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

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Exhibit 6. ARCOS Data: State Rankings on Per Capita Consumption of Buprenorphine and Methadone Compared, January – December 2005 Vermont (rank=1) Maine (rank=2) Massachusetts (rank=3) Rhode Island (rank=4) Maryland (rank=5) U.S. Average Buprenorphine Grams Per 100,000 Pop. Methadone Grams Per 100,000 Pop. 583.56 Vermont 991.56 (rank=22) 324.02 Maine 1,973.83 (rank=6) 253.17 Massachusetts 800.05 (rank=32) 204.27 Rhode Island 422.77 (rank=48) 127.56 Maryland 878.66 (rank=28) 56.73 U.S. Average 929.95 Source: U.S. Drug Enforcement Administration: Automation of Reports and Consolidated Orders System, ARCOS 2, Report 4, 01/01/2005 to 12/31/2005. Conclusion: State officials believe that primary care physicians are using buprenorphine to treat many patients who would be enrolled in opioid treatment programs if places were available, and that some patients are attempting to selfmedicate with buprenorphine while awaiting availability of care. Based on information provided by state officials, this factor appears to be the most significant contributor to high per capita rates of buprenorphine consumption in Vermont. Recommendation: The outside experts consulted for the case study endorsed Vermont officials’ efforts to recruit and train additional physicians to use buprenorphine in officebased practice, because knowledgeable officials strongly endorse the hypothesis that one factor in nonmedical use of buprenorphine is lack of access to adequate and appropriate addiction care. Thus, the experts agreed that the answer to problems with buprenorphine (or methadone, or other opiates) involves more – rather than less – access to these important therapies. Finally, access to care would be enhanced if thirdparty payers would compensate physicians for officebased treatment of addiction at parity with the fees paid for other physician services of similar complexity. It also is important to eliminate distortions in the payment system, such as policies that cover detoxification but not maintenance treatment with buprenorphine. Such distortions may be an underlying cause of the relatively high proportion of Vermont patients who are detoxified but do not receive the followup care necessary to achieve and sustain recovery. Results of the Vermont Case Study 14
Hypothesis 6: Significant levels of buprenorphine diversion and abuse are occurring in Vermont. Relevant Information: Dr. Mandell first began to receive reports of buprenorphine abuse in early 2005. Because the reports were entirely anecdotal, he has used the limited data available to him – as well phone consultations with prescribing physicians and other sources of information – to try to clarify the situation. Peter Lee of the Vermont SSA reported that some buprenorphine diversion and abuse is occurring in Vermont. Mr. Lee confirmed that he has received anecdotal reports of buprenorphine tablets being crushed and injected. However, he described this as “horizontal” diversion within the addicted population – who rent pills for pill checks, for example, or sell part of their supply of buprenorphine to a friend who cannot access treatment – rather than “vertical” diversion into the general population. An official of the Vermont Department of Corrections reported that buprenorphine was being smuggled into the State’s correctional institutions, and said that the amount exceeded that of methadone or oxycodone. He also described buprenorphine as easy to obtain on the street, as compared to oxycodone, which he described as not widely used in Vermont (however, this anecdotal report is not consistent with the DAWN medical examiner data). Several other corrections officials suggested that buprenorphine was being smuggled into correctional facilities to sell to inmates who wanted to “get high” or to help inmates withdraw from heroin. Officials said some inmates who were addicted to heroin reported stockpiling buprenorphine prior to their incarceration. On the other hand, Gretchen Feussner of DEA’s Office of Diversion Control confirmed that the DEA field office for Vermont had not received any reports of buprenorphine diversion. The head of the Vermont State Police Laboratory reported that, in all of 2004 and 2005, buprenorphine had been seized in only eight cases. In every case, the formulation involved was Suboxone. Five seizures involved one tablet each, one seizure involved two tablets, and one involved three tablets. Thus, the Vermont State Police laboratory does not consider diversion of buprenorphine to be a significant problem at this time. Multiple datasets were examined in an effort to determine whether and to what degree buprenorphine was cited as either a primary or secondary drug of abuse by individuals entering addiction treatment in Vermont. While SAMHSA’s Drug Abuse Warning Network (DAWN) provides data on adverse events associated with a large number of drugs, no hospital emergency departments in Vermont report to DAWN. Boston is the closest metropolitan area with reporting hospitals. Interestingly, Boston also reports more emergency department visits related to buprenorphine than any other metropolitan area in the DAWN system (Exhibit 7). Results of the Vermont Case Study 15
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 and 10: Exhibit 2a. Vermont Data: Distribut
Page 11 and 12: the prescriptions were dispensed. D
Page 13: Moreover, an interview with Allan W
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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