Opioid overdoses: Buprenorphine deaths didn't rise during pandemic

• During the COVID-19 pandemic, the U.S. government allowed qualified practitioners to remotely prescribe buprenorphine to treat opioid use disorder.
• A cross-sectional study looked at 74,474 opioid-involved overdose deaths from July 2019 to June 2021.
• Researchers report that buprenorphine was involved in less than 3% of opioid-involved overdose deaths during this time period.
• The proportion of opioid-involved overdose deaths involving buprenorphine did not increase when prescription regulations were loosened due to the pandemic.

Health practitioners consider medication-assisted treatment to be the gold standard for the treatment of opioid use disorder.

Both prescription and illegal use of opioids can lead to the disorder. Some examples of opioids include:

• fentanyl
• codeine
• morphine
• oxycodone
• heroin

Over time, individuals can become dependent on opioids. When they attempt to stop taking the drugs, they might experience physical and psychological withdrawal symptoms.

A doctor may prescribe medication-assisted treatment using methadone or buprenorphine.

Buprenorphine belongs to a class of drugs called partial opioid agonists, which means it only partially activates opiate receptors. Buprenorphine can help diminish withdrawal symptoms and cravings that come with opioid use disorder.

A cross-sectional study by researchers at the National Institute on Drug Abuse (NIDA), part of the National Institutes of Health, and the Centers for Disease Control and Prevention (CDC) was published in JAMA Network Open

In it, researchers report that the proportion of deaths from opioid overdose involving buprenorphine did not increase in the months after the government loosened regulations for prescribing buprenorphine during the COVID-19 pandemic. The changes included allowing qualified prescribers to remotely prescribe the drug over the internet and the phone.

Beth Macy, a journalist who chronicles the United States’ opioid epidemic in the books “Dopesick” and “Raising Lazarus,” told Medical News Today that the study “is underscored by every interview I’ve done on the opioid crisis.”

“Anything we can do to make lifesaving buprenorphine treatments more available to people with [opioid use disorder] in an era of deadly fentanyl is good,” Macy said. “We have to do more to create more urgency to address these deaths, and telehealth takes away barriers to treatment, particularly for rural people.”

Expanding access to treatment 

Dr. Nora Volkow, the director of NIDA and lead author of the study, explained to MNT that it was crucial to compile data to illustrate what impact these changes to prescribing buprenorphine made and especially whether the changes were associated with adverse effects.

Volkow was not surprised that the analysis showed overdoses involving buprenorphine did not increase after the government allowed more flexibility in prescribing the drug.

On the illicit market, she pointed out, there are opiates that are cheaper and more potent. “Buprenorphine is not a drug that is favored for its rewarding effects,” Volkow said.

Even so, she stressed, the importance of data.

“You can say ‘I doubt that is going to contribute negatively,’ but it’s crucial that one has the the evidence that actually demonstrates this,” Volkow said.

An underused treatment

In their paper, the researchers explain that prescribing buprenorphine to someone with opioid use disorder has been shown to result in reduced illicit opioid use and prescription opioid misuse as well as decreased risk for injection-related infectious diseases and decreased risk for overdoses, both fatal and nonfatal.

A 2022 study reported that the more flexible prescribing rules for buprenorphine led to improved retention of care over six months.

Despite its benefits, buprenorphine is underused. Another 2022 study found fewer than half of Americans received medication-assisted therapy at the time of treatment initiation for opioid use disorder.

Opioid-involved overdose deaths increased during pandemic

The researchers analyzed drug overdose death trends in 31 states and the District of Columbia that occurred from July 2019 to June 2021. This was nine months previous to more flexible prescriptions regulations being implemented and 15 months afterward.

They also studied drug co-involvement, decedent demographics, and urbanicity in 47 jurisdictions with death certificate data available for at least one 6-month period during the same time period.

Ultimately, they looked at 89, 111 total overdose deaths and 74,474 opioid-involved overdose deaths. Of those, 1,955 were buprenorphine-involved overdose deaths, accounting for less than 3% of opioid-involved overdose deaths.

Among buprenorphine-involved overdose deaths, 98% were categorized as unintentional and less than 2% were categorized as undetermined intent. In addition, 92% involved at least one other drug.

A larger proportion of individuals who died from buprenorphine-involved overdoses were female and a higher proportion occurred in the 35 to 44 years age group.

More than 85% of buprenorphine-involved overdose deaths occurred among white, non-Hispanic individuals.

Compared to other opioid–involved deaths, buprenorphine-involved overdose deaths were also more likely to involve prescription medications such as stimulants and benzodiazepines and less likely to involve illicitly manufactured fentanyl.

Individuals who died from buprenorphine-involved overdoses were also more likely to be receiving mental health treatment and more likely to die at home.

In their paper, researchers point to a 2019 study that found buprenorphine misuse was associated more with attempts to manage withdrawal symptoms rather than to get high.

Dr. Randall Dwenger, the chief medical officer at Mountainside Treatment Center, a center for alcohol and drug rehab with locations in the northeastern United States, pointed out to MNT that “if you look at the study, there’s also people combining buprenorphine with with other prescribed medications or illicit drugs and those are contributing to basically the respiratory depression that takes their lives.”

Overdose prevention education needed

The researchers write in their paper that the findings illustrate the need to advance clinical strategies that take into account the complexity of polysubstance abuse as well as address co-occurring mental health issues.

They stress that both individuals at risk for overdose and their caregivers need naloxone and overdose prevention education.

The researchers highlight in their paper that of the individuals who died from opioid–involved overdoses, fewer than 6% were in treatment for opioid use disorder and only 3% were receiving medication-assisted treatment.

“How do we get people who are using opiates to engage in some sort of treatment?” Dwenger noted. “Access really is key.”

He stressed the importance of increasing the number of health practitioners willing to prescribe medications for treatment.

“I think that we need to increase education in our medical schools and in our advanced training for nurse practitioners, so that everybody feels comfortable… whenever they see somebody who has an opioid addiction, to be able to give them this life saving medication,” he said.

New regulations on opioid use

Similar to this study, a 2022 study found no association between methadone-involved overdose deaths and more flexible prescription regulations for methadone-based opioid use disorder treatment that began during the pandemic.

The U.S. Drug Enforcement Administration announced in February a proposed rule that could extend some flexibility for treatments.

If the proposed rule is drafted into final regulations, health practitioners could still use telemedicine to order an initial 30-day supply of buprenorphine, but individuals would still need to complete an in-person visit for a refill.

“That has not been finalized,” Volkow stressed. “It seems that buprenorphine is [one] where the data may be more solid to show that it appears to be safe to prescribe buprenorphine by telemedicine… I’m optimistic. We’ll see, right?”

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