RTI International, Research Triangle, NC, USA.
Division of Infectious Disease, Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA.
Harm Reduct J. 2023 Oct 17;20(1):150. doi: 10.1186/s12954-023-00888-6.
Recent policies have lessened restrictions around prescribing buprenorphine-naloxone (buprenorphine) for the treatment of opioid use disorder (OUD). The primary concern expressed by critics of these policies is the potential for buprenorphine diversion. However, the population-level effects of increased buprenorphine diversion are unclear. If replacing the use of heroin or fentanyl, use of diverted buprenorphine could be protective.
Our study aim was to estimate the impact of buprenorphine diversion on opioid overdose using an agent-based model calibrated to North Carolina. We simulated the progression of opioid misuse and opioid-related outcomes over a 5-year period. Our status quo scenario assumed that 50% of those prescribed buprenorphine diverted at least one dose per week to other individuals with OUD and 10% of individuals with OUD used diverted buprenorphine at least once per week. A controlled prescription only scenario assumed that no buprenorphine would be diverted, while an increased diversion scenario assumed that 95% of those prescribed buprenorphine diverted and 50% of individuals with OUD used diverted buprenorphine. We assumed that use of diverted buprenorphine replaced the use of other opioids for that day. Sensitivity analyses increased the risk of overdose when using diverted buprenorphine, increased the frequency of diverted buprenorphine use, and simulated use of diverted buprenorphine by opioid-naïve individuals. Scenarios were compared on opioid overdose-related outcomes over the 5-year period.
Our status quo scenario predicted 10,658 (credible interval [CI]: 9699-11,679) fatal opioid overdoses. A scenario simulating controlled prescription only of buprenorphine (i.e., no diversion) resulted in 10,741 (9895-11,650) fatal opioid overdoses versus 10,301 (9439-11,244) within a scenario simulating increased diversion. Compared to the status quo, the controlled prescription only scenario resulted in a similar number of fatal overdoses, while the scenario with increased diversion of buprenorphine resulted in 357 (3.35%) fewer fatal overdoses. Even when increasing overdose risk while using diverted buprenorphine and incorporating use by opioid naïve individuals, increased diversion did not increase overdoses compared to a scenario with no buprenorphine diversion.
A similar number of opioid overdoses occurred under modeling conditions with increased rates of buprenorphine diversion among persons with OUD, with non-statistical trends toward lower opioid overdoses. These results support existing calls for low- to no-barrier access to buprenorphine for persons with OUD.
最近的政策放宽了阿片类药物使用障碍（OUD）治疗中丁丙诺啡-纳洛酮（丁丙诺啡）的处方限制。这些政策的批评者主要关注的是丁丙诺啡可能被转移的问题。然而，增加丁丙诺啡转移的人群水平影响尚不清楚。如果用丁丙诺啡替代海洛因或芬太尼的使用，那么使用被转移的丁丙诺啡可能具有保护作用。
我们的研究目的是使用基于代理的模型估计丁丙诺啡转移对阿片类药物过量的影响，并对北卡罗来纳州进行校准。我们模拟了 5 年内阿片类药物滥用和阿片类药物相关结果的进展。我们的现状情景假设，50%的开丁丙诺啡处方的患者每周至少有一次将药物转移给其他 OUD 患者，10%的 OUD 患者每周至少使用一次转移的丁丙诺啡。控制仅处方的情景假设没有丁丙诺啡转移，而增加转移的情景假设 95%的开丁丙诺啡处方的患者和 50%的 OUD 患者使用转移的丁丙诺啡。我们假设当天使用转移的丁丙诺啡替代其他阿片类药物。敏感性分析增加了使用转移的丁丙诺啡的过量风险，增加了转移的丁丙诺啡的使用频率，并模拟了阿片类药物无经验者使用转移的丁丙诺啡。在 5 年内比较了不同情景下与阿片类药物过量相关的结果。
我们的现状情景预测会有 10658 例（可信区间[CI]：9699-11679）致命阿片类药物过量。模拟丁丙诺啡控制仅处方（即无转移）的情景导致 10741 例（9895-11650）致命阿片类药物过量，而模拟增加转移的情景导致 10301 例（9439-11244）致命阿片类药物过量。与现状相比，控制仅处方的情景导致的致命过量数量相似，而增加丁丙诺啡转移的情景导致的致命过量数量减少了 357 例（3.35%）。即使在增加使用转移的丁丙诺啡的过量风险并纳入阿片类药物无经验者使用的情况下，增加丁丙诺啡的转移也不会导致过量，而不是没有丁丙诺啡转移的情况。
在 OUD 患者中增加丁丙诺啡转移的比例较高的建模条件下，发生的阿片类药物过量数量相似，而阿片类药物过量的非统计趋势呈下降趋势。这些结果支持了现有的呼吁，即为 OUD 患者提供低至无障碍的丁丙诺啡。
