Motivations for Diverted Buprenorphine Use in a Multisite Qualitative Study

• Published date: 01 October 2020
• Date: 01 October 2020
• DOI: http://doi.org/10.1177/0022042620941796
• Subject Matter: Articles

https://doi.org/10.1177/0022042620941796

Journal of Drug Issues

2020, Vol. 50(4) 550 –565

© The Author(s) 2020

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DOI: 10.1177/0022042620941796

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Article

Motivations for Diverted

Buprenorphine Use in a

Multisite Qualitative Study

Philip R. Kavanaugh1 and Katherine McLean2

Abstract

Drawing on a multisite sample of 40 persons who sell, share, or use diverted buprenorphine

to manage opioid use disorder, in this study we describe why individuals seek to obtain

buprenorphine outside of formal treatment contexts, and between-site variation regarding

their motives and means. Findings indicate that both the provision and purchase of diverted

buprenorphine support user-defined risk minimization strategies to avoid withdrawal, reduce

heroin use, and satiate opioid cravings in periods of lowered tolerance. We also found that a

subset of the sample used buprenorphine recreationally, and that it functioned to extend or

augment illicit drug use careers. Implications of the findings are discussed in light of federal and

state drug control and treatment policies.

Keywords

opioid, heroin, buprenorphine, treatment, drug diversion

While the total number of drug overdose fatalities in the United States appears to have declined

or plateaued from 2017 to 2018, deaths from synthetic opioids—driven principally by fentanyl-

adulterated heroin in the Northeast, MidAtlantic, Midwest and Midsouth—continued to rise over

this same period (Centers for Disease Control, 2019; Lopez, 2019). The increase has occurred

despite additional billions funneled to state and local municipalities to bolster addiction treatment

efforts. Since 2016 the U.S. Congress has appropriated more than US$110 billion in funding to

various states to address the opioid problem, framed as an historic public health crisis (U.S.

Department of Health and Human Services [HHS], 2019). In September 2019 an HHS press

release announced: “[b]y the end of 2019, HHS will have awarded more than $9 billion in grants

to states and local communities to help increase access to treatment and prevention services”

(HHS, 2019).

In 2002 the U.S. Food and Drug Administration approved the use of Schedule III narcotic medi-

cations Subutex® (buprenorphine) and Suboxone® (buprenorphine/naloxone) for the treatment of

opioid addiction. Increasing access to buprenorphine maintenance therapy (BMT)—long regarded

as the “gold standard” in treating opioid use disorder (OUD)—has featured prominently in efforts

to boost both treatment uptake and effectiveness. Enrollment in outpatient BMT programs

1Penn State Harrisburg, Middletown, PA, USA

2Penn State Greater Allegheny, McKeesport, PA, USA

Corresponding Author:

Philip R. Kavanaugh, School of Public Affairs, Penn State Harrisburg, 777 W Harrisburg Pike, Middletown, PA 17057,

USA.

Email: prk114@psu.edu

941796JODXXX10.1177/0022042620941796Journal of Drug IssuesKavanaugh and McLean

research-article2020

Kavanaugh and McLean 551

is associated with reductions in illicit opioid use, criminal involvement, overdose mortality, and

likelihood of relapse (Fudala et al., 2003; Mattick et al., 2014; Schwartz et al., 2013). Despite fed-

eral (and additional state) funding purposed to increase access, data suggest BMT programs are

underutilized relative to demand. As the U.S. opioid problem approached crisis levels in 2012 and

after having increased steadily for two decades, by 2018 BMT was offered at just 27.6% of outpa-

tient facilities nationally (Substance Abuse and Mental Health Services Administration, 2019).

Research has shown that a significant portion of persons who use opioids seek and acquire

buprenorphine on the illicit market, although estimates of prevalence vary widely by region and

sampling scheme (e.g., Bazazi et al., 2011; Bretteville-Jensen et al., 2015; Daniulaityte et al.,

2012; Genberg et al., 2013; Monte et al., 2009; Schuman-Olivier et al., 2010). Where Daniulaityte

et al. (2012) found that 7.8% of individuals recruited within an Ohio “community sample” of

opioid users reported lifetime buprenorphine misuse, Monte et al. (2009) showed that fully 96%

of individuals entering two New England opioid addiction programs had previously consumed

diverted buprenorphine. Studies by Cicero et al. (2018) and Bazazi et al. (2011) have additionally

documented high levels of past illicit buprenorphine use among opioid users at the point of treat-

ment and out-of-treatment, at 58% and 76%, respectively. A meta-analysis of studies on diverted

buprenorphine shows that for the most part it is used similarly as in formal BMT programs—to

manage withdrawal symptoms, to maintain abstinence, or “temporarily rest” from heroin

(Chilcoat et al., 2019, p. 154). While a smaller percentage report using diverted buprenorphine to

experience a “high” (a pattern of consumption that this article will hereafter characterize as “rec-

reational use”; Daniulaityte et al., 2012; Furst, 2014; Lofwall & Havens, 2012; Novak et al.,

2015), few indicate that buprenorphine is their “drug of choice” (Cicero et al., 2018).

Buprenorphine Maintenance and Diversion

The gap between OUD treatment need relative to availability has been long documented (Farabee

et al., 1998; Friedmann et al., 2003; Metsch & McCoy, 1999; Wenger & Rosenbaum, 1994; Zule

et al., 1997), especially in regard to methadone maintenance therapy. BMT, however, was pack-

aged as a more flexible and scale-able MAT, when in 2000 the Drug Addiction Treatment Act

(DATA-2000) permitted physicians to obtain waivers to prescribe buprenorphine from office-

based settings. Patient rosters were restricted to 30 in the first year, and 100 thereafter until a

2016 amendment invited interested providers to treat up to 275 persons (following DEA authori-

zation). The 2016 Comprehensive Addiction and Recovery Act allowed nurse practitioners and

physician assistants to apply for a buprenorphine prescription waiver, pending 24-hr training

period (American Society for Addiction Medicine, n.d.). These changes to federal buprenorphine

policy have occurred within a broader context of expanded health care and treatment access, as

the 2010 Affordable Care Act expanded eligibility for public health insurance (Medicaid, eligi-

bility for which is defined by income-level), and defined substance abuse treatment as an “essen-

tial benefit” of insurance plans (Patient Protection and Affordable Care Act, 2010).

Despite a sustained federal effort to expand BMT availability, these policies have not always

translated into meaningful increases in local BMT utilization. A report by the HHS’s Office of

Inspector General found 40% of counties still lacked a single waivered physician as of April

2018, and that 56% of the 1,100 U.S. having the “greatest need for buprenorphine services”

lacked the capacity for office-based buprenorphine treatment (HHS, 2020). Several studies have

also found that most waivered physicians are currently prescribing at levels far below legal

capacity (Sigmon, 2015; Stein et al., 2016; Thomas et al., 2017). In addition to geographic varia-

tion in access, particularly the urban–rural divide (e.g., Andrilla et al., 2019; Rosenblatt et al.,

2015; Stein et al., 2016; Wen et al., 2018), local prescribers may also be constrained by state-

level decisions to opt out of Medicaid expansion (Knudsen et al., 2015).