Posts Tagged ‘injection of suboxone’

Treatment Implications for Intravenous Buprenorphine Use

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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) seventeen 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 year I’m seeing more and more new patients who say they use 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 who snort buprenorphine also get higher blood levels than those who use this medication sublingually. Compared to intravenous use, it’s probably less risky to use in this manner, but still can cause problems with irritation to the mucosa of the nose and sinuses. We don’t know about long-term damage because – of course – no studies have been done on this topic, since the medication isn’t intended to be used intranasally.

People who have used opioids intravenously or intranasally often associate the act of injecting or snorting with euphoria. They can become addicted to the process of both means of ingestion. This can happen with buprenorphine too, though studies show most people who inject or snort are trying to keep themselves out of withdrawal with the medication, and not to feel euphoria.

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 year I’ve seen three patients with spinal abscesses from injecting drugs, though not necessarily buprenorphine.

When 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, not only the monoproducts. Granted, it’s less common, but it still occurs.

But this is only my opinion. I can’t find any research that randomizes patients with histories of intravenous buprenorphine and/or buprenorphine/naloxone use to either care at opioid treatment programs with daily dosing, or care at office-based treatment settings.

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 treated with methadone, or buprenorphine – with precautions.

Opioid treatment programs can do observed, daily, on-site dosing of buprenorphine.

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. Some of the diversion was in patients who wanted to inject their dose later. This is particularly risky, given the bacteria that live in our mouths.

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 discuss depot naltrexone, or refer them to another form of treatment.

If patients with histories of injecting buprenorphine want treatment with buprenorphine, I tell them I’m willing to give it a try, but that they 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.

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

This isn’t a perfect system. But for the most part, we give people with a history of intravenous buprenorphine use a way to use buprenorphine as a treatment medication and as an alternative to methadone.