such an intervention. Future work should also examine acceptability among people with severe OUD in North America. Our review was limited by the quality of included studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12954-022-00695-5.

Exploring prison buprenorphine misuse in the United Kingdom: a qualitative study of former prisoners

The United Kingdom Ministry of Justice recently highlighted the extent of buprenorphine (Subutex) misuse in English andWelsh prisons, naming it the third most misused drug overall. Yet little is known regarding how illicit buprenorphine is obtained in prison and what influences prisoners to use it. Qualitative research was used to explore prison drug using practices. Thirty men who were former prisoners with a history of injecting drug use were interviewed in depth about their illicit prison drug use, including buprenorphine. Interviews were conducted over 18 months, from August 2006 to January 2008 and were analysed using Framework. The misuse of Subutex by snorting emerged as a significant theme. Accounts suggested that the diversion of prison prescribed Subutex was widespread and prisoners used various tactics to obtain the medication. Various complex and interlinked reasons were given to explain why Subutex was snorted in prison. The main motivation for snorting was to experience a prolonged euphoric opiate effect, believed to help to combat the boredom of being in prison. The price of illicit Subutex in prison was linked to its availability, but it was generally cheaper than heroin, thus contributing to its use. Participants'narratives identified the belief that snorting Subutex in prison was not risk free, but risks were lower than continuing to use other drugs, particularly injecting illicit opiates. The implications of prison Subutex misuse for prisoners, prison medical services, commissioners, and prescribing policy and practice are discussed.

Buprenorphine misuse among heroin and amphetamine users in Malmo, Sweden: purpose of misuse and route of administration

Buprenorphine misuse by injecting drug users was assessed in a survey of 350 needle exchangers, either amphetamine (57%) or heroin users (42%). 89% of heroin users and 24% of amphetamine users reported using buprenorphine at some time during the previous year. Most users reported illicit acquisition. Among illicit users, 87% of heroin users reported intake for withdrawal treatment or self-detoxification, and 11% for euphoria. Euphoria seeking was more common among amphetamine users (62%, p < 0.001). Intravenous misuse was reported by 43% of illicit users, and snorting by 29%. Sole sublingual intake was more common among heroin users than among amphetamine users (46 vs. 20%, p < 0.05), and less common among patients reporting euphoria seeking (20 vs. 46%, p < 0.05).

Buprenorphine-containing treatments: place in the management of opioid addiction

Although the synthetic opioid buprenorphine has been available clinically for almost 30 years, its use has only recently become much more widespread for the treatment of opioid addiction. The pharmacodynamic and pharmacokinetic profiles of buprenorphine make it unique in the armamentarium of drugs for the treatment of opioid addiction. Buprenorphine has partial mu-opioid receptor agonist activity and is a kappa-opioid receptor antagonist; hence, it can substitute for other micro-opioid receptor agonists, yet is less apt to produce overdose reactions or dysphoria. On the other hand, buprenorphine can block the effects of opioids such as heroin (diamorphine) and morphine, and can even precipitate withdrawal in individuals physically dependent upon these drugs. Buprenorphine has significant sublingual bioavailability and a long half-life, making administration on a less than daily basis possible. Furthermore, its discontinuation is associated with only a mild withdrawal syndrome. Clinical trials have demonstrated that sublingual buprenorphine is effective in both maintenance therapy and detoxification of individuals addicted to opioids. The introduction of a sublingual formulation combining naloxone with buprenorphine further reduces the risk of diversion to illicit intravenous use. Because of its relative safety and lower risk of illegal diversion, buprenorphine has been made available in several countries for treating opioid addiction in the private office setting, greatly enhancing treatment options for this condition.

Buprenorphine diversion and injection in Melbourne, Australia: an emerging issue?

AIMS

To examine indicators of buprenorphine diversion and injection among injecting drug users in Melbourne, Australia and to determine the factors associated with buprenorphine injection.

DESIGN

Melbourne arm of the 2002 Illicit Drug Reporting System (IDRS) cross-sectional study.

SETTING

Five Needle and Syringe Programme sites in Melbourne, Australia.

PARTICIPANTS

A total of 156 current injecting drug users (IDU). Study eligibility criteria were at least monthly injection during the previous 6 months, and Melbourne residence for at least the preceding 12 months.

MEASUREMENTS

Structured questionnaire covering demographic characteristics, drug use history, the price, purity and availability of drugs, criminal activity, risk-taking behaviours, health-related issues and general drug use trends.

FINDINGS

Over one-third (37%) of the study sample reported injecting buprenorphine in their life-time and 33% reported injecting the drug in the last 6 months. Recent buprenorphine injection was associated with the injection of other drug types (i.e. polydrug injectors), opioid substitution treatment, injection-related health problems and involvement in crime. Almost half (47%) of those who reported recent buprenorphine injection reported obtaining the drug illicitly at least once during that time.

CONCLUSIONS

Given the significant health harms associated with intravenous buprenorphine use (e.g. vein damage, abscesses and infections, precipitated withdrawal, blood-borne virus transmission, hospitalization and death), routine monitoring of the misuse of buprenorphine in Melbourne is warranted. These results suggest the need for development of effective countermeasures to address diversion and injection of buprenorphine in this setting.

Controlled trial of maintenance treatment of intravenous buprenorphine dependence

BACKGROUND

Buprenorphine dependence is a relatively novel addiction.

AIMS

To compare the treatment outcome in three groups over 12-weeks of treatment.

METHODS

Two hundred and four intravenous (i.v.)-buprenorphine-dependent patients were randomised into three groups. Subjects received 50 mg oral methadone tablet, or 5 mg sublingual buprenorphine tablet, or 50 mg oral naltrexone, and a weekly 30-minute clinical counselling session.

RESULTS

The majority (80%) had a history of opium or heroin dependency before they were introduced to i.v. buprenorphine. The main source of buprenorphine for misusers was street sale (91%). The mean duration of buprenorphine dependence was 1.9 years and the mean dose per day was 3.9 ampoules (1 ampoule contains 0.3 mg of buprenorphine in 1 ml). Overall 59% of the patients completed the 12-week study. Retention in the 50 mg methadone group was significantly better than the 5 mg dose buprenorphine group (p=0.001) and the 50 mg dose naltrexone group (p=0.000). Retention in the 5 mg buprenorphine group was significantly better than the 50 mg naltrexone dose group (p=0.000).

CONCLUSIONS

These results support the efficacy and safety of oral methadone and sublingual buprenorphine tablets for injection buprenorphine-dependent patients.

Controlled, randomized trial in maintenance treatment of intravenous buprenorphine dependence with naltrexone, methadone or buprenorphine: a novel study

AIMS

To test the effect of a 50-mg day-1 dose of naltrexone in the maintenance treatment of intravenous-buprenorphine dependence in comparison with a 50-mg day-1 dose of methadone and also a 5-mg day-1 dose of buprenorphine over a 24-week treatment period.

PARTICIPANTS

Two hundred and four intravenous-buprenorphine-dependent patients who met the DSM-IV criteria for opioid dependence were randomized to three equal groups and were treated in a clinic in Iran where they were also offered a weekly 0.5-h counselling session, in 2002.

FINDINGS

The mean age was 31.2 years (range 17-53). The majority [63.2%] was between 20 and 34 years of age. The educational level of most of them [55.4%] was between 6 and 12 years of study. Completion rates by groups were 83.8% for the 50-mg dose methadone group, 58.8% for the 5-mg dose buprenorphine group and 20.6% for the 50-mg dose naltrexone group (P = 0.000). Retention in the 50-mg methadone group was significantly better than in the 5-mg dose buprenorphine group (P = 0.001) and the 50-mg dose naltrexone group (P = 0.000). Retention in the 5-mg buprenorphine group was significantly better than in the 50-mg naltrexone dose group (P = 0.000).

CONCLUSIONS

Evaluation of the Iranian experience on this subject may be useful for other countries.

Buprenorphine: an analgesic with an expanding role in the treatment of opioid addiction

Buprenorphine, a long-acting opioid with both agonist and antagonist properties, binds to mu-opioid (OP(3)), kappa-opioid (OP(2)), delta-opioid (OP(1)), and nociceptin (ORL-1) receptors. Its actions at these receptors have not been completely characterized, although buprenorphine is generally regarded as a mu-opioid receptor partial agonist and a kappa-opioid receptor antagonist. Its pharmacology is further complicated by an active metabolite, norbuprenorphine. Although buprenorphine can be used as an analgesic agent, it is of greater importance in the treatment of opioid abuse. Because of its partial agonist activity at mu-opioid receptors and its long half-life, buprenorphine has proven to be an excellent alternative to methadone for either maintenance therapy or detoxification of the opioid addict. Although buprenorphine may ultimately prove to be superior to methadone in the maintenance of the pregnant addict, its effects on the developing fetus must be carefully evaluated.

Buprenorphine: blending practice and research

Although pharmacotherapy has been a mainstay in opiate addiction, not much research in the development of new opiate medications has been translated into clinical practice. In part, this is because opiate pharmacotherapy has not been an integral element of mainstream medical practice and because new medications developed by research are not available to clinicians. All that will change with the availability of buprenorphine for addiction treatment. For the first time in nearly a century, clinicians will be able to treat opiate addicts in the general medical setting, in the same manner they treat other patients. The unique pharmacological properties of buprenorphine, with its high patient acceptance, favorable safety profile, and ease of clinical administration, should facilitate its clinical integration. However, successful implementation will require changes in the understanding and attitude of clinicians, policymakers, and society.

An exploratory study of buprenorphine use in Bangladesh: a note

A pilot study was carried out in Bangladesh during August and September, 1995, using a "snowball" technique with 30 male multiple drug users in order to investigate buprenorphine use, characteristics of the users, their reasons for its use and the drug's effects.

Buprenorphine: "field trials" of a new drug

Buprenorphine is being introduced as a new treatment drug for narcotics addiction in the United States. The authors were asked by the National Institute on Drug Abuse to conduct a field trial to determine if buprenorphine might play a role in street markets. Because no street use of the drug existed in the United States, the authors used three sources of information: (a) "street readings" of clinical studies, (b) Internet discussion lists, and (c) research in other countries. By using an emergent style of analysis that relies on replication of patterns across disparate data sources, it was determined that buprenorphine has desirable characteristics from a street addict point of view. An evaluation of the field trial 5 years later evaluates its accuracy.

Improving the quality of substance dependency treatment with pharmacotherapy

This article provides an overview of current pharmacological treatments for alcohol, opioid, cocaine, and nicotine use disorders. Guidelines for a "patient-treatment" matching framework to physicians working with various "substance-abusing" patients are presented, as well as recommendations regarding when to initiate and discontinue pharmacotherapy. Standard and newer pharmacological treatments for substance dependence are reviewed, as well as therapies that may be especially useful when treating the patient with comorbid substance dependency and psychiatric disorders. To maximize the therapeutic benefits of substance dependency treatment, patients should be individually assessed and provided adjunctive medications as clinically indicated. Specific areas for future laboratory and/or clinical research are recommended.

Screening for drugs of abuse (II): Cannabinoids, lysergic acid diethylamide, buprenorphine, methadone, barbiturates, benzodiazepines and other drugs

Requirements for the provision of an efficient and reliable service for drugs of abuse screening in urine have been summarized in Part I of this review. The requirements included rapid turn-around times, good communications between requesting clinicians and the laboratory, and participation in quality assessment schemes. In addition, the need for checking/confirmation of positive results obtained for preliminary screening methods was stressed. This aspect of the service has assumed even greater importance with widespread use of dip-stick technology and the increasing number of reasons for which drug screening is performed. Many of these additional uses of drug screening have possible serious legal implications, for example, screening school pupils, professional footballers, parents involved in child custody cases, persons applying for renewal of a driving licence after disqualification for a drug-related offence, doctors seeking re-registration after removal for drug abuse, and checking for compliance with terms of probation orders; as well as pre-employment screening and work-place testing. In many cases these requests will be received from a general practitioner or drug clinic with no indication of the reason for which testing has been requested. This also raises the serious problems of a chain of custody, provision of two samples, stability of samples, and secure and lengthy storage of samples in the laboratory-samples may be requested by legal authorities several months after the initial testing. The need for confirmation of positive results is now widely accepted but it may be equally important to confirm unexpected negative results. Failure to detect the presence of maintenance drugs may lead to the patient being discharged from a drug treatment clinic and, if attendance at the clinic is one of the terms of continued employment, to dismissal. It seems likely that increasing abuse of drugs and the efforts of regulatory authorities to control this, will lead to the manufacture of more designer drugs. Production of substituted phenethylamines was facilitated by the drug makers' cook book, 'PIHKAL' (Phenethylamines I Have Known And Loved) by Dr Alexander Shulgin and Ann Shulgin, and production of substituted tryptamines is promised in their next book, TIHKAL. Looking to the future, laboratories will need to ensure that they can detect and quantitate an ever-increasing number of drugs and related substances. The question of confidence in results of drugs of abuse testing raised in 1993 by Watson has assumed even greater importance as a result of attention focused on the OJ Simpson trial in Los Angeles. Toxicological investigations are likely to be challenged more frequently in the future. Even if analyses have been performed by GC-MS, there is a need to establish the level of match between the spectrum of the unknown substance and a library spectrum which is considered acceptable for legal purposes. It will also be essential to ensure that computer libraries contain spectra for all substances likely to be encountered in drugs of abuse screening.

Naloxone-induced withdrawal in patients with buprenorphine dependence

Naloxone-induced withdrawal was studied in seven patients currently dependent only on injecting buprenorphine, within 3 to 6 hours of their last dose. Withdrawal severity began to rise from 5 minutes and reached a peak at 60 minutes after 1.2 mg naloxone given intravenously. The mean withdrawal severity score was significantly higher at 30, 60 and 90 minutes compared to the baseline. The most frequent withdrawal signs and symptoms were mydriasis, systolic hypertension, tachypnoea, muscle pains, yawning, anxiety, restlessness and craving.

Alternate-day dosing during buprenorphine treatment of opioid dependence

Thirteen opioid-dependent outpatients participated in a double-blind, placebo-controlled, crossover trial. Twenty-one days of daily sublingual buprenorphine administration were compared to 21-days of alternate-day buprenorphine administration where patients received twice their daily maintenance dose every other day with placebo on the interposed day. Observer- and subject-rated measures of opioid agonist and withdrawal effects, pupillary diameter, and dose identifications were collected daily. Ten subjects (77%) completed the study (n = 6, 4 mg/70 kg; n = 4, 8 mg/70 kg); 8 subjects (62%) participated in a second crossover. Sixteen of seventeen measures of opioid agonist and withdrawal effects obtained during alternate-day administration did not differ significantly from those obtained during daily dosing in the ten subjects completing the study. The only significant difference observed was in subject-rated agonist effects, which were significantly lower during alternate-day than daily administration. No differences were observed between treatments on any measure for the eight subjects completing a second crossover. These data suggest that buprenorphine can be administered safely every 48 hours by doubling the maintenance dose. This alternate-day schedule permits patients to attend the clinic less frequently without the risk of diversion associated with take-home doses, may be cost-effective for programs, and may be useful in settings in which travel to the clinic is a barrier to treatment.

Consumption of buprenorphine and other drugs among heroin addicts under ambulatory treatment: results from cross-sectional studies in 1988 and 1990

We assessed the prevalence of consumption of buprenorphine and other drugs among heroin addicts under ambulatory treatment in two cross-sectional studies conducted in 1988 (188 subjects) and in 1990 (197 subjects). Patients were enrolled in one of three different programmes: methadone maintenance programme (MMP), antagonist maintenance programme (AMP) and drug-free programme (DFP). Information given by participants was compared with results of urine screening for drugs. Urine samples were tested using enzyme immunoassay for the detection of heroin, cocaine, dextropropoxyphene, cannabis and benzodiazepines, and radioimmunoassay for buprenorphine. Sixty-six percent of patients in 1988 and 71% of patients in 1990 reported having consumed buprenorphine at some time during their history of drug dependence (period prevalence) and 5.9% and 6.1%, respectively, tested positive to the drug (point prevalence). In over 70% of these patients consumption was by the intravenous route. Consumption of cannabis, cocaine and benzodiazepines was also very high in the study population. Overall, patients in the DFP group consumed the largest number of the drugs tested, while those in the AMP group consumed the smallest number. Abuse of buprenorphine could be more widespread than previously reported.

Effects of buprenorphine on motility in chronically morphine treated rats

The effects of buprenorphine (0.01-0.1 mg/kg) on the activity of nondependent and morphine dependent rats (a 20 mg/kg dose for 28 days) were determined. In naive animals buprenorphine exhibited both depressive and stimulatory actions upon the motility of rats, as repeatedly described for morphine. When buprenorphine was administered to rats chronically treated with morphine, the depressive effect disappeared (cross-tolerance to the inhibitory action); on the contrary the excitatory effect was enhanced (cross-sensitization). The results are discussed in terms of cross-sensitization to the excitatory effects in morphine dependent animals as predictor of morphine-like addictive properties in humans.

Cases of buprenorphine abuse in India

Buprenorphine was introduced as a potent analgesic with low abuse potential. Reports of buprenorphine abuse by opiate abusers have accumulated over the years, highlighting its use as a cheap alternative to heroin. The lower potency compared with heroin is being compensated by using a cocktail of buprenorphine with benzodiazepines or cyclizine. This study of 18 cases seen over 3 years broadly confirms these findings. Four cases reported haematemesis during acute withdrawal, a symptom not reported in earlier studies.

Assessment and management of opioid withdrawal symptoms in buprenorphine-dependent subjects

The spontaneous physical dependence of buprenorphine was assessed in opioid addicts who switched from heroin to sublingual or intravenous buprenorphine. Twenty-two patients were randomly assigned to double-blind administration of methadone (n = 11) or placebo (n = 11) for 13 days after abrupt withdrawal of buprenorphine. Methadone was administered according to four pre-established dosing schedules depending on the previous amount of daily consumed buprenorphine. No methadone-treated patient required modification of the therapeutic regimen, whereas eight of eleven placebo-treated patients needed treatment with methadone. Buprenorphine withdrawal syndrome was of opioid type, began somewhat more slowly, and showed a peak until day 5. The occurrence, time-course and characteristics of buprenorphine withdrawal syndrome make it necessary to reconsider the abuse potential of this analgesic.

Buprenorphine abuse: report from India

Buprenorphine has been stated a drug of low abuse potential and often used therapeutically in the management of opiate addicts. An analysis of 2 1/2 years' experience of opiate addiction cases at a de-addition clinic revealed its increasing rate of abuse, especially as a substitute for heroin.

Opioid antagonist challenges in buprenorphine maintained patients

Following one month of sublingual buprenorphine treatment, 15 patients at either 2 mg (n = 7) or 3 mg (n = 8) were hospitalized and the buprenorphine was abruptly stopped by placebo substitution. On the morning following their last dose of buprenorphine, 10 patients were given 1 mg oral naltrexone and 5 were given 0.5 mg/kg intravenous naloxone in a double blind placebo controlled challenge. The naltrexone challenges produced no increase in opioid withdrawal symptoms, plasma MHPG levels, or blood pressure compared to placebo, while naloxone produced significant symptoms and blood pressure increases compared to placebo challenges.

Lephetamine abuse and dependence: clinical effects and withdrawal syndrome

Lephetamine (L-SPA) is a compound with central analgesic and anti-inflammatory action, recently reported to be abused in Italy. In this study, cases of L-SPA abuse were recorded. The survey included 15 patients who were assessed for effects caused by using L-SPA and induced by withdrawal. Moreover L-SPA was administered to 15 volunteers. L-SPA displayed effects partly similar to opiates and its withdrawal caused both subjective and objective symptoms. It is concluded that L-SPA exhibits abuse liability and dependence potential of a certain degree.