Buprenorphine-involved overdose deaths did not increase after implementation of prescribing flexibilities

Reviewed by Emily Henderson, B.Sc.Jan 20 2023

The proportion of opioid overdose deaths involving buprenorphine, a medication used to treat opioid use disorder, did not increase in the months after prescribing flexibilities were put in place during the COVID-19 pandemic, according to a new study. These data provide evidence that may help to inform buprenorphine prescribing policies. Published today in JAMA Network Open, this study was a collaborative effort between 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).

These data are consistent with a recent study reporting that COVID-era expansion of methadone access for the treatment of opioid use disorder was not associated with an increase in methadone-involved overdose deaths.

In 2021, nearly 107,000 people died of a drug overdose, with 75% of those deaths involving an opioid. The overall rise in overdose deaths is largely attributable to the proliferation in the drug supply of illicit fentanyl, a highly potent synthetic opioid. Though the benefits of providing medication for opioid use disorder are well-known, only 22% of people with opioid use disorder receive medications. Buprenorphine, one of these medications, helps reduce opioid misuse, decrease risk for injection-related infectious diseases, and decrease risk for fatal and non-fatal overdoses.

Research has shown beyond a doubt that medications for opioid use disorder are overwhelmingly beneficial and can be lifesaving, yet they continue to be vastly underused. Expanding more equitable access to these medications for people with substance use disorders is a critical part of our nation's response to the overdose crisis. The findings from this study strengthen existing evidence suggesting that greater flexibility in prescribing may be one safe method for working toward this goal."

Nora Volkow, M.D., NIDA Director and Senior Author

While the recently signed Fiscal Year 2023 omnibus appropriations bill amended the Controlled Substances Act to eliminate the requirement that clinicians obtain a specific waiver to prescribe buprenorphine to treat opioid use disorder, buprenorphine remains a Schedule III controlled substance with restrictions on prescribing. During the onset of the COVID-19 pandemic, the United States government implemented prescribing flexibilities to facilitate buprenorphine access for patients with opioid use disorder. These updated policies allowed clinicians to remotely prescribe buprenorphine to new patients without conducting in-person examinations, expanded payment for telehealth services, and provided flexibility on accepted communication technologies to deliver clinical care for people with substance use disorders via telehealth.

To investigate the impact of these policy changes, researchers used data from the CDC's State Unintentional Drug Overdose Reporting System (SUDORS) to assess overdose deaths from July 2019 to June 2021 in 46 states and the District of Columbia. SUDORS combines data from death certificates, medical examiner and coroner reports, and postmortem toxicology testing.

Researchers found that buprenorphine was involved in a very small proportion of drug overdose deaths between July 2019 and June 2021. During this study period, there were 1,955 buprenorphine-involved overdose deaths, which represented 2.2% of the 89,111 total overdose deaths and 2.6% of the 74,474 opioid-involved overdose deaths recorded in the SUDORS dataset. Between April 2020 and June 2021, when buprenorphine prescribing regulations were relaxed in response to the COVID-19 pandemic, the researchers found that while monthly opioid-involved overdose deaths increased overall, the proportion of those deaths involving buprenorphine did not increase.

Additionally, the study found that 92.7% of buprenorphine-involved overdose deaths also involved at least one other drug, compared to 67.2% of deaths involving an opioid other than buprenorphine. Specifically, compared with other opioid-involved overdose deaths, buprenorphine-involved overdose deaths were more likely to also involve prescription medications such as benzodiazepines (36.9% vs. 14.5%), antidepressants (13.9% vs. 5.0%), and anticonvulsants (18.6% vs. 5.4%). Buprenorphine-involved overdose deaths were less likely to also involve illicitly manufactured fentanyls (50.2%) compared to other opioid-involved overdose deaths (85.3%).

"These findings help us better understand the circumstances of overdose deaths involving buprenorphine, which is crucial in our ability to inform policy, ensure safety, and improve clinical outcomes for people with substance use disorders," said Lauren Tanz, Sc.D., an epidemiologist at CDC's National Center for Injury Prevention and Control and lead author on the study. "It is important to note the presence of other drugs in overdose deaths involving buprenorphine. The complex nature of substance use disorders and polysubstance use requires specific strategies to address it."

Data also showed that non-Hispanic white people represented a higher proportion of the deaths involving buprenorphine (86.1%), compared to deaths related to other opioids (69.4%). In contrast, buprenorphine-involved overdose deaths included fewer Black, non-Hispanic people (5.7%), and Hispanic people (5.5%) compared with other opioid-involved overdose deaths (18.8% and 9.4%, respectively), which the authors note might be related to inequitable access to treatment.

Regardless of the drugs involved, the investigators found that most people who died of an overdose involving any opioid, including buprenorphine, had no evidence of current treatment for substance use disorders. In addition, most deaths occurred without another person being present, a known risk factor for fatal overdose.