CESAR FAX Publishes Report Warning of Emerging Epidemic of Buprenorphine Misuse

Prior research has shown that criminal offenders’ drug test results can help identify emerging drug epidemics well before they become evident in surveys and other community indicators. CESAR staff recently pilot tested the Adult Offender Population Urine Screening (OPUS) Program in Maryland as a rapid, low-cost tool for detecting and assessing emerging local drug trends.

In 2008, 1,061 urine specimens* originally collected and screened for 5 or fewer drugs by Maryland Division of Parole and Probation (DPP) agents were systematically sampled and sent to an independent laboratory for expanded testing for 31 drugs. The results showed an increase in the percentage of persons testing positive for buprenorphine since a smaller 2005 pilot study, and that these specimens often contained other drugs, suggesting possible misuse. Of the 98 specimens that tested positive for buprenorphine, 45% also contained two or more additional drugs and more than 60% contained other opioids (data not shown).

The drugs most frequently found were morphine (45%), cocaine (27%), marijuana (19%), and benzodiazepines (19%; see figure below).  Both other opioids and benzodiazepines could have lethal consequences if used with buprenorphine1.

A unique benefit of OPUS is that it enables the identification of local areas where drug misuse may be emerging. Once specific hot spots are identified, follow-up interviews can provide concrete details about substance use that can be used to guide criminal justice and public health efforts. CESAR staff conducted interviews in 2010 with 15 supervisees in one of the six probation offices close to Baltimore that submitted a high percentage of buprenorphine- positive specimens. The supervisees reported wide-spread availability of buprenorphine in the street and in prisons. While the most frequently mentioned reason for using buprenorphine was for self-medication to manage withdrawal symptoms, several participants mentioned that buprenorphine could be used to get high or to enhance the effects of other drugs. Additional reports of the smuggling of buprenorphine into jails and diversion of the drug to the street have also been reported across the country2.

The Maryland Adult OPUS findings, combined with national indicators of increased buprenorphine availability, diversion, and nonmedical use, suggest that there may be an epidemic of buprenorphine misuse emerging across the U.S. Unfortunately, “current testing protocols do not routinely include buprenorphine and cannot inform us of the magnitude and scope of buprenorphine misuse. Thus, offenders smuggle the drug into jails and prisons because its use will go undetected and buprenorphine-related deaths cannot be tracked because medical examiners and coroners do not routinely test for the drug in most states” (p. 6).

The authors recommend that “buprenorphine be added to all relevant drug testing regimens, if only to gauge the extent of diversion and misuse” (p. 6). In addition, the authors suggest that physician education programs “redouble their efforts to teach strategies to deter diversion and misuse of the drug” (p. 3) and that doctors closely monitor dosing “to ensure that the appropriate amount is prescribed, thereby reducing the likelihood of diversion” (p. 6). The OPUS model could be easily replicated in other states interested in tracking emerging prescription and other drug problems.

Percentage of Buprenorphine-Positive Specimens Testing Positive for Other Drugs, 2008 (N=98)


*To enhance the likelihood of detecting less commonly used drugs, we targeted random samples of 15 drug-positive specimens and 5 drug-negative specimens submitted by each DPP office.

1) Reckitt Benckiser Pharmaceuticals Inc., Suboxone Tablet Product Information, 2012. Available online at: http://www.suboxone.com/pdfs/SuboxonePI_tablet.pdf.  2) CESAR FAX, Volume 20, Issue 33 and CESAR FAX Buprenorphine Series, 2012. Available online at http://www.cesar.umd.edu/cesar/cesarfax.asp.

Source: Adapted by CESAR from Wish, ED, Artigiani, E, Billing, A, Hauser, W, Hemberg, J, Shiplet, M, and DuPont, R, “The Emerging Buprenorphine Epidemic in the United States,” Journal of Addictive Diseases 31(1):3-7, 2012. Available online at: http://www.tandfonline.com/doi/abs/10.1080/10550887.2011.642757.