Treatment Implications for Intravenous Buprenorphine Use

Hokey Pokey

 

 

During the admission of new patients for opioid use disorder treatment, I ask about prior use of all drugs. I include the medications we use for treatment. I’ve done this since I started working at opioid treatment programs (OTPs) fifteen years ago.

Over the last few years, more patients say they’ve used illicit buprenorphine in the past. At first, I saw patients who were using it sublingually (under the tongue), as recommended, though still illicitly. Most of them wanted to see if this medication would work for them before they committed to the time and expense of entering a treatment program.

Over the past six months, I’m seeing more and more new patients who say they’re using buprenorphine intravenously. This past month, I’d estimate that a fourth of the patients who use buprenorphine illicitly are injecting it. Only a few said they snort buprenorphine.

This presents a big wrinkle to the treatment process.

I see why people use intravenous buprenorphine. It has low sublingual bioavailability, at around thirty percent. That means injecting two or three milligrams gives the same blood level as eight milligrams sublingually. In the short term, people injecting buprenorphine feel like it saves them money. In the long term, I’m certain it will cost more than they can imagine.

Buprenorphine tablets and films were not designed to be injected. Pills and films have fillers in them, and they aren’t sterile. Heating a mixture prior to injection will kill off some of the bacteria, so that’s a harm reduction practice. Using a filter can remove some of the particulate matter, also reducing the potential for harm. However, heat and filters can’t remove all the risk of injecting.

People on the internet insist the bioavailability of snorted buprenorphine is higher than sublingual use, but I doubt that. Either way, you bypass the liver because it crosses to the bloodstream via the veins of the nose or tongue. Plus, alkaline environments increase absorption and bioavailability for this drug, and the mouth is more alkaline than the nose.

Of course there is another reason people with opioid use disorder inject or snort their medication. Their brains associate the act of injecting or snorting with pleasure and euphoria, and can become addicted to the process and feeling of both means of ingestion.

Due to the ceiling on buprenorphine’s opioid effect, it is… arguably… one of the safest opioids a person could inject. But intravenous use is never safe.

Here’s only a partial list of complications from intravenous drug use:

  1. Overdose resulting in death, brain damage from low oxygen, stroke or heart attack from prolonged low oxygen
  2. Pulmonary edema (lungs fill with fluid)
  3. Skin abscesses and cellulitis
  4. Endocarditis (infection of heart valve that is life-threatening)
  5. Deep vein thrombosis (blood clot)
  6. Septic thrombophlebitis (infected blood clot)
  7. Contracting infections: HIV, Hep C or B
  8. Bacterial infections and abscesses in weird places like the spine, brain, joints, spleen, muscles, or eye
  9. Necrotizing fasciitis – rapid, “flesh- eating” infection, also botulism
  10. Pneumonia
  11. Septic emboli – when infected clots break off and go to the lungs, brain from infected heart valves
  12. Fungal blood/eye infections – (seen frequently when pills mixed with saliva are injected)

I have seen patients with every one of these complications. Most of them were in the distant past, when I was an Internal Medicine resident during the late 1980’s, but not all of them. Over the past six months, I’ve seen two patients with spinal abscesses from injecting drugs, though not necessarily buprenorphine.

The last time I posted about intravenous use of buprenorphine (November 2015), Dr. Wartenberg M.D. (pioneer in the addiction treatment field) wrote about the mitochondrial disease, which has caused liver failure, in European IV buprenorphine drug users. This disorder is specific to buprenorphine

So what are the treatment implications for a new patient who has injected buprenorphine?

First of all, these patients aren’t appropriate for office-based practices, even if the physician plans to prescribe the combination product with buprenorphine/naloxone. Clearly there are some patients who inject combination products and monoproducts. Granted, it’s less common, but it still occurs. There’s usually not enough oversight available at office-based practices to treat more complicated patients. I think they should be referred to opioid treatment programs, where they can be offered treatment with methadone.

What if the patient refuses methadone for some reason, or their risk with methadone is at too high from a medical view? Should patients with a history of injecting buprenorphine ever be treated with buprenorphine?

I think they can be – with great caution and daily dosing, on-site at the opioid treatment program.

At our OTP, we ask all buprenorphine patients to sit in a designated area while their dose dissolves. It usually takes around ten minutes, and they are watched by program personnel. Before they leave, each buprenorphine patient shows one of the staff their mouth, to show the medication is completely dissolved. It does feel a little “police-y” but we had a high incidence of diversion until we started this close observation.

If a patient tries to spit out their medication, they meet with me. I’m rarely willing to continue to prescribe buprenorphine if it appears they are trying to divert their medication. I meet with the patient and we discuss the option of methadone. If they refuse methadone, we try to refer them to another form of treatment.

If a patient with a history of injecting buprenorphine wants treatment with buprenorphine, I tell him I’m willing to give it a try, but that he can’t expect take home doses for a very long time, after months of observed dosing and stability. So far, this approach seems to be working. These patients are getting counseling, and haven’t attempted to divert their medication, so far as we can see. I’ve checked these patients for track marks, which in all cases appear to be healing, with no new marks.

When/if to grant these patients take homes remains a huge question. I don’t want to unduly burden a patient by insisting he must come every day forever, but I also don’t want to give the patient take home doses that could lead to a relapse back to intravenous use.

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5 responses to this post.

  1. Posted by shifter9A on October 24, 2016 at 7:08 am

    If it were given to them in injectible form, it sure would prevent a lot of harm, as they are going to do it anyway. To anyone else, including me, it sounds insane, but obviously nothing will deter them.

    Reply

  2. Posted by meghan on October 24, 2016 at 5:25 pm

    It upsets me to hear that people still abuse bup by snorting and shooting. I loved snorting and shooting drugs in the old days too so I get that the ritual of doing so is part of the turn on. But at some point one has to stop with the needles and the straws and try to accept the medication for what it is. It’s designed to save our lives and give us back as much as a normal functioning life we drug addicts can possibly hope for. Anyone who still can’t give up the needles and straws are halfway there but still need to make the push to get the rest of the way there. Which is on the drug using it as the doctor prescribes it and nothing other than that is really acceptable. JMHO It’s taken so long for those of us that use it correctly to get where we’re being trusted enough that our doctors give us refills and don’t treat us like junkies. News like this makes me sad that it ruins it for others. I can’t blame anyone tho. We’re addicts and I know we do what addicts do. It’s just frustrating to hear since I take my subs as prescribed and have not felt this “normal” in more than 10 years. This drug is a life saver is you want to save your life.

    Reply

  3. Posted by Alan Wartenberg MD on October 24, 2016 at 6:11 pm

    Would point out that if you are using buprenorphine in an OTP, you can bring virtually any patient automatically to 3 day status by just re-titrating after you find their stable daily dose. So if they are stable on 12 mg per day, they can be either gradually (or actually even abruptly) switched to 24 mg on Mon and Wed and 36 mg on Friday, or just put on 24 mg every other day. Some folks have even gone to twice weekly dosing if travel or access to the program is a problem.

    Reply

    • When I started using buprenorphine in the OTP setting, I did try M, W, F dosing, but none of those patients did well. For whatever reason, the patients who wanted to dose three times per week all kept using illicit opioids. Of course, this is all anecdotal experience.
      Maybe I’ll try this again with this patient population – thanks for the idea.

      Reply

  4. I know of one hospital that used to use injections of Buprenorphine instead of Methadone for detox before Suboxone and subutex came out. (Long before DATA 2000) was this common in some places at one time?

    Reply

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