Buprenorphine use and disparities in access among emergency department patients with opioid use disorder: A cross-sectional study.

BACKGROUND: Buprenorphine, a partial mu-opioid agonist and kappa-opioid antagonist, is an approved treatment for opioid use disorder (OUD). Studies demonstrate that buprenorphine decreases cravings for other opioids, effectively ameliorates withdrawal symptoms, and decreases opioid overdose and mortality. However, buprenorphine remains under-utilized. Despite its low potential for misuse, research has reported wide use of non-prescribed buprenorphine, seemingly for its effectiveness in treating withdrawal and helping to maintain sobriety. We designed our study to describe patient experiences with both prescribed and non-prescribed buprenorphine usage and to identify potential disparities in buprenorphine access within a high-risk population of patients with OUD.

METHODS: This was a cross-sectional study conducted in the emergency department (ED) of a large inner-city university hospital from January 15, 2015, through April 30, 2018. Patients were eligible to participate in the study if they presented with opioid intoxication or after an opioid overdose and were 18 years of age or older. Research assistants administered surveys after the ED team deemed an eligible patient to be clinically sober.

RESULTS: The study enrolled 423 patients. Most patients in this study were white (59.8%) and male (77.5%), with a mean age of 37.5 years. A majority of patients (58.4%) had Medicaid insurance. Of those, 15.8% had previously been on medication for opioid use disorder (MOUD) with methadone, and 16.3% received outpatient buprenorphine. Most (72.8%, 95% CI 68.6-77.0%) respondents reported having used buprenorphine at one point. Of the participants reporting prior buprenorphine use, 15.5% had either traded, shared, or sold their buprenorphine in the past. Patients who obtained non-prescribed buprenorphine generally purchased it from a dealer, took only 8 mg at a time, and paid $10 per dose. Of those patients with a history of using buprenorphine, only 3.2% reported taking buprenorphine for euphoric effects, though 45.5% of participants declined to provide a specific reason for using the drug. Patients younger than 40 were more likely than those older than 40 to have taken buprenorphine in the past (81% vs 60%, p < 0.001). Further, white patients were more likely than nonwhite patients to have both used (42% vs 31%) and been prescribed buprenorphine (46% vs 25%, p < 0.001).

DISCUSSION: Familiarity with buprenorphine is high among patients with OUD, and our data show that there is a strong demand among these patients for access to legal buprenorphine-based treatment programs. However, a variety of issues hamper access to this medication. Most patients in our study reported having been to an in-patient detox or rehabilitation program, yet only 16% of patients participated in a buprenorphine-based program. Furthermore, less than half of patients surveyed (37%) received a prescription for buprenorphine, and few participants reported taking buprenorphine for euphoric effects. Our findings suggest that a major barrier exists in legally obtaining buprenorphine for treatment of OUD, and that there appear to be racial and other disparities in buprenorphine prescribing, further limiting access to patients. Buprenorphine access needs to be expanded to satisfy the unmet need for appropriate treatment of those struggling with OUD, with particular attention to older and nonwhite patients.