Buprenorphine, an opioid partial agonist, is a cornerstone of medication-assisted treatment for opioid use disorder. It helps people stay in treatment and cuts illicit opioid use. Combination transmucosal products pair it with naloxone, an opioid antagonist that blunts the desired effect and can bring on sudden withdrawal if the product is injected. That design is meant to discourage injection, but people have been reported injecting these products anyway.
Earlier research found that in 2016–2017, 14.6% of about 127,000 emergency department (ED) visits for nonmedical use of prescription opioids involved buprenorphine, often for complications of injecting it. These visits involved less severe overdose effects, such as unresponsiveness or cardiorespiratory failure, than visits involving other opioids. A short CDC report looked more closely at the injection complications, which are a potentially preventable harm.
The numbers
The data came from the National Electronic Injury Surveillance System–Cooperative Adverse Drug Event Surveillance project, a nationally representative surveillance system covering EDs. Reviewing records from 2016–2018, CDC found 598 cases of nonmedical injection of prescription opioids, from which it estimated an average of 47,437 such ED visits a year nationwide (95% confidence interval 27,004–67,871). About a third (34.2%) involved transmucosal buprenorphine.
Among the estimated visits for injecting transmucosal buprenorphine:
| Finding | Estimate |
|---|---|
| Average patient age | 33 years (range 20–56) |
| Patients who were men | 66.0% |
| Visits involving a buprenorphine/naloxone combination product | 85.4% |
| Patients treated and released, or who left against medical advice | 66.0% |
| Visits where heroin, cocaine or other nonpharmaceutical drugs were also used | 31.6% |
| Visits with a complication specific to injection | 67.2% |
"Nonmedical use" here covered abuse, taking the drug in a way other than directed (for example, to self-treat withdrawal), and overdoses where no purpose was documented.
Complications
Among 101 surveillance cases of ED visits for injection-specific complications, the problems recorded were:
- cellulitis (41)
- abscess (37)
- noninfectious complications such as clotting or loss of blood flow at the injection site (14)
- unspecified injection-site infections, such as a "hand infection" (3)
- infective endocarditis (2)
- sepsis (2)
- septic arthritis (2)
The national estimates probably undercount these visits, because patients may not say they injected, and chronic infections that follow injection, such as HIV or hepatitis C, may go unrecognized.
Preventing harm without limiting treatment
The authors stress that buprenorphine treatment is an important part of the response to the opioid overdose epidemic, and that the aim is to prevent injection complications while keeping this effective therapy available. They suggest that EDs and other settings seeing patients with injection-related complications:
- refer them to syringe services programs, where these exist, and teach infection prevention
- link them to treatment for substance use disorders and to recovery support services
- build counseling about the risks of injecting buprenorphine into patient education for medication-assisted treatment
Sources
- Tanwar S, Geller AI, Lovegrove MC, Budnitz DS. "Notes from the Field: Emergency Visits for Complications of Injecting Transmucosal Buprenorphine Products — United States, 2016–2018." MMWR 69(32). https://www.cdc.gov/mmwr/volumes/69/wr/mm6932a5.htm
Licence: CC0 1.0 (public domain) · Adapted from www.cdc.gov
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