Evidence shows that buprenorphine treatment in medication-assisted treatment (MAT) programs improves outcomes for people with opioid use disorder (OUD). A recent study published in the Journal of the American Medical Association (JAMA) explores whether easing rules around buprenorphine during the COVID-19 pandemic increased rates of buprenorphine-involved overdose deaths. Concern about increased overdose deaths resulting from expanded access was warranted. As an opioid medication, risk of diversion for illicit purpose accompanies any buprenorphine prescription.
In this article, we’ll discuss that study and answer an important question:
Did increasing access to buprenorphine treatment during COVID-19 increase risk of fatal overdose?
Let’s find out.
Buprenorphine Treatment for Opioid Use Disorder: A Key Component of Our National Strategy
In a press release published by the National Institute on Drug Abuse (NIDA) in January 2023, NIDA Director Dr. Nora Volkow observed:
“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.”
That’s the core of the issue we address here. Medications for opioid use disorder (MOUD) are effective, but drastically underutilized. Expanding access to these medications is a balancing act between the health of patients and the risks inherent in any treatment plan involving opioid medication. The current research assesses that balance to determine exactly where buprenorphine stands in this process: does expanded help people, or harm them?
In the federal budget for 2023, the U.S. government changed several rules in the Controlled Substances Act that affect the way physicians can prescribe buprenorphine. One new rule allows physicians to prescribe buprenorphine to treat opioid use disorder without obtaining a specific waiver, known as the X waiver. This rule change is related to the accommodations the federal government instituted during the COVID-19 public health crisis, which included:
- Allowing remote prescriptions for buprenorphine
- Expanding Medicaid/Medicare payments for telehealth services for mental health and addiction treatment
- Increasing the number of accepted communication technologies used for remote care/virtual treatment, care, and support
To understand the effect of the rule changes, researchers examined data from the State Unintentional Drug Overdose Reporting System (SUDORS) maintained by the Centers for Disease Control (CDC). The SUDORS system collects data on overdose deaths from 46 states and the District of Columbia, using:
- Death certificates
- Medical examiner/coroner’s reports
- Postmortem drug testing
Researchers analyzed records from before and during the pandemic, from July 2019 to June 2021. Their primary goal was to identify any change in the overdose death rate during that period and determine the role of buprenorphine in any increases or decreases.
We’ll discuss the results of this research effort in a moment. First, we’ll offer a quick update on the current state of the opioid crisis in the U.S.
The Opioid Crisis in the U.S.: Where Are We Now?
The latest data from the CDC offers preliminary evidence that we may be turning a corner, and that our efforts over the past five years are having an impact. We say that not because opioid overdose rates are decreasing dramatically, but rather, that between 2021 and 2022, they did not increase dramatically.
Here’s the data. We’ll include several years to put these numbers in perspective.
- Total fatal drug overdose: 19,934
- Opioid-related: 9,486
- Total fatal drug overdose: 41,340
- Opioid-related: 22,784
- Total fatal drug overdose: 70,237
- Opioid-related: 42,435
- Total fatal drug overdose: 91,799
- Opioid-related: 68,630
- Total fatal drug overdose: 106,699
- Opioid-related: 80,411
2022 (provisional data through November):
- Total fatal drug overdose: 103,550
- Opioid-related: 78,333
We can see preliminary evidence that our overall national strategy is beginning to work in the change in the percent increases in overall overdose deaths and opioid-related overdose deaths over the past five years.
From 2001 to 2011, records show a 107 percent increase in overall overdose deaths, and a 140 percent increase in opioid-related overdose death. Between 2011 and 2017, records show those increases at 70 percent and 85 percent, respectively. Between 2017 and 2021, records show those increases at 16 percent and 17 percent, respectively. Finally, between 2021 and 2022 – if we extrapolate from given data – records show those increases at 5.8 percent and 6.2 percent, respectively.
The data tells us that we haven’t stopped or completely reversed the trend in drug overdose or opioid overdose, which is the big-picture goal, but we have attenuated the yearly increases. What that means, in real human terms, is that our collective efforts are saving lives.
Now let’s look at the data from the study we introduce above.
Buprenorphine Treatment and Overdose Risk: National Study
In the study “Trends and Characteristics of Buprenorphine-Involved Overdose Deaths Prior to and During the COVID-19 Pandemic” researchers examined data from close to 90,000 reported overdose fatalities. Here’s the basic demographic information on the people who died of overdose during the study period:
- Male: 67,489
- Female: 27,875
- 18-24: 7,118
- 25-44: 50,125
- 45+: 37,482
- No high school degree: 19,213
- High school degree or equivalent: 49,063
- Some college/completed college: 24,087
- Urban: 27,923
- Suburban: 24,159
- Small town: 6,971
- Rural: 3,782
Those figures give us an idea of the groups most vulnerable to overdose: males in urban areas between the age of 25 and 44 with a high school degree or the equivalent. The research team controlled for specific factors, eliminated records with incomplete or unusable data, and reported the following data on the role of buprenorphine in fatal overdoses.
Total Overdose Deaths:
- 74,474 involved opioids
Buprenorphine-Related Overdose Deaths:
- 1,955 overdose deaths involved buprenorphine
- 2.2% of total overdose deaths
- 2.6% of opioid-involved overdose deaths
That’s the first confirmation that increasing access to buprenorphine did not increase risk of fatal overdose: over 97 percent of overdose deaths were not related to buprenorphine. Now let’s look at another key metric: the involvement of other substances in overdose fatalities.
Polysubstance Misuse and Overdose Fatality
When a person misuses more than one substance it’s called polysubstance misuse. Combining drugs, along with the influx of fentanyl in the national illicit drug market, drives the current phase of the overdose crisis. We can see this impact in the increase in overdose deaths between 2017 and 2020: overdose rates rose significantly, and authorities indicate the presence of fentanyl is largely responsible for this increase.
When researchers narrowed their focus to look at data for overdose deaths between April 2020 and June 2021, the period during which authorities eased buprenorphine regulations, the data showed that while the rate of opioid-related overdose deaths increased, the rate of buprenorphine-related deaths did not increase.
They also identified evidence of widespread polysubstance misuse:
- 92.7% of buprenorphine-related deaths involved a second, non-opioid drug
- 67.2% of buprenorphine-related deaths involved another opioid
The takeaway from those two bullet points is that these overdose deaths were more likely caused by the other drugs, rather than buprenorphine. That’s the second confirmation that increasing access to buprenorphine did not increase risk of fatal overdose: the vast majority of deaths involved a complicated mix of substances, and cannot be attribute to buprenorphine.
Let’s take a closer look at the role of other substances in the overdose deaths examined in the study. Researchers found that buprenorphine-involved overdose deaths often involved prescription medications, including:
- Involved in 36.9% of buprenorphine-related overdose deaths
- Involved in 14.5% of other opioid-related overdose
- Involved in 13.9% of buprenorphine-related overdose deaths
- Involved in 5.0% of other opioid related overdose deaths
- Involved in 18.6% of buprenorphine-related overdose deaths
- Involved in 5.4% other opioid related overdose deaths
In addition, they found that fewer buprenorphine-related overdose deaths involved fentanyl than other opioid related overdose deaths:
- 50.2% of buprenorphine-related overdose deaths involved fentanyl
- 85.33% of other opioid related overdose deaths involved fentanyl
Other Illicit Drugs
- 28.4% of buprenorphine-related overdose deaths involved illicit drugs
- 38.5% of other opioid related overdose deaths involved illicit drugs
We now have sufficient information to answer the question posed at the beginning of this article:
Did increasing access to buprenorphine treatment during COVID-19 increase risk of fatal overdose?
The data indicates the answer is a clear “No.”
The data also indicates that a primary cause for the increase in overdose deaths was polysubstance misuse, and the presence of fentanyl in the illicit drug supply in the U.S.
Increasing Access and Harm Reduction: Effective Strategies for the Present and Future
Increasing access to medications for opioid use disorder is a key component of our national strategy to address the overdose crisis. This increase is part of an overall approach to substance use treatment called harm reduction. Harm reduction also involves components that can mitigate harm caused by polysubstance misuse, such as therapy, counseling, lifestyle changes, community support, and resources to address inequities in the social determinants of health.
To read more about harm reduction, please navigate to the blog section of our website and read this article:
That article includes an overview of harm reduction, how it works, its basic principles, and how we harm reduction can reduce the negative effects of substance use disorder (SUD) in general, and opioid use disorder (OUD) in particular.
With regards to the impact of increasing buprenorphine access on overdose fatalities, we’ll give the last word in this article to the study authors themselves:
“The proportion of buprenorphine-involved overdose deaths…did not increase when buprenorphine prescribing regulations were relaxed due to the COVID-19 pandemic. These findings have important policy implications when policy makers consider whether COVID-19–related buprenorphine prescribing flexibilities should be permanently adopted.”
Almost the last word. We’ll close by reminding anyone reading this article who needs treatment or has a friend or loved one who needs treatment that the sooner a person with SUD who needs treatment gets treatment, the better the outcome. People with opioid use disorder (OUD) can visit the Buprenorphine Practitioner Locater maintained by the Substance Abuse and Mental Health Services Administration (SAMHSA).