The case for decriminalizing the street sale of buprenorphine

Isolation and anxiety caused by the Covid-19 pandemic has fueled an already out of control overdose crisis. In 2020 alone, more than 100,000 individuals died from overdose.

With overdose rates reaching unfathomable heights, dramatic steps are needed to stem the loss of life.

The Department of Health and Human Services took one important step by eliminating a special training requirement — obtaining a so-called X waiver — for clinicians to be able to prescribe buprenorphine, a partial opioid agonist used to treat opioid use disorder. This drug helps people avoid opioids by reducing opioid cravings and withdrawal symptoms.

While the waiver elimination aims to expand access to this lifesaving medication, some critics says that deregulation would lead to increased “diversion” of buprenorphine, meaning its use for some purpose other than its intended use, or by someone other than the person it was prescribed for.

Although it is difficult to get high on buprenorphine, some people do use it as a recreational drug. Rates of overdose, however, are low: Buprenorphine accounted for less than 5% of overdose deaths in Tennessee in 2020.

People who use buprenorphine prescribed for someone else generally use it to help treat their opioid use disorder. One study from Massachusetts found that greater than 90% of individuals who had used diverted buprenorphine did so to prevent opioid craving or withdrawal, while less than 10% used it to get high.

Although medication diversion of any sort is generally considered harmful, as we argue in a commentary published on Tuesday in the Journal of the American Board of Family Medicine, the potential of diverted buprenorphine to save lives outweighs any hypothetical harms of its use.

The effects of buprenorphine are stunning. One meta-analysis found that people taking buprenorphine are 64% less likely to die from overdose as those not taking medications for opioid use disorder. For reference, statins, regarded as one of the most beneficial and universally supported medications used in the treatment of heart disease, reduce the risk of major coronary events by roughly 30%.

Though we recognize the potential dangers of buying and selling drugs “on the street,” we must point out that the lifesaving effect of buprenorphine remains even when it is being diverted. A recent study found that use of non-prescribed buprenorphine, even when used less than once a week, reduced the risk of unintentional overdose. Buprenorphine in and of itself, even when separated from structured medical care, is a powerful tool to reduce the risk of overdose.

Another benefit of diverted buprenorphine is that it offers a stepping stone for people who are not being treated for addiction to seek medical care. The National Survey on Drug Use and Health found that only 10% of individuals who need substance use treatment received care from an addiction specialist. While some of the deficit is due to a lack of available clinicians or treatment centers, there are many people who intentionally avoid seeking medical care due to a long history of mistreatment, stigma, and marginalization of people who use drugs.

As we have heard from patients and colleagues, a large proportion of those seeking medications for treating opioid use disorder have tried buprenorphine they’ve been given by a friend or bought on the street. For those who have reasons to distrust the medical system, diverted buprenorphine from a close contact offers an important gateway into medically supervised treatment. Indeed, studies have demonstrated an association between use of non-prescribed buprenorphine and that individual’s willingness to participate in treatment with a medical provider.

Over the last few years, opioids sold on the street have become dramatically more potent. The Centers for Disease Control and Prevention estimates that more than 70% of overdose deaths since the Covid-19 pandemic started have been caused by synthetic opioids such as fentanyl. Fentanyl has dominated the opioid market, and is now found in many other recreational drugs sold on the street, potentially contributing to the increasing the rates of overdose nationwide.

While buprenorphine carries its own risk of overdose, it is minuscule compared to that posed by fentanyl. A recent study of 534 opioid-involved deaths found that only one death was solely attributable to buprenorphine. The presence of diverted buprenorphine as an alternative to fentanyl offers a safer option for people who use drugs.

The availability of buprenorphine is particularly important as medications for opioid use disorder prescribed by a medical provider can be difficult to access. In one study done in New York, people who use heroin, a historically marginalized and underinsured group, have high levels of interest in using buprenorphine but low levels of access to it. And these difficulties in accessing buprenorphine disproportionately affect racially minoritized populations. While buprenorphine access increased between 2004 and 2013 for all New York City ZIP codes, this increase was greatest in primarily wealthy, white neighborhoods.

The availability of diverted buprenorphine may help increase access to communities that have historically been excluded from medically directed buprenorphine. However, it is important to acknowledge that this is not a legitimate long-term solution, and that additional work must be done to bridge the gap in care for these populations.

The overdose crisis shows no signs of abating; the last 12 months have been the deadliest in history, with over 100,000 overdose deaths for the first time. In times of crisis, we need to prioritize saving lives over and above our personal comfort zones or individual morals and values otherwise. With respect to overdose deaths, this means that buprenorphine should be available to everyone who needs it, whether that’s via prescriptions or otherwise. Making that happens requires easing concerns about diversion of buprenorphine and decriminalizing its sale.

This is more than just a pipe dream: in June of 2021, Vermont and Rhode Island became the first two U.S. states to decriminalize possession of non-prescribed buprenorphine.

Buprenorphine saves lives. It’s time to promote its use for those with opioid use disorders.

John C. Messinger is a third-year student at Harvard Medical School in Boston. Anand Chukka is a second-year student at Harvard Medical School. J. Wesley Boyd is a psychiatrist and professor of psychiatry and medical ethics in the Center for Medical Ethics and Health Policy at Baylor College of Medicine in Houston; and a lecturer on global health and social medicine at Harvard Medical School.