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

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Indicators of a Potential Problem. Although none of the formal indicators used by the manufacturer or the government signaled any adverse effects attending the introduction of buprenorphine, in December 2005 SAMHSA/CSAT officials received several anecdotal reports of buprenorphine diversion and abuse in Vermont. To address the reports, SAMHSA/CSAT commissioned an independent assessment of buprenorphine diversion and abuse (the results of which are described in a separate report). The assessment included a case study of the situation in Vermont, which was undertaken in collaboration with Vermont officials. Using information gathered from multiple sources, analysts set out to determine whether diversion and abuse of buprenorphine were occurring in the state and, if so, to assess the nature, extent, and source of the problem (if any) and to formulate recommendations for its amelioration. The plan of action devised for the Vermont case study consisted of several steps: 1. Working in concert with Vermont officials, gather additional information about the anecdotal reports of buprenorphine diversion and abuse. 2. Analyze all available information (Appendices A and B) to determine whether there is evidence to support or refute the anecdotal reports. 3. Convene a panel of outside experts (Appendix C) to examine and interpret the information gathered and to formulate recommendations for future action. The results are summarized below. FINDINGS, CONCLUSIONS AND RECOMMENDATIONS The case study employed interviews with Vermont officials, as well as analysis of data from the DEA’s Automation of Reports and Consolidated Orders System (ARCOS) and National Forensic Laboratory Information System (NFLIS) reports, Vermont Medicaid records, SAMHSA’s DAWNLive! medical examiner reports, treatment data from the Vermont Office of Drug and Alcohol Programs and SAMHSA’s Treatment Episode Data Set (TEDS), the Northern New England Poison Control Center, and the Vermont state police and corrections system. ARCOS data show a rate of buprenorphine consumption in Vermont – as measured in grams per 100,000 population – that is more than ten times the national average: 583 grams per 100,000 population in Vermont, compared with a U.S. average of 56 grams per 100,000 population (Exhibit 1). Unfortunately, the data do not tell us the reasons for these rankings, which may reflect a problem with diversion and abuse of buprenorphine but, equally plausibly, may suggest that Vermont officials have been very effective in recruiting physicians to prescribe buprenorphine, and that a consumption rate of 583 grams per 100,000 population indicates that the goals for officebased treatment of opioid addiction are being met in the state. Multiple explanations were tested through a detailed examination of the various datasets and through informationcollection interviews with State and Federal officials and other experts. The results are summarized below. Results of the Vermont Case Study 6
Vermont Maine Exhibit 1. ARCOS Data: States With the Highest Per Capita Consumption of Buprenorphine (in grams and dosage units per 100,000 population), January – December 2005 Massachusetts Rhode Island Maryland U.S. Average Dosage Units Grams Per Per 100,000 Pop. 100,000 Pop. 82,948 Vermont 583.56 53,573 Maine 324.02 37,642 Massachusetts 253.17 31,783 Rhode Island 204.27 20,588 Maryland 127.56 9,090 U.S. Average 56.73 Source: U.S. Drug Enforcement Administration: Automation of Reports and Consolidated Orders System, ARCOS 2, Report 4, 01/01/2005 to 12/31/2005. Hypothesis 1: Vermont has been unusually successful in recruiting primary care physicians to prescribe buprenorphine, resulting in high levels of per capital consumption. Relevant Information: Todd Mandell, M.D., Medical Director of the Vermont SSA, reported that Vermont has a very small number of certified addiction medicine or addiction psychiatry specialists (e.g., only six ASAM members and a similarly small contingent of members of AAAP or AOAAM), so engaging nonspecialist physicians in the use of buprenorphine to treat addiction is a key strategy in increasing access to treatment. In an effort to engage physicians in the use of buprenorphine to treat addiction, Vermont has developed administrative and clinical guidelines for officebased practice (Appendix D) and offered modest financial incentives. In addition, Dr. Mandell offers telephone consultations to waivered physicians who have questions about buprenorphine dosing and other patient management issues. Dr. Mandell encourages such physicians not to exceed 16 to 20mg dose levels without obtaining outside consultation. As a result of these efforts, Vermont has the highest rate of participating physicians in the U.S. Conclusions: Experts consulted for the case study commended Vermont officials for their efforts to recruit physicians to use buprenorphine in officebased treatment of opioid addiction. Specifically, they were very supportive of the proposed incentive plan to expand the availability of medicationassisted treatment in Vermont. The Vermont Legislature provided Medicaid with a onetime fund of $500,000 for the incentive plan and a onetime fund of $350,000 to the Vermont Office of Drug and Alcohol Programs for the purpose of training physicians and developing a Results of the Vermont Case Study 7
Page 1 and 2: Diversion and Abuse of Buprenorphin
Page 3 and 4: CONTENTS Summary 5 Background 5 Fin
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Page 9 and 10: Exhibit 2a. Vermont Data: Distribut
Page 11 and 12: the prescriptions were dispensed. D
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

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