Better Access to MOUD Reduces Diversion

Efforts to facilitate access to buprenorphine—a gold-standard medication for opioid use disorder (MOUD)—are on the rise across the United States. In New Mexico, HB 137 would require pharmacies to stock buprenorphine. Kentucky SB 82/HB 153 would reduce barriers currently deterring uptake of office-based prescribing, and Tennessee HB 1984 would expand the list of clinicians who can dispense mono-buprenorphine products and patients who can receive them.

MOUD are supported by decades of real-world use and research. Both methadone and buprenorphine dramatically reduce patients’ illicit drug use and risk of overdose while improving treatment retention; however, less than a quarter of people with an opioid use disorder (OUD) take them—due in large part to regulatory barriers that deter clinician uptake and make treatment inconvenient, disruptive, and dehumanizing for patients. Thus, lawmaker efforts to facilitate more and lower barrier access to MOUD could go a long way toward saving lives and improving public health and safety.

Unfortunately, fear of diversion routinely hinders efforts to reduce barriers despite the fact that expanded access to these medications has proven to reduce diversion rather than increase it.

What is diversion?

Diversion occurs when prescription drugs are dispensed or obtained outside of official, legal channels, regardless of whether they are sold, traded, or gifted. The majority of drug diversion in the United States happens among friends and family members. About 30 of every 100,000 buprenorphine prescriptions and 10 of every 100,000 methadone prescriptions are diverted, meaning the practice is actually quite rare and on par with other opioid medications used to treat pain.

Why do people use diverted MOUD?

Diversion implies a demand for MOUD that current formal channels cannot meet. Thus, we must determine why that demand exists before identifying how policy can affect diversion rates.

Between two-thirds and 90 percent of people who use diverted buprenorphine or other MOUD do so to manage symptoms related to an OUD. For example, many report using diverted MOUD to abstain from other opioids like fentanyl or heroin and to manage withdrawal symptoms. Individuals often turn to diverted medication because of barriers to accessing MOUD through formal channels. Some use diverted buprenorphine either for pain relief or to self-medicate for psychiatric issues. In fact, roughly 80 percent of people who have used diverted buprenorphine say they would have preferred to receive the medication through a clinician. While there is less research on methadone diversion in the United States, research from other countries notes that it, too, is diverted to manage OUD symptoms rather than for recreational purposes.

Thus, diverted MOUD fills part of the gap between desire for and access to treatment while providing an avenue for individuals who are not in treatment to reduce their use of other opioids.

What happens when we make MOUD more accessible?

In theory, making MOUD easier to get through formal medical channels should lead to lower rates of diversion. Although MOUD diversion has increased in the last two decades, the reason why is more complicated than a simple increase in access.

Increased MOUD diversion rates coincided with skyrocketing overdoses driven by greater incidence of OUD, followed by the forced switch from prescription opioids to illicit opioids, and eventually the proliferation of illicitly manufactured fentanyl. These climbing overdose rates brought about an increase in MOUD access points (i.e., more opioid treatment programs dispensing methadone and more clinicians prescribing buprenorphine) although they still do not meet need. As a result, MOUD access and diversion rates both increased along roughly parallel timelines.

However, when the government significantly relaxed MOUD regulation during the COVID-19 pandemic, diversion did not climb proportionately. This supports the idea that the simple expansion of MOUD supply was not a key factor in increasing diversion. Rather, a growing demand for MOUD—coupled with the insufficient expansion of evidence-based OUD treatment—are likely the primary drivers.

There is some evidence that MOUD diversion can actually save lives and keep communities safer, especially in the absence of a system that meets treatment need. For example, a modeling study found that increasing buprenorphine diversion led to a 3.35 percent reduction in overdose deaths. And diverted buprenorphine often serves as a bridge to formal treatment. According to one study, almost half of patients entering OUD treatment were already taking buprenorphine, with almost one-fifth reporting they accessed the medication through informal channels.

What are the most important takeaways for policymakers?

• While MOUD diversion does happen, it is rare.
• Diverted MOUD is usually used to treat OUD-related symptoms.
• Most people who use diverted MOUD would prefer to get it through formal channels.
• MOUD diversion may help protect communities in which treatment infrastructure does not meet treatment need.
• Increasing MOUD access does not increase diversion; in fact, increasing treatment capacity to meet community need could actually reduce it.

Expanding access and reducing barriers to MOUD is an important step policymakers can take to make their communities both safer and healthier.