Characteristics and experiences of buprenorphine-naloxone use among polysubstance users

ABSTRACT

Background: With a rise in overdoses and medical emergencies related to opioids, buprenorphine-naloxone (bup-nx) is seen as a preferred treatment for opioid dependence. However, the research examining experiences with bup-nx among polysubstance users who may or may not be opioid dependent has been limited. Objectives: The purpose of the study was to examine use, characteristics of users, and experiences of bup-nx use among polysubstance users entering drug-free recovery programs. Methods: This study examined secondary data on 896 opioid or opiate user individuals (53.4% male) collected by drug-free, self-help-based residential recovery centers during intake. Results: One-quarter of users said bup-nx helped them with their substance use while 75% of bup-nx users reported that bup-nx either had no effect or a negative effect on their drug problems. Of the very few (4%-7%) obtaining bup-nx solely through a prescription, over 90% reported relief from withdrawal. However, over 80% of those who obtained bup-nx through illicit means reported using bup-nx until their preferred drug could be obtained and used it for its euphoriant effect. Three groups of opioid users were created including one group with no bup-nx use, one with lifetime but not recent bup-nx use, and one with recent (past 6 month) use. There were differences in substance use patterns and characteristics of bup-nx experiences between the different groups. Conclusions: Results suggest that the views of bup-nx by individuals in drug-free recovery centers are varied, with many seeing bup-nx as not unlike other opioids while others report bup-nx as self-medication.

KEYWORDS:

• Buprenorphine experiences
• polysubstance use
• diversion

This article is referred to by:

Buprenorphine in the real world: coming to terms with misuse and diversion

Introduction

In 2015, there were 52,404 drug overdose deaths in the US, 22,598 of which were due to opioid pain relievers (1,2). In 2016, the provisional count of opioid/opiate overdose deaths in the US had risen to 56,526 or about 155 per day(3). The rise in overdose deaths and medical emergencies related to opioids has led to increased interest in medically assisted treatments, including buprenorphine preparations, for opioid dependence.

Buprenorphine acts on the brain’s opioid receptor sites, particularly µ-opioid receptors where it is a partial agonist and antagonist at the κ-opioid receptor sites(4). Naloxone was added to buprenorphine with the rationale of reducing the risk for intravenous misuse(5). The resulting agonist/antagonist effects of buprenorphine/naloxone (bup-nx) plus the suggested ceiling effect of buprenorphine by comparison with methadone suggests it might be less subject to misuse and diversion as has been noted as a concern for methadone and other prescription opioid preparations (4,6,7). However, there has been limited research examining experiences with bup-nx among individuals with polysubstance use.

Buprenorphine in combination with naloxone is of particular interest in the treatment of opioid addiction. By 2008, 6 years after FDA approval, there were 368,962 patients treated with buprenorphine on any given day(8). In the 12 months prior to 30 November 2010, a total of 887,482 patients received buprenorphine prescriptions and there are over 18,000 prescribers of buprenorphine preparations nationwide(8). The IMS Institute for Healthcare Informatics reports that the number of retail buprenorphine prescriptions increased from 8.2 million in 2012 to 12.5 million in the 12 months ending on 30 June 2016(9). Other forms of bup-nx that have obtained FDA approval, including sublingual tablets (Zubsolv®) and implants, are soon to be a part of the prescribing repertory(10).

About 9 million buprenorphine product prescriptions were filled in 2013 overall and even Medicare’s prescription drug benefit experienced 16,749 bup-nx patients nationwide in 2014 at a retail program cost of $41.8 million. (11,12) However, the costs of bup-nx treatments must be understood against mortality rates, which are 75% higher among persons receiving drug-free treatment (13,14).

Questions about the effectiveness of bup-nx preparations involve several different objectives and metrics. Chalk et al (15). identified 643 articles relating to effectiveness of the three major medications for opioid dependence (methadone, buprenorphine/naloxone, and naltrexone) and found 75 research articles suitable for review. All three medications had consensus findings that supported the use of medically assisted treatment for opioid addiction, but methadone had over 50 years of support findings in regard to effectiveness(15). Three studies suggest that methadone may be superior to bup-nx in retaining clients in treatment (16–18). However, bup-nx has enjoyed rising use as a medically assisted treatment in the past decade(19). For the specific objective of reducing overdose opioid deaths, bup-nx appears to be effective(15). The review by Chalk et al (15). suggests that bup-nx preparations have efficacy in suppressing withdrawal symptoms, retaining patients in treatment, reducing illicit opiate/opioid use, and reduced HIV, hepatitis risk behavior by virtue of eliminating needle use. Bup-nx preparations for maintenance have been tested against abstinence-oriented outpatient treatment with a finding of longer retention in treatment in the medicated group (20–26).

Currently, bup-nx has been adopted by clinical, research, and federal funding sources as a medication, and governmental policies strongly support the use of bup-nx to treat opioid dependence(27). However, within this context there are still concerns about the harm reduction uses of bup-nx (27,28). For example, several studies point toward growing illicit use of bup-nx (29–31). What remains largely untapped are the experiences of bup-nx from polysubstance users who are not selected into clinical trials or currently in treatment with bup-nx. Several key studies that examined the impact of bup-nx have screened out participants with polysubstance use (32–34) leaving open a question about how polysubstance users in a community recovery sample might characterize bup-nx.

The principal goal of this study was to examine the attitudes, beliefs, and experiences with bup-nx among a group of polysubstance users entering long-term drug-free residential recovery programs in one state that share the same program guidelines and the same Twelve-Step approach to recovery. Specifically, this study analyzes secondary intake data from a statewide sample of clients as they enter a drug-free residential program to examine four questions: (1) what are the demographic, economic, health, and substance use patterns among three groups of polysubstance users: (a) those who report never having used bup-nx; (b) those who report using bup-nx but not in the 6 months before entering the recovery program; and (c) those who report recent bup-nx use (within the 6 months of entering the recovery program); (2) among polysubstance users who have used bup-nx how was it obtained (e.g., doctor prescription, illegally, both prescription and illegally); (3) what were the experiences of bup-nx when prescribed; and, (4) what were experiences of bup-nx when obtained without a prescription. The rationale for the two bup-nx user groups was to examine possible differences between recent and lifetime users.

Method

Participants

Participants were adults who were admitted to long-term drug-free residential recovery centers in one state. The programs are non-medical facilities that are not licensed treatment programs but that loosely resemble therapeutic communities. Participants were referred by other community programs and by the courts and were admitted following their decisions to commit to a 6-month residential recovery episode where they participate in 12-Step self-help groups and where they contribute to the operations of the programs in much the same way as clients in therapeutic communities. The programs rely heavily on 12-Step concepts and practices. During a 6-week special study period, admission data were collected on 1,674 individuals, of whom, 896 reported having opioid or opiate use and 673 of these also reported bup-nx use.

Measures

Bup-nx Use questions were added to the intake assessment collected on every client at program entry by program staff. The secondary intake data was analyzed for this paper. The questions about bup-nx use were developed and piloted with 158 clients before being revised and added to the intake survey. The questions were descriptive in nature and asked about lifetime use of bup-nx, if the client had a prescription for bup-nx from a doctor, and if the client ever bought or received bup-nx from someone without having a prescription. All of those reporting bup-nx use were asked whether they had ever overdosed when combining bup-nx with other drugs or alcohol and overall and whether they thought their use of bup-nx helped treat their drug problem, had no effect on their drug problem, or made their drug problem worse.

Clients who had had a prescription for bup-nx were asked how the doctor recommended they use the medication, whether the doctor advised the client to seek substance misuse services, and whether the doctor gave clients counseling in addition to prescriptions. Clients were also asked about the effects of bup-nx (e.g., stopped craving, prevent withdrawal symptoms, made other drugs feel more powerful, helped you in any way at all). Clients were asked if they took other drugs or alcohol to get high while taking bup-nx and whether they had ever sold, traded or gave away any of the bup-nx that was prescribed. Then clients were asked the main reasons they stopped taking bup-nx.

If clients reported obtaining the bup-nx without a prescription they were asked about the purposes for using bup-nx including whether bup-nx was a bridge drug until they could get their preferred drug or whether it was used just to get “high” or to or feel euphoria. They were also asked if they sought information about how to increase the “high” from bup-nx.

Other substance use measures were adapted from the Addiction Severity Index (ASI) which has good validity and reliability in measuring substance use (35–37). Clients were asked about the use of each class of substances 6 months before entering the recovery programs.

Demographic and living status information included age, race, gender, marital status, and education level. Clients were also asked how many months they worked in the 6 months before entering the recovery programs, whether they perceived themselves to be homeless and if so why they considered themselves homeless, and how many nights they had spent in jail in the 6 months before entering the recovery program.

Health and mental health information was obtained by asking clients to rate their overall health with items from the Behavioral Risk Factor Surveillance System (BRFSS) and the Health-Related Quality of Life (HRQOL) and the SF-36 (38–40). Their mental health items were from the Patient Health Questionnaire-9 and the Generalized Anxiety Disorder-7 (41,42). Clients were also asked if they had experienced at least 2 weeks in a row when they were consistently depressed or down most of the day nearly every day or 2 weeks in a row when they were much less interested in most things or much less able to enjoy he things they used to enjoy most of the time. If they answered yes to either of these questions and at least 5 of the 9 additional symptom questions they were classified as having depression symptoms. Clients were also asked if in the 6 months before entering the recovery programs they worried excessively or were anxious about multiple things on more days than not for all 6 months. If they indicated a yes to that question and at least 3 of the 6 additional symptom questions they were classified as having anxiety symptoms.

Procedure

The data for this study were collected between 1 September 2015 and 13 October 2016 as part of an ongoing study of recovery center client outcomes in one state. The larger study is an annual outcome study that examines change in substance use, mental health and health problems, employment, and criminal justice involvement from intake to 12 months after admission to the program. Intake data are collected by the program staff and follow-up data 12 months later are collected by university researcher not affiliated with the program. The data for this article were taken from the intake interview data for the approximately 6 weeks’ worth of intake data to examine the buprenorphine-specific items that were the special focus of this smaller part of the larger outcome study. The bup-nx items were only added to the outcome study for the limited time of this examination. All clients’ data for the 6 weeks were included in this bup-nx substudy.

Overall, 896 (60.7%) of the 1,674 individuals who completed intake data collection reported using either an opiate or opioid in the past 6 months. Of those who reported using any opiate or opioid, 70 did not answer questions about bup-nx experiences. Also, because the focus of this article was to examine recent substance use patterns including bup-nx, participants who were incarcerated more than 5 out of the 6 months before entering the program were also excluded (n = 305). This left a sample of 1,299, of whom, 403 did not report use of opioids or opiates (heroin, opioids, or methadone) in the 6 months before entering the recovery program leaving a final sample of 896 who reported any recent opiate/opioid use and who responded to the bup-nx questions, thus making this sample eligible for examination of bup-nx use.

The sample of opiate/opioid users was then broken into three groups for comparison: (1) those that reported never using bup-nx (No Bup-nx Use, n = 223); (2) those that reported bup-nx use at some point in their life but not in the 6 months before entering the program (Lifetime Bup-nx Use, n = 241); and (3) those that reported using bup-nx in the 6 months before entering the program (Recent Bup-nx Use, n = 432). Characteristics and substance use patterns for the three groups were examined with a series of Chi-squares and Analysis of Variance (ANOVAs).

Results

Bup-nx group differences

Table 1 displays the similarities and differences in the three bup-nx groups with regard to sociodemographic and health information. The Recent Bup-nx Use group was significantly younger than the other two groups (F(2, 891) = 5.92, p < .01) and fewer in the No Bup-nx Use group were white (X²(2) = 5.69). About half were males in the three groups (53.4%–55.6%) and about half of the sample had never been married (50.2%–53.5%). A little over half of participants in the three groups (55.3%–64.6%) had been employed at least 1 month in the 6 months before entering treatment. About 1 in 7 (13.3%–15.2%) had less than a high school diploma. More of the Recent Bup-nx Use group had depression symptoms (X²(2) = 6.78, p < .01) and rated their overall health as poor (X²(4) = 17.6, p < .01) compared to the other two groups. Fewer in the No Bup-nx Use group spent a night in jail in the 6 months before entry into the recovery programs (X²(2) = 12.2, p < .01) compared to both of the bup-nx use groups.

Table 1. Comparison of bup-nx groups (n = 896).

	No Bup-nx Use (n = 223)	Lifetime Bup-nx Use (N = 241)	Recent Bup-nx Use (N = 432)
Average age	33a	31b	31b**
Male	53.4%	49.8%	55.6%
White	91.0% a	95.9%b	94.9%b
Never married	50.2%	49.0%	53.5%
Employed at least 1 month in the 6 months before program entry	64.6%	60.6%	55.3%
Education
Less than HS	15.2%	13.3%	14.8%
HS	43.9%	39.8%	41.0%
Some college +	40.8%	46.9%	44.2%
Anxiety symptoms	74.0%a	79.3%b	83.8%b*
Depression symptoms	71.7%a	72.6%a	79.6%b*
Overall health rated poor	22.1%a	25.0%a	34.9%b**
Chronic pain	29.6%a	21.6%b	28.7%a
Perceived homeless (n = 388)	38.6%a	41.5%b	46.8%b
Stayed on the street or living in car	23.2%	28.1%	30.8%
Stayed in a shelter	4.9%	7.9%	6.5%
Stayed temporarily with friends or family	72.0%	64.0%	62.7%
Any nights in jail	59.6%a	73.4%b	71.1%b**

*p ≤ .05; **p ≤ .01; ***p ≤ .001.

Subscripts that differ indicate significant differences at p ≤ .05.

Table 2 displays the polysubstance use patterns for the three bup-nx use groups. More of the Lifetime and Recent Use groups smoked (X²(2) = 12.4, p < .01) and used e-cigarettes (X²(2) = 9.2, p < .05) compared to the No Bup-nx Use group. However, more of Recent Bup-nx Use group used Marijuana (X²(2) = 9.9, p < .01), Benzodiazepines (X²(2) = 48.1, p < .001), Barbiturates (X²(2) = 9.9, p < .01), Stimulants (X²(2) = 40.9, p < .001), Cocaine (X²(2) = 30.1, p < .001), Hallucinogens (X²(2) = 8.6, p < .05), and Synthetic drugs (X²(2) = 15.9, p < .001) in the 6 months before entering the recovery programs compared to the No Bup-nx Use and the Lifetime Bup-nx Use groups. The Recent Bup-nx Use group had used significantly more drug types (opioids, stimulants, benzodiazepines, etc) than the No Bup-nx Use or the Lifetime Bup-nx Use groups (F(2, 893) = 170.76, p < .001).

Table 2. Self-reported substance use among opioid/opiate users by bup-nx groups (n = 896).

Substance	No Bup-nx Use (n = 223)	Lifetime Bup-nx Use (N = 241)	Recent Bup-nx Use (N = 432)
Smoking	83%a	90%b	91.9% b**
E-cigs	20.2% a	29% b	31.3% b*
Alcohol intoxication	52.9%	51.5%	52.1%
Marijuana	55.2% a	53.1% a	64.4% b**
Benzodiazepines	36.8% a	42.3% a	62.5% b***
Barbiturates	7.6% a	6.6% a	13.4% b**
Stimulates, methamphetamine	48% a	47.3% a	68.8% b***
Cocaine	27.8% a	36.1% a	49.1% b***
Hallucinogens	8.1% a	8.3% a	14.4% b*
Inhalants	3.6%	2.9%	6.5%
Synthetic, designer drugs	12.1% a	7.5% a	18.3% b***
Average number of drug types used in past 6 months	3.4	3.6	5.9***

*p ≤ .05; **p ≤ .01; ***p ≤ .001

Subscripts that differ indicate significant differences at p ≤ .05.

Bup-nx experiences

Overall, very few bup-nx users obtained bup-nx only through a prescription and about one-third used bup-nx both illegally and with a prescription (see Table 3). More in the Recent Bup-nx Use group reported using bup-nx with a prescription and illegally (X²(2) = 9.9, p < .01). Also, about two-fifths of the Recent Bup-nx Use group indicated bup-nx made their drug use worse compared to about one-third of the Lifetime Bup-nx Use group (X²(2) = 9.3, p < .01). While only 5% of the Lifetime Bup-nx Use group reported they had overdosed while taking bup-nx with other drugs, 10% of the Recent Bup-nx Use group reported overdose with bup-nx and other drugs (X²(2) = 4.2, p < .05).

Table 3. Comparison of bup-nx experiences by bup-nx groups (n = 673).

	Lifetime Bup-nx Use (N = 241)	Recent Bup-nx Use (N = 432)
Method of obtaining bup-nx:**
Prescription only	7.1%	4.2%
Illegal only	68%	60%
Both prescriptions and illegal means	24.9%	35.9%
Bup-nx: **
Helped treat my drug problem	23.7%	25.2%
Had no effect on my drug problem	42.7%	31.5%
Made my drug problem worse	33.6%	43.3%
Overdosed while taking bup-nx with other drugs or alcohol	5.4%	10%*

*p ≤ .05; **p ≤ .01

Prescribed bup-nx experiences

Of all those who reported bup-nx use, 32% of the Lifetime Bup-nx Use group and 40% of the Recent Bup-nx Use group reported having a prescription for bup-nx (X²(2) = 4.3, p < .05) as Table 4 shows. Of those with a prescription, just over one-third indicated their doctor suggested it for long-term use and just over one-third indicated their doctor said it was for both detox and long-term use across both groups. A large proportion of both groups reported their doctor advised them to seek substance misuse services (self-help groups, counseling, or treatment) and about 60% of both groups reported their doctor counseled them about substance misuse in addition to giving them a prescription.

Table 4. Comparison of experiences among bup-nx users who obtained the drug from a physician.

	Lifetime Bup-nx Use (N = 241)	Recent Bup-nx Use (N = 432)
Obtained bup-nx by prescription	32%	40%*
Why prescribed:	(n = 77)	(n = 173)
Detox only	10.4%	7.5%
Long–term use to stay away from other drugs	32.5%	39.3%
Both for detox and long-term use	33.8%	37%
Reason not discussed	10.4%	8.7%
Don’t remember the reason it was prescribed	13%	7.5%
Did doctor:
Advise attending recovery support meetings or substance misuse treatment/counseling	70.1%	68.2%
Provide counseling about substance misuse	61%	61.8%
Did you:
Took other drugs or alcohol to get high while taking prescribed bup-nx	70.1%	83.8%*
Sold, traded, or gave away any of the prescribed bup-nx	84.4%	80.3%
Did the bup-nx:
Stop cravings	70.1%	69.9%
Prevent withdrawal symptoms	94.8%	93.6%
Make other drugs have less effect	64.9%	76.9%*
Help in any way at all	74%	79.8%
Free you up from having to hustle for drugs	66.2%	67.1%
Give a satisfactory high	53.2%	56.1%
Make other drugs feel more powerful	23.4%	31.8%
Main reasons for stopping bup-nx use:
Cost	41.6%	34.7%
Treatment program did not allow	19.5%	21.4%
Was not helping	22.1%	27.2%
Difficulty accessing clinic or physician where it was prescribed	16.9%	16.8%

*p ≤ .05

Over 70% of both groups reported they took other drugs or alcohol to get high while taking bup-nx although more of the Recent Bup-nx Use group reported they had done this (X²(2) = 6.2, p < .05). Further, over 80% of both groups reported diverting bup-nx.

When asked what impact bup-nx had on them, the majority of both groups reported it stopped drug cravings, prevented withdrawal symptoms, helped them in some way, and made other drugs have less effect although more of the Recent Bup-nx Use group indicated that bup-nx made other drugs have less effect (X²(2) = 6.2, p < .05). About half of both groups indicated that bup-nx gave a satisfactory high, over 60% of both groups indicated bup-nx freed them up from having to hustle for drugs, and over 20% of both groups indicated bup-nx made other drugs feel more powerful.

When asked for the main reason for stopping using bup-nx, over one-third reported cost was an issue while around 20% of both groups reported other reasons including that it was not helping them and that they had trouble accessing bup-nx.

Bup-nx without a legal prescription

Table 5 shows that over 90% of both groups obtained bup-nx without a prescription or illicitly in addition to a prescription. Although a large majority of lifetime and recent use groups reported they used bup-nx to get through rough days, to get high, and that they could get higher by increasing the amount of bup-nx they were taking, more of the Recent Bup-nx Use group reported each of these including using bup-nx to get through rough days (X²(1) = 6.8, p < .01), to get high (X²(1) = 4.9, p < .05), and increasing the amount of bup-nx to get higher (X²(1) = 5.6, p < .05). Also, close to 60% of both groups reported they got information about how to increase the “high” from other people and/or the internet.

Table 5. Comparison of experiences among bup-nx users who obtained the drug illegally.

	Lifetime Bup-nx Use (N = 241)	Recent Bup-nx Use (N = 432)
Obtained bup-nx without a prescription	92.9%	95.8%
Bup-nx was used to:	(n = 224)	(n = 414)
Get through rough days until preferred drug could be obtained	84.8%	91.5%**
Get a high, a buzz, or to feel euphoria	73.7%	81.2%*
Increase high by increasing bup-nx amount	54.5%	64%*
Got information from other people and/or internet about how to boost bup-nx high	59.4%	66.4%

*p ≤ .05; **p ≤ .01

Discussion

This study adds to the literature on bup-nx by examining self-reported experiences of bup-nx among polysubstance opiate/opioid users in long-term drug-free residential recovery programs in one state. Unlike studies which have examined users with a diagnosed primary opioid dependence, this study examined opioid users who also reported a wide range of other drug use in a self-help oriented recovery environment. Two groups of opiate/opioid users with bup-nx experiences were examined and were found to be similar in many respects but more of the individuals in the Recent Bup-nx Use group reported using marijuana, benzodiazepines, cocaine, stimulants, hallucinogens, and synthetic substances and have a significantly higher number of drug types used in their polysubstance use profile. This study suggests an emerging population of individuals with bup-nx use who are decidedly polysubstance users with extensive drug use histories – not just a clear opioid dependence pattern. Consistent with this pattern, more of the Recent Bup-nx Users reported taking other drugs even while on bup-nx in order to get high. In addition, consistent with other research on opioid misuse and mental health problems, significantly more of the Recent Bup-nx Use group reported symptoms of depression(43). One other interpretation of this study’s findings might be that opioid users with extensive polysubstance use might have more severe SUD symptoms, thus calling for a different level of interventions. In fact, extensive polysubstance use might be considered a marker for greater substance use disorder complexity and greater executive planning deficits thus point toward a need for more services than just medical harm reduction services(44).

The data from this more naturalistic than clinical study suggests that at some level, polysubstance users in drug-free recovery programs may view bup-nx largely as they do other street drugs and that, consistent with some literature, they have found out how to increase its euphoriant effects and how to use it with other non-opioid drugs to obtain desired highs where the buprenorphine blockade effect would not obtain(45). While just under one-fourth of this sample of polysubstance users found bup-nx helped with their drug problems, almost 39% said it made their problem worse and another 36.5% said it had no effect on their drug problem. Unexpectedly, only a little over one-fourth (27.0%) reported cost as a reason for stopping the use of bup-nx. Other research suggests that some users may use illicit bup-nx due to difficulties in obtaining legitimate prescriptions and getting access to reliable sources of legitimate bup-nx(46).

There is concern that bup-nx might fuel yet another wave of illicit drug use through diversion, thus adding to the already serious problem with opioid diversion(47). Wish et al (31). suggest that emergency department visits secondary to nonmedical buprenorphine use have increased in a linear fashion from 4,440 visits in 2006 to 14,266 in 2009 and the DAWN report shows emergency department visits due to medical and nonmedical buprenorphine increased to 30,135 by 2010(48). They also reported that 98 of 1,061 probationers in Maryland tested positive for illicit buprenorphine in their routine urine surveillance program(31).

Client reports of finding ways to boost the euphoriant effect of bup-nx may lie in part with the fact that the naloxone part of the drug has a short half-life (one hour) whereas the buprenorphine has a very long half-life (32 hours) and a potentially questionable plateau effect among heavy users absent sufficient blood levels of the medication(49). A recent study showed that when depot buprenorphine blood levels are high enough, an effective blockade against hydromorphone is instantiated, thus suggesting that careful clinical monitoring might be important in treatment applications(50).

Overall, the clients in this study present a rather balanced view of bup-nx including supportive comments about its direct pharmacological effects on buffering craving and withdrawal. These subjective reports are consistent with the research literature. However, the client views also suggest the potential for using bup-nx non-medically – even if some of this use might turn out to be self-medication. What is unknown from these accounts is whether their blood levels of buprenorphine were ever assessed and whether they were sufficient to create a blockade effect against other opioids.

Future research might use qualitative approaches to further examine polysubstance users’ experiences with bup-nx and explore the degree to which it is used as a self-medication. Is it being used to bridge gaps between regular supply of other opioids, used just to manage withdrawal periods and as part of down-regulating the level of opioid use? Or is it being employed as any other opioid primarily for its euphoriant effect? In addition, future research might examine the value of a comprehensive substance misuse focus where bup-nx is but one component of a wrap-around intervention that could simultaneously address all forms of substance use and other related problems.

Future research should continue to examine health services data and the subjective accounts of bup-nx users to better understand its use as a treatment versus being used simply for euphoriant effect along with other drugs. There is a lingering question about the longer-term experiences with bup-nx as it makes its way further into wide use. Clinical trials of bup-nx often have exclusion criteria that eliminate heroin users, and users with co-occurring disorders, pregnancy or likely to become pregnant(51), medical conditions(17), depression(50) have low follow-up rates, and reduced, but not arrested drug use at follow-up, including opioids(34). As bup-nx trials include clinical populations more like those in typical clinical settings, the greater the likelihood of more generalizable findings about the efficacy of bup-nx. In addition, long-acting injections of buprenorphine, one of which is on the market and another two versions which can be anticipated soon, may also change the ways and the degrees in which all formulations of buprenorphine are used and misused(52).

There are several limitations to this descriptive study. All of the study participants were in long-term drug-free recovery programs that follow Twelve-Step approaches and being newly admitted residents in this setting might influence how clients report and feel about bup-nx. A random sample of bup-nx users across many different treatment environments might elicit different views and attitudes about the drug. In addition, the reports are all self-reports that may be subject to problems of recall for past 6-month experiences. However, given that the objective of the study was not to measure quantity or frequency of actual use, but clients’ perceptions of their experiences with bup-nx, the usual worries about self-reports may be diminished. Another limitation is that the study attempted to learn about client experiences with bup-nx using a select number of bup-nx-specific items in a larger baseline assessment tool. An argument can be made that qualitative methods might have elicited more specific information about client accounts of their experiences with bup-nx. Also, no standardized or validated instrument was found to examine these questions about perceptions and experiences with bup-nx and thus, in spite of face validity of the items, there may be validity concerns.

Bup-nx enjoys wide-ranging support of its effectiveness is reducing illicit opioid use and offering some hedge against overdose crises. However, this descriptive study of polysubstance using individuals in drug-free recovery programs finds that accounts of bup-nx experiences include many non-medical uses and that euphoriant effect is one of the desired aims of its use. The treatment profession views bup-nx largely through therapeutic eyes, but individuals with polysubstance use may have a very different take on the substance. It may be seen as but one more opioid drug that is now becoming more available from multiple sources. A recent study of 38,096 individuals’ pharmacy claims data suggested that 43% of individuals receiving buprenorphine prescriptions also filled prescriptions for other opioids during the treatment episode and 67% filled prescriptions for opioids after the treatment episode(53). Another study of 100 opioid and polysubstance users recruited from the community in Providence, Rhode Island found that 76% reported having obtained bup-nx illicitly(30).

Pharmaceutical supported research suggests that implant buprenorphine may provide greater security against abuse or diversion but, unlike this study, the studies of its effectiveness have used largely employed, well-educated participants and have not focused on follow-up drug use apart from opioids and, in one study, cocaine (54,55). The high percent of individuals in this study who reported recently using illicit bup-nx to relieve withdrawal symptoms (93.6%) and craving (69.9%) certainly suggests an interest in what might be called a self-medication use pattern. But close to half (43.3%) of the recent users also felt that bup-nx use made their drug problem worse. Future research might focus on therapeutic applications of bup-nx in community programs among under-employed, less educated individuals with polysubstance use to examine it effects on overall substance use outcomes.

Acknowledgments

The authors also want to thank members of the Bup-nx Working Group including Burns M. Brady, M.D., ASAM, Quinn T. Chipley, M.D., Patrick Fogarty, B.A., B.S., C.A.D.C., Greg Jones, M.D., ASAM, Cory Moneymaker, M.S.S.W., LCADC, Ridley Sandidge, B.A., CADA, and Mike Townsend, M.S.S.W.

Additional information

Funding

The study was supported by a contract with the Kentucky Housing Corporation, an agency of the Commonwealth of Kentucky. None of the authors in this study were funded in full or in part by private pharmaceutical corporations.