Buprenorphine Abuse Patterns and Methods
Buprenorphine is commonly abused through diversion, injection, intranasal use, and concurrent use with other substances, particularly benzodiazepines, which significantly increases the risk of respiratory depression and death. 1
Common Methods of Buprenorphine Abuse
Diversion
- Buprenorphine products are frequently diverted from legitimate prescriptions 2, 1
- Diversion occurs through:
- Selling prescribed medication
- Sharing with others
- Doctor shopping to obtain multiple prescriptions
- Theft from legitimate users or healthcare facilities
Routes of Administration
- Injection: Crushing tablets and dissolving for intravenous use (particularly concerning with pure buprenorphine formulations)
- Intranasal use: Crushing and snorting tablets
- Sublingual misuse: Taking higher doses than prescribed or using without prescription
Concurrent Substance Use
Buprenorphine is frequently abused in combination with other substances:
- Benzodiazepines: Most common and dangerous combination 1, 3
- Increases risk of respiratory depression and death
- Creates enhanced sedative effects
- Alcohol: Increases CNS depression risk 1
- Other substances commonly used concurrently: 3
- Marijuana (most prevalent illicit drug used with buprenorphine)
- Cocaine (concerning as it decreases buprenorphine exposure)
- Other opioids (hydrocodone, oxycodone)
Motivations for Buprenorphine Abuse
While buprenorphine has abuse potential, research shows mixed motivations for illicit use: 4
- Therapeutic self-treatment (79% to prevent withdrawal, 67% to maintain abstinence)
- Self-detoxification (53% use to self-wean off other opioids)
- Euphoric effects (52% report using to get high or alter mood)
- Access barriers (33% reported difficulty finding a doctor or obtaining prescription)
Risk Factors and Warning Signs
High-Risk Populations
- Patients with history of opioid use disorder
- Patients with concurrent benzodiazepine use
- History of injection drug use
- Limited access to legitimate buprenorphine treatment
Warning Signs of Abuse
- Early refill requests
- Lost or stolen medication reports
- Urine drug screens showing unprescribed substances
- Signs of injection (track marks)
- Deteriorating function despite treatment
Prevention Strategies
Formulation Considerations
- Buprenorphine/naloxone combination is preferred for outpatient treatment as it decreases (but doesn't eliminate) abuse potential 5
- Naloxone component precipitates withdrawal if injected, deterring this route of abuse
Monitoring and Management
- Regular urine drug testing to verify adherence and detect other substance use 6
- Frequent visits initially (weekly for first month), with monthly visits once stable 6
- Prescription Drug Monitoring Program checks before prescribing and dispensing 2
- Proper assessment of patients and maintaining records of medication prescribed 1
Clinical Implications
Overdose Risk
- While buprenorphine has a ceiling effect on respiratory depression making overdose less likely than with full opioid agonists, risk increases significantly when combined with:
- Benzodiazepines
- Alcohol
- Other CNS depressants 1
Treatment Considerations
- For patients with suspected buprenorphine misuse, evidence-based treatment (medication-assisted treatment with buprenorphine or methadone combined with behavioral therapies) should be offered 2
- Target dose of buprenorphine is typically 16mg daily (range 4-24mg based on individual response) 6
Important Caveats
- Despite abuse potential, buprenorphine remains a critical medication for treating opioid use disorder, reducing mortality by up to threefold 2
- Barriers to legitimate access may contribute to illicit use - 81% of those using diverted buprenorphine indicated they would prefer prescribed buprenorphine if available 4
- Preventing diversion requires balancing accessibility for those who need treatment with measures to reduce misuse 7