Diversion and Abuse of Buprenorphine: A Brief Assessment of ...

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In a further effort to determine the purposes for which buprenorphine is being prescribed in Vermont, distribution data for various formulations and dose strengths were examined. This showed that shipments of Buprenex, which is the formulation most frequently used in the management of pain, is the formulation least widely distributed in Vermont (Exhibit 3). 400,000 350,000 300,000 250,000 200,000 150,000 100,000 Exhibit 3. ARCOS Data: Comparison of Various Formulations and Dose Strengths of Buprenorphine Shipped to Vermont, 2003 – 2005* 1295 5700 59760 195990 347700 50,000 32940 38850 0 3270 2785 1 900 14730 12420 210 330 6960 Buprenex Buprenorpine Suboxone 2mg Suboxone 8mg Subutex 8mg Subutex *ARCOS Data Run of 2/3/06 Injectable 2.16mg 21180 14340 Source: U.S. Drug Enforcement Administration: Automation of Reports and Consolidated Orders System. Conclusion: The distribution of waivered physicians and the pattern of distribution of Subutex and Suboxone do not support the hypothesis that buprenorphine is widely used to treat pain. Recommendation: Based on data from the Vermont Medicaid program and the Vermont SSA, the case study suggests that this factor is a minimal contributor to high per capita rates of buprenorphine consumption in Vermont. However, a definitive determination requires further examination and followup by State officials. Relevant Information: Todd Mandell, M.D., Medical Director of the Vermont SSA, examined the Medicaid drug claims data for buprenorphine. He found more than 100 claims for Subutex or Suboxone prescribed by physicians who do not hold Federal waivers to use buprenorphine in addiction treatment. This may reflect offlabel use of buprenorphine to treat pain. However, when interviewed by Dr. Mandell, some physicians denied having prescribed buprenorphine at all. For example, some of the prescriptions bore the name of a gynecologist who, according to Medicaid records, had prescribed buprenorphine to several men. Conclusion: While the claims anomalies may represent simple coding errors at the time of data entry, there are a sufficient number to warrant further examination. For example, if coding errors do not explain all 100 claims, a logical next step would be to ask the Vermont Board of Pharmacy to send investigators to examine the actual prescription forms at the pharmacies where Results of the Vermont Case Study 10
the prescriptions were dispensed. Dr. Mandell has committed to work with Scott Strenio, M.D., Medical Director of the Vermont Medicaid program, to clarify the situation. Hypothesis 3: High rates of consumption of buprenorphine in Vermont and other New England States may reflect correspondingly high levels of opioid abuse and addiction. Relevant Information: Over the past several years, Federal data and anecdotal reports have identified New England (and particularly Maine) as a “hot spot” for diversion and abuse of OxyContin® and other prescription opioids. For example, SAMHSA’s Treatment Episode Data Set (TEDS) collects information on all publicly funded treatment programs. TEDS data show that the number of patients entering treatment who report Other Opiates (including oxycodone, hydrocodone, and buprenorphine) as their primary drug of abuse is increasing nationally. Similarly, in Vermont, treatment admissions related to Other Opiates show a steady upward trend. In contrast, Vermont admissions related to heroin slowly trended upward from 1998 to 2002, then dropped slightly in 2003 and 2004 (Exhibit 4). Moreover, Vermont treatment data for the past two years also show that patients who reported Other Opiates as their primary drug of abuse were more likely to use their primary drug on a daily basis than were those who reported heroin as their primary drug. Exhibit 4. TEDS Data: Vermont Treatment Admissions Related to “Other Opiates” Compared to Heroin and As a Percent of All Admissions, 1998 – 2004 12% 10% 8% 6% 4% 2% 0% 1998 1999 2000 2001 2002 2003 2004 Heroin Other Opiates Source: SAMHSA Office of Applied Studies: Treatment Episode Data Set. Data gathered from medical examiners in Vermont who report to the DAWN Medical Examiner system show that, in 2003 – the latest year for which data are available – the largest number of drugrelated deaths in Vermont involved oxycodone. In contrast, the largest number of drugrelated deaths in Maine and New Hampshire involved methadone. In all three states, more deaths were associated with prescription opiates than with heroin (Exhibit 5). Results of the Vermont Case Study 11
Page 1 and 2: Diversion and Abuse of Buprenorphin
Page 3 and 4: CONTENTS Summary 5 Background 5 Fin
Page 5 and 6: Diversion and Abuse of Buprenorphin
Page 7 and 8: Vermont Maine Exhibit 1. ARCOS Data
Page 9: Exhibit 2a. Vermont Data: Distribut
Page 13 and 14: Moreover, an interview with Allan W
Page 15 and 16: Hypothesis 6: Significant levels of
Page 17 and 18: Buprenorphine is not reported separ
Page 19 and 20: Based on all of the information exa
Page 21 and 22: APPENDIX A INFORMATION SOURCES CONS
Page 23 and 24: APPENDIX B STATE OFFICIALS CONSULTE
Page 25 and 26: APPENDIX C OUTSIDE EXPERTS CONSULTE
Page 27 and 28: Results of the Vermont Case Study A
Page 29 and 30: Once training is completed, the phy
Page 31 and 32: Screening/Intake: depending on the
Page 33 and 34: Patients dependent on SHORT ACTING
Page 35 and 36: 1 Levels of care range from ambulat
Page 37: ~ BUPRENORPHINE ~ Prior Authorizati

Diversion and Abuse of Buprenorphine: A Brief Assessment of ...

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