Journal
JOURNAL OF MEDICAL TOXICOLOGY
Volume 17, Issue 1, Pages 10-15Publisher
SPRINGER
DOI: 10.1007/s13181-020-00795-3
Keywords
Buprenorphine; Fentanyl; Overdose; Fatality; Polypharmacy; Co-exposure
Categories
Funding
- COBRE on Opioids & Overdose - US National Institute of General Medical Sciences [P20-GM125507]
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A retrospective review of opioid-involved drug overdose fatalities in Rhode Island from 2016 to 2018 found that 5.4% of deaths included buprenorphine, with polysubstance use being common in cases where buprenorphine was detected. One case showed buprenorphine as the only contributing drug to death, while all other cases had additional drugs involved. Further research is needed to explore the role of buprenorphine in fatal overdose pharmacology.
Background Buprenorphine is a unique mu-opioid receptor partial agonist with avid receptor binding, nominal euphoric reward, and a ceiling effect on sedation and respiratory depression. Despite a pharmacologic profile that enhances safety, cases of fatal opioid overdose with buprenorphine on postmortem toxicology are reported, but details of these cases in the literature are limited. Methods A retrospective review of opioid-involved drug overdose fatalities in Rhode Island (RI) from 2016 to 2018 using the RI Department of Health State Unintentional Drug Overdose Reporting System (SUDORS) database. Deaths with buprenorphine on toxicology testing versus opioid-involved overdose deaths without buprenorphine were compared to assess the type and number of co-exposures. Results Of 534 opioid-involved deaths, 29 (5.4%) included buprenorphine and/or norbuprenorphine on toxicology. Most frequent co-exposures are as follows: fentanyl (75.9%), norfentanyl (72.4%), cocaine (41.4%), benzoylecgonine (41.4%), cannabinoids (31.0%), ethanol (31.0%), levamisole (31.0%), and free morphine (31.0%). An average number of co-exposures for fatalities with buprenorphine were 9.24 versus 6.68 in those without buprenorphine. In one case buprenorphine was the only drug listed to cause death; all other fatalities with buprenorphine on toxicology reported additional drugs contributing to death. Conclusion Decedents with buprenorphine detected on toxicology testing commonly had documented polysubstance use. Although data are limited, buprenorphine may provide some risk mitigation against full agonist opioid overdose including fentanyl. Further work should explore the use of postmortem concentrations of buprenorphine, norbuprenorphine, and other opioid metabolites to determine the role of buprenorphine in fatal overdose pharmacology.
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