Examining buprenorphine diversion through a harm reduction lens: an agent-based modeling study

• Published in: Harm reduction journal Vol. 20; no. 1; pp. 1 - 150
• Main Authors: Adams, Joëlla W, Duprey, Michael, Khan, Sazid, Cance, Jessica, Rice, Donald P, Bobashev, Georgiy
• Format: Journal Article
• Language: English
• Published: London BioMed Central Ltd 17-10-2023; BioMed Central; BMC
• Subjects: Agent-based models; Analysis; Buprenorphine; Diversion; Dosage; Drug abuse; Drug dosages; Drug overdose; Drug withdrawal; Drugs; Fentanyl; Harm reduction; Heroin; Methadone; Modeling; Modelling; Mortality; Naloxone; Narcotics; Opioids; Overdose; Pharmaceutical policy; Policies; Prescribing; Prescription drugs; Prescription writing; Sensitivity analysis; Simulation; Substance abuse treatment; Substance use disorder; Waivers; North Carolina; United States > US
• ISSN: 1477-7517; 1477-7517
• DOI: 10.1186/s12954-023-00888-6

Abstract
Background
Recent policies have lessened restrictions around prescribing buprenorphine-naloxone (buprenorphine) for the treatment of opioid use disorder (OUD). The primary concern expressed by critics of these policies is the potential for buprenorphine diversion. However, the population-level effects of increased buprenorphine diversion are unclear. If replacing the use of heroin or fentanyl, use of diverted buprenorphine could be protective.
Methods
Our study aim was to estimate the impact of buprenorphine diversion on opioid overdose using an agent-based model calibrated to North Carolina. We simulated the progression of opioid misuse and opioid-related outcomes over a 5-year period. Our
status quo
scenario assumed that 50% of those prescribed buprenorphine diverted at least one dose per week to other individuals with OUD and 10% of individuals with OUD used diverted buprenorphine at least once per week. A
controlled prescription only
scenario assumed that no buprenorphine would be diverted, while an
increased diversion
scenario assumed that 95% of those prescribed buprenorphine diverted and 50% of individuals with OUD used diverted buprenorphine. We assumed that use of diverted buprenorphine replaced the use of other opioids for that day. Sensitivity analyses increased the risk of overdose when using diverted buprenorphine, increased the frequency of diverted buprenorphine use, and simulated use of diverted buprenorphine by opioid-naïve individuals. Scenarios were compared on opioid overdose-related outcomes over the 5-year period.
Results
Our
status quo
scenario predicted 10,658 (credible interval [CI]: 9699–11,679) fatal opioid overdoses. A scenario simulating
controlled prescription only
of buprenorphine (i.e., no diversion) resulted in 10,741 (9895–11,650) fatal opioid overdoses versus 10,301 (9439–11,244) within a scenario simulating
increased diversion
. Compared to the
status
quo, the
controlled prescription only
scenario resulted in a similar number of fatal overdoses, while the scenario with
increased diversion
of buprenorphine resulted in 357 (3.35%) fewer fatal overdoses. Even when increasing overdose risk while using diverted buprenorphine and incorporating use by opioid naïve individuals, increased diversion did not increase overdoses compared to a scenario with no buprenorphine diversion.
Conclusions
A similar number of opioid overdoses occurred under modeling conditions with increased rates of buprenorphine diversion among persons with OUD, with non-statistical trends toward lower opioid overdoses. These results support existing calls for low- to no-barrier access to buprenorphine for persons with OUD.