Thread by @MyHarmReduction

Congratulations to advocates in Vermont, who successfully decriminalized the possession of small amounts of buprenorphine without a prescription!

Here's a thread on why this is great news and how it will save lives during the overdose crisis (1/x)

vtdigger.org/2021/06/03/ver…

Q: What is buprenorphine?

Buprenorphine (AKA Suboxone), is a lifesaving medication for Opioid Use Disorder. It helps people get off street opioids.

Check out my thread about how it reduces mortality

https://twitter.com/MyHarmReduction/status/1400830281116962818

Q: Why should we decriminalize buprenorphine when people should just go to their doctor and get a legitimate prescription instead?

A1: Up until a few weeks ago, not all doctors or other providers with prescription privileges COULD prescribe this medication.

A1 cont'd:

Since ~2000, doctors and other providers with prescription privileges had to take several hours of training and submit paperwork in order to be granted an X-waiver - special permission to prescribe buprenorphine.

This deterred busy docs because it was a hassle.

A1 cont'd:

Check out this map from a recent study that showed many parts of the nation don't even have a single X-waivered prescriber.

More than half of all rural counties had no provider; a third of rural Americans live in a county with no provider. onlinelibrary.wiley.com/doi/abs/10.111…

A2: Even if your provider has an X-waiver, chances are they may not actually be writing buprenorphine prescriptions to many of their patients. Or at all.

STUDY: Less than 5% of waivered doctors are prescribing to the bulk of patients in the US.

doi.org/10.1001/jama.2…

A2 cont'd: Even if a provider has an X-waiver, there are huge racial disparities in who actually gets a prescription.

STUDY: Black patients were 77% less likely to get a buprenorphine prescription than white patients
jamanetwork.com/journals/jamap…

A2 cont'd:

Black pregnant people with opioid use disorder were 76% less likely to get a buprenorphine prescription that white; Latinx pregnant people were 66% less likely.
jamanetwork.com/journals/jaman…

A2 cont'd:

Black veterans receiving care in the Veterans Health Administration were less likely to get started on buprenorphine.
doi.org/10.1080/088970…

A2 cont'd:

STUDY: Black youth who had an opioid overdose were 85% less likely to get a prescription, and estimate could not be calculated for Latinx youth because 0 in study got one.
jamanetwork.com/journals/jamap…

A3: Even if your doctor writes you a prescription for buprenorphine, your pharmacy may not fill it!

Paper in NEJM: Pharmacists fear DEA prosecution for filling prescriptions, lack training about OUD, are suspicious of local prescribers and patients
nejm.org/doi/10.1056/NE…

A3 cont'd:

STUDY: Doctors often have troubling interactions with pharmacists who are overreaching
doi.org/10.1080/108260…

A3 cont'd:

STUDY: Pharmaceutical distributors fear the DEA coming after them, so their preemptive measures to deter opioid overdispensing at pharmacies actually disrupts care for patients while making pharmacies anxious too journals.lww.com/journaladdicti…

A4: If you continue to see your provider for buprenorphine, you may need to pay in cash or require prior authorization every time you refill. You also may be required to undergo frequent urine drug testing and a counseling requirement.

These end up being burdensome to patients.

Q: How do you know that people on the street aren't misusing these diverted buprenorphine prescriptions?

A1: There is a growing number of qualitative studies with people who have used buprenorphine on the street. They seek it out for a number of really important reasons.

A1 cont'd:

STUDY: People used non-prescribed buprenorphine for 4 main reasons: too many barriers/demands in treatment, so they could move, to self-initiate treatment, & "to bolster a sense of self-determination and agency in their recovery trajectory"

pubmed.ncbi.nlm.nih.gov/32203863/

A1 cont'd:

STUDY: "Our data confirm that NPB use among individuals with opioid use disorder is driven by self-treatment related reasons because nearly 90% reported using NPB in the past 6 months to self-treat opioid withdrawals"

pubmed.ncbi.nlm.nih.gov/31568934/

A1 cont'd:

STUDY: "the most frequently cited reasons for non-prescription use were consistent with therapeutic use. Diversion was partially driven by barriers to access, & an unmet need for OUD treatment persists."
sciencedirect.com/science/articl…

A2: Trying diverted buprenorphine out on the street can motivate people to get a prescription!

STUDY: "Seeking buprenorphine/naloxone treatment in the previous 12 months was positively associated with using diverted medication in the past 2 months" journals.lww.com/journaladdicti…

A3: Using diverted buprenorphine can reduce overdose risk by avoiding street supply.

STUDY: "higher frequency of non-prescribed buprenorphine use is associated with lower risk of drug overdose, a potential harm reduction consequence of diversion"

sciencedirect.com/science/articl…

TL, DR: The use of diverted buprenorphine is an attempt by people who use drugs to manage the risk of navigating an unregulated drug supply and a policy environment that creates barriers to this life-saving medication. Don't arrest people for helping themselves. FIN

https://twitter.com/MyHarmReduction/status/1401583079144275973