Notes from the Field: Emergency Visits for Complications of Injecting Transmucosal Buprenorphine Products — United States, 2016–2018
Weekly / August 14, 2020 / 69(32);1102–1103
Sukarma Tanwar, MMed1,2; Andrew I. Geller, MD2; Maribeth C. Lovegrove, MPH2; Daniel S. Budnitz, MD2 (View author affiliations)View suggested citation
Views equals page views plus PDF downloads
The opioid partial agonist buprenorphine is a critical component of medication-assisted treatment for opioid use disorder and is associated with improved treatment adherence and decreased illicit opioid use (1). Combination buprenorphine/naloxone transmucosal products are designed to deter injection owing to the opioid-antagonist actions of naloxone and can reduce the desired effects and precipitate rapid withdrawal when these products are administered intravenously; nonetheless, injection of transmucosal buprenorphine/naloxone has been reported (2,3). During 2016–2017, 14.6% of approximately 127,000 emergency department (ED) visits for nonmedical use* of prescription opioids involved buprenorphine products, commonly for injection-related complications (4). ED visits for nonmedical use of buprenorphine involved less severe overdose morbidity (e.g., unresponsiveness or cardiorespiratory failure) than did those involving other opioids (4). Complications of injecting transmucosal buprenorphine products represent a potentially preventable source of morbidity from nonmedical use of buprenorphine. Further description of complications related to buprenorphine injection can help prevent these complications while preserving access to this effective therapy for opioid use disorder.
During 2016–2018, among ED visits tracked by the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project, a nationally representative active public health surveillance system (5), 598 cases of nonmedical injection of prescription opioids were identified by record review. CDC used these cases to derive an estimate that an average of 47,437 (95% confidence interval [CI] = 27,004–67,871) ED visits for nonmedical injection of prescription opioids occurred in the United States annually. Of these ED visits involving nonmedical injection of prescription opioids, approximately one third (34.2%; 95% CI = 19.3%–56.1%) involved transmucosal buprenorphine products.
Among estimated ED visits for nonmedical injection of transmucosal buprenorphine, mean patient age was 33 years (range = 20–56 years), and two thirds (66.0%; 95% CI = 60.9%–71.0%) of patients were men. ED visits for nonmedical injection of transmucosal buprenorphine usually involved a transmucosal buprenorphine/naloxone combination product (85.4% [95% CI = 76.3%–94.5%] of estimated visits). An estimated two thirds (66.0%; 95% CI = 43.0%–89.0%) of buprenorphine nonmedical injection visits resulted in the patient being treated and released or leaving against medical advice. Concurrent use of nonpharmaceutical substances (e.g., heroin, cocaine) was documented in approximately one third (31.6%; 95% CI = 21.7%–41.6%) of estimated visits for nonmedical injection of buprenorphine.
Injection-specific complications were documented in an estimated two thirds (67.2%; 95% CI = 53.7%–80.6%) of buprenorphine nonmedical injection ED visits. Among 101 ED surveillance cases of visits for buprenorphine nonmedical injection-specific complications, those reported included abscess (37), cellulitis (41), infective endocarditis (two), sepsis (two), septic arthritis (two), unspecified injection-site infections (e.g., “hand infection” not further specified) (three), and noninfectious injection-specific complications (e.g., injection site thrombosis/ischemia) (14). The national estimates likely represent an undercount of the true number of visits for injection-related complications because patients might not disclose injections, and secondary chronic infections (e.g., human immunodeficiency virus or hepatitis C) might not be identified.
Buprenorphine treatment is an important component of the public health response to the opioid overdose epidemic. Patients evaluated in EDs and other settings with injection-related complications might be referred to syringe services programs, where available, and educated on infection prevention practices (6). Linking these patients to care for underlying substance use disorders and recovery support services might improve recovery rates. Counseling on risks of injecting buprenorphine could be incorporated into patient education regarding medication-assisted treatment and might reduce the frequency of injection complications.
Jana McAninch, Judy Staffa, Office of Surveillance and Epidemiology, Center for Drug Evaluation and Research, Food and Drug Administration; Judy Racoosin, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration.
Corresponding author: Sukarma Tanwar, email@example.com, 678-431-9047.
All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.
* Nonmedical use included abuse (clinician diagnosis of abuse or documentation of recreational use), therapeutic misuse (documented therapeutic intent, but not used as directed; e.g., taking buprenorphine to self-treat withdrawal symptoms), or overdoses without documentation of therapeutic intent, self-harm, abuse, or misuse (e.g., patients who have documented overdoses but are unable or unwilling to describe the event).
- Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1). CrossRefexternal icon PubMedexternal icon
- Bazazi AR, Yokell M, Fu JJ, Rich JD, Zaller ND. Illicit use of buprenorphine/naloxone among injecting and noninjecting opioid users. J Addict Med 2011;5:175–80. CrossRefexternal icon PubMedexternal icon
- White N, Flaherty I, Higgs P, et al. Injecting buprenorphine-naloxone film: findings from an explorative qualitative study. Drug Alcohol Rev 2015;34:623–9. CrossRefexternal icon PubMedexternal icon
- Lovegrove MC, Dowell D, Geller AI, et al. US emergency department visits for acute harms from prescription opioid use, 2016–2017. Am J Public Health 2019;109:784–91. CrossRefexternal icon PubMedexternal icon
- Geller AI, Dowell D, Lovegrove MC, et al. U.S. emergency department visits resulting from nonmedical use of pharmaceuticals, 2016. Am J Prev Med 2019;56:639–47. CrossRefexternal icon PubMedexternal icon
- CDC. Prevent bacterial & fungal infections in patients who inject drugs. Atlanta, GA: US Department of Health and Human Services, CDC; 2019. https://www.cdc.gov/vitalsigns/staph/pdf/vs-safe-drug-use_hcp.pdfpdf icon
Suggested citation for this article: Tanwar S, Geller AI, Lovegrove MC, Budnitz DS. Notes from the Field: Emergency Visits for Complications of Injecting Transmucosal Buprenorphine Products — United States, 2016–2018. MMWR Morb Mortal Wkly Rep 2020;69:1102–1103. DOI: http://dx.doi.org/10.15585/mmwr.mm6932a5external icon.
MMWR and Morbidity and Mortality Weekly Report are service marks of the U.S. Department of Health and Human Services.
Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.
References to non-CDC sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement of these organizations or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of pages found at these sites. URL addresses listed in MMWR were current as of the date of publication.
All HTML versions of MMWR articles are generated from final proofs through an automated process. This conversion might result in character translation or format errors in the HTML version. Users are referred to the electronic PDF version (https://www.cdc.gov/mmwr) and/or the original MMWR paper copy for printable versions of official text, figures, and tables.
Questions or messages regarding errors in formatting should be addressed to firstname.lastname@example.org.