Misuse and Diversion

Buprenorphine misuse and diversion do occur in OBOT practices. Remember that, prior to treatment, buprenorphine patients were misusing opioids for months or years. Misuse is a common and learned behavior and one that can be a hard habit to break. Diversion is also on the rise as the street demand for buprenorphine rises.


Common Reasons for Misuse


Common Reasons for Diversion

  • patient thinks he/she needs a higher dose
  • to relieve opioid craving
  • to relieve opioid withdrawal
  • to get high
  • to help addicted friends
  • peer pressure
  • to make money

Detecting Misuse and Diversion

Signs of misuse and diversion may include:

  • Missed appointments
  • Claims that pills were lost, stolen, accidentally laundered, etc.
  • Pharmacy calls asking for early refills
  • Urine screens negative for buprenorphine, positive for opioids
  • Physical signs of injection drug use
  • Police reports of selling on the streets
  • Calls from others to report diversion

Misuse and diversion must be addressed when suspected or verified. If not addressed, the patient's health and safety could be at risk. Additionally, the overall "reputation" of OBOT could be damaged. Also, increase in diversion could lead to tighter DEA oversight of buprenorphine -- and the oversight is already fairly substantial, of course.

Managing Misuse and Diversion

Misuse or diversion should not mean automatic discharge from your OBOT program. However, you should have a policy in place for how you deal with misuse and diversion. For instance, you may want to follow these steps when diversion or misuse occur:
diversion

  • Reassess treatment plan and patient progress
  • Make changes as needed: alter dose, intensify psychosocial requirement
  • Reassess the patient again after a short interval
  • Arrange for alternative treatment if needed

Preventing Misuse and Diversion

There are some simple approaches that can be built into an OBOT practice that will help prevent buprenorphine misuse and diversion.

  • Prescribe a therapeutic dose of buprenorphine. Due to ceiling effects, there is very little clinical benefit to taking more than 16mg/day. Be sure to question patients who come to the office who say they need significantly higher doses.
  • Prescribe what is needed based on careful titration of dose. Don't routinely provide an additional supply "just in case."
  • Make sure that treatment agreement is clear about prescription guidelines - number of doses in each prescription, policies regarding refills, rules regarding "lost" prescriptions.
  • Require patients to use only one pharmacy for filling all prescriptions, buprenorphine and otherwise. Obtain consent for two-way communication with the pharmacist; if the patient doesn't consent, you have to question why.
  • Monitor treatment through regular but random urine tests, pill/filmstrip counts in the office between writing prescriptions, state prescription monitoring system, feedback from family members, etc.
  • Openly discuss misuse and diversion with your patients so they know that you are aware of the issues and have a plan to deal with these problems if they arise.
  • (Lofwall 2011)

View ReferencesHide References
Substance Abuse and Mental Health Services Administration. Drug Abuse Warning Network. National estimates of drug-related emergency department visits . Substance Abuse and Mental Health Services Administration website. 2004-2009. Available at: http://www.samhsa.gov/data/DAWN.aspx#Dawn Accessed on: 2012-07-19.