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January 30, 2023
4 min read
Source/Disclosures
Disclosures:
Tanz and Volkow report no relevant financial disclosures. Please see the study for all other authors’ relevant disclosures.
The proportion of buprenorphine-involved overdose deaths did not significantly increase after prescribing flexibilities were introduced in the beginning of the COVID-19 pandemic, according to recent findings published in JAMA Network Open.
Lauren J. Tanz, ScD, an epidemiologist at CDC’s National Center for Injury Prevention and Control and lead author of the study, and colleagues wrote that, despite its effectiveness, buprenorphine is underused in the treatment of opioid use disorder (OUD).
Data derived from: Tanz LJ, et al. JAMA Netw Open. 2023;doi:10.1001/jamanetworkopen.2022.51856.
However, the United States government offered prescribing flexibilities at the beginning of the pandemic to facilitate continued access to care for people with OUD.
“Recent studies have reported that clinicians have used these emergency authorizations to initiate and continue buprenorphine treatment during the COVID-19 pandemic and that patients have benefited,” they wrote. “However, questions remain about whether there was an increase in buprenorphine-involved overdose deaths following implementation of these new emergency authorizations that removed historical measures intended to reduce diversion and misuse of buprenorphine.”
The CDC estimates that 107,622 overdose deaths occurred in 2021, with about two-thirds of these attributed to the highly potent synthetic opioid fentanyl. The 2021 rates represented a nearly 15% jump from 2020 — the year that held the record for overdose deaths in 1 year — and experts are predicting higher rates in the years to come.
The benefits of providing medication for OUD are well-known, but many primary care physicians do not receive training on addiction and may be unfamiliar with how to treat patients. As a result, only 22% of those with OUD receive medications, according to a press release.
“Research has shown beyond a doubt that medications for opioid use disorder are overwhelmingly beneficial and can be lifesaving, yet they continue to be vastly underused,” Nora Volkow, MD, director of the National Institute on Drug Abuse and senior author of the study, said in the release. “Expanding more equitable access to these medications for people with substance use disorders is a critical part of our nation’s response to the overdose crisis. The findings from this study strengthen existing evidence suggesting that greater flexibility in prescribing may be one safe method for working toward this goal.”
For the cross-sectional study, Tanz, Volkow and colleagues analyzed data from the State Unintentional Drug Overdose Reporting System to assess overdose deaths in 46 states and Washington, D.C., from July 2019 to June 2021.
The researchers identified 89,111 overdose deaths during the study period, 74,474 of which involved opioids and 1,955 of which involved buprenorphine. Overall, buprenorphine-involved overdose deaths accounted for 2.6% of opioid-involved overdoses and 2.2% of total drug overdoses.
Although there was an overall increase in the proportion of monthly opioid-involved overdose deaths, the proportion involving buprenorphine did not, according to Tanz, Volkow and colleagues. More than 92% (95% CI, 91.5-93.7) of buprenorphine-involved overdose deaths also involved another drug compared with 67.2% of deaths involving other opioid-involved deaths.
In addition, compared with other opioid-involved overdose deaths, buprenorphine-related overdoses were more likely to involve anticonvulsants (18.6% vs. 5.4%), benzodiazepines (36.9% vs. 14.5%) and antidepressants (13.9% vs. 5.%), and were less like to involve fentanyl (50.2% vs. 85.3%).
“These findings help us better understand the circumstances of overdose deaths involving buprenorphine, which is crucial in our ability to inform policy, ensure safety, and improve clinical outcomes for people with substance use disorders,” Tanz said in the release. “It is important to note the presence of other drugs in overdose deaths involving buprenorphine. The complex nature of substance use disorders and polysubstance use requires specific strategies to address it.”
Compared with other opioid-involved decedents, a higher proportion of buprenorphine-involved overdose decedents were:
- female (36.1% vs. 29.1%),
- white (86.1% vs. 69.4%), and
- living in rural areas (20.8% vs. 11.4%).
“The finding that a larger proportion of buprenorphine-involved overdose deaths, compared with other opioid-involved overdose deaths, were white non-Hispanic persons, may reflect lower rates of buprenorphine treatment among Black and Hispanic individuals,” Tanz and colleagues wrote. “Disproportionate increases in overdose death rates have been reported among American Indian, Alaska Native and Black persons compared with white persons in counties with higher [substance use disorder] treatment availability.
Additionally, compared with other opioid-involved overdose decedents, buprenorphine decedents were more likely to be receiving mental health treatment (31.4% vs. 13.3%) and to die at home.
“Most overdose deaths, regardless of drugs involved, occurred without another person being present, a known risk factor for fatal overdose,” the researchers wrote. “Together, these findings highlight the need to advance programmatic and clinical strategies that embrace the complexity of polysubstance use rather than single-drug approaches, address cooccurring mental health and [substance use disorder] in a comprehensive and coordinated manner and integrate provision of naloxone and overdose prevention education for both individuals at risk for overdose and family members, caregivers or others who might be in a position to respond to overdoses.”
Tanz and colleagues concluded that “efforts are needed to expand more equitable and culturally competent access to and provision of buprenorphine-based treatment.”
“The findings of this cross-sectional study suggest that actions taken by the U.S. federal government to facilitate access to buprenorphine-based medications for OUD during the pandemic were not associated with an increased proportion of overdose deaths involving buprenorphine, providing evidence to inform discussions on permanent adoption of COVID-19–related buprenorphine prescribing authorities,” they wrote. “Nonetheless, although rare, overdose deaths involving buprenorphine highlight the importance of overdose prevention and support for those using buprenorphine both under medical supervision or outside of treatment for [substance use disorder] or pain. Efforts to expand more equitable provision of medications for OUD and harm reduction strategies are needed to address the increasing overdose crisis.”
References:
Opioid Resource Center
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