Study highlights threat of dual use of buprenorphine and other opioids

Nearly half of a large group of patients receiving buprenorphine treatment continued to fill opioid prescriptions during therapy, and nearly 70% used prescription opioids after treatment, according to a new study. The 2010-2012 analysis, based on pharmacy records from more than 38,000 patients, did not include any possible use of non-prescription opioids in its calculations.

The study's striking findings reveal a glaring need for more resources to address continued use of opioids during and after treatment, as well as better monitoring of prescription opioids, according to the study's co-authors.

G. Caleb Alexander, MD, associate professor of epidemiology at the Johns Hopkins Bloomberg School of Public Health and co-author of the study, says the research examined whether individuals receiving buprenorphine treatment were also filling prescriptions for other opioids during or immediately after receiving treatment. “We found a remarkably high proportion of individuals were doing so, highlighting the need for greater resources devoted to medication-assisted treatment, a common, evidence-based tool to address the opioid epidemic,” says Alexander, who also co-directs the Bloomberg School's Center for Drug Safety and Effectiveness.

The patient cohort was identified using a pharmacy database, and the researchers say they do not know precisely what percentage of the patients were using buprenorphine for opioid dependence and how many were using it for pain.

Details of study

The study paper, published in Addiction, examined records of just over 38,000 new buprenorphine users across 11 states who received treatment between 2010 and 2012. Researchers reviewed how many of them filled opioid prescriptions between 2006 and 2013, focusing on any non-buprenorphine opioid prescriptions that were issued before, during and after an individual’s treatment.

Overall, 43% of patients filled an opioid prescription during buprenorphine treatment, and 67% filled an opioid prescription within the first year after their treatment ended. The researchers were not able to estimate other sources of opioid use, such as non-prescription use of opioid medications or use of heroin, so the figures likely underestimate the extent of concurrent or post-treatment opioid use.

“The statistics are startling, but are consistent with studies of patients treated with methadone showing that many patients resume opioid use after treatment,” Alexander said last month in a news release announcing the study's results.

Matthew Daubresse, a doctoral student in the Department of Epidemiology at the Bloomberg School and co-author of the report, says the study highlights the need to find better ways to keep patients engaged in long-term treatment. While overdose is one aspect of concern with dual use of buprenorphine and other opioids, long-term recovery is also at stake.

“It’s not about the risks alone, but both the risks and the benefits,” Daubresse tells Addiction Professional. “I think the real question is whether there is a favorable risk/benefit balance to justify the use of other opioids among patients receiving buprenorphine. We can’t identify the exact proportion of patients on buprenorphine for pain, but for these patients, it may be less concerning to see combined buprenorphine and other opioid use.”

Additional opioid use during buprenorphine treatment may be clinically justified in patients with high rates of chronic pain, according to the study, particularly in an effort to avoid forcing these patients to turn to illicit drug use or abuse of other prescriptions in order to get relief. However, opioid use during buprenorphine treatment may not provide the desired relief either, Daubresse points out.

“For these patients, buprenorphine is going to make the other opioids less effective since it occupies the same receptors in the brain,” he says.

Buprenorphine works by providing a low opioid dose—just enough to reduce physical withdrawal symptoms. It is weaker than other opioids, such as heroin or oxycodone, and is a shorter-acting alternative to methadone.

“The majority of buprenorphine users are receiving it for opioid use disorder,” Daubresse says. “For these patients, the question is why are they receiving other prescription opioids and how does this impact their chances of recovery?”

Gaps in monitoring

Prescription drug monitoring programs (PDMPs) should provide some safeguard against combined buprenorphine and opioid use, but clinic-based opioid treatment programs (OTPs) and office-based buprenorphine prescribers are not currently required to check PDMPs in most states, despite a recommendation to do so by the American Association for the Treatment of Opioid Dependence (AATOD). Also, according to the National Alliance for Model State Drug Laws, buprenorphine prescriptions written for opioid use disorder are not required to be filed with a PDMP unless the order was filled with a paper prescription at a pharmacy, due in part to privacy regulations.

Daubresse says other strategies to avoid dual use could include improving coordination between behavioral and medical healthcare systems, as well as developing guidelines for pain management in patients receiving buprenorphine or other types of medication-assisted therapy.

“PDMP design varies across states and the success of a PDMP depends on who can access [it] as well as the ease and frequency of use,” Daubresse says. “PDMPs don’t work if clinicians don’t use them. Although many states have PDMPs, not all require physicians to check a patient’s prescription history before prescribing an opioid.”

Daubresse says a 2014 Johns Hopkins study revealed that while 72% of physicians were aware of their state’s PDMP, only 53% had used the resource.

Daubresse says he hopes the new report will provide motivation to delegate additional resources to support patients engaged in stable, ongoing medication treatment, and to provide professional education and support to physicians and addiction professionals. “We must improve coordination between medical and behavioral healthcare systems, so that physicians can provide safe and effective pain management for patients receiving medication-assisted treatment,” he says.