Buprenorphine Experiences: Self-reports from Three Programs in Kentucky Quintin Thomas Chipley, M.A., M.D., Ph.D. and Greg Jones, M.D., ABFM, ABAM, ASAM, MRO Prepared for CAPTASA 2017

DISCLOSURES Neither presenter has any financial interest in any medication or institution as discussed in this presentation. Quintin Chipley is employed at the University of Louisville as a counselor to students at the Health Science Center. The U of L is gracious to allow Chipley latitude to pursue professionally-relevant endeavors outside of his work duties, but the university should not be considered responsible for the opinions and conclusions offered in this presentation. Greg Jones began participation in this study when medical director of the Kentucky Physicians Health Program. Although that organization continues to be a long-standing supporter of CAPTASA, and also supports Dr. Jones’ relevant professional endeavors exterior to his employment, the KPHF should not be considered responsible for the opinions and conclusions offered in this presentation. In November, 2016, he joined the Addiction Psychiatry program within the Department of Psychiatry, The University of Florida, as clinical faculty, associate professor. That institution and its affiliates should not be considered responsible for the opinions and conclusions offered here.

Study History The study began in Fall, 2015 as an investigation of the subjective experience of men and women who had chosen to enter their gender- respective campuses of the The Healing Place in Louisville, Kentucky. That center is a residential, peer-support, recovery-community for people with alcoholism and addictions. The THP does not administer any types on Medication Assisted Treatment (MAT) on its premises. The center will accept participants who are using opioid antagonist MAT but will not accept or retain participants who are using any opioid with agonist properties. Prohibited substances include buprenorphine. The information from that pilot study with some 232 subjects was reported at CAPTASA 2016

Study History (Continued) In the last months of 2016 and across the first eight months of 2017, more data was collected from The Healing Place. In that same span, data was collected from the multiple Recovery Kentucky residential locations across the state a division of the Commonwealth of Kentucky’s Housing Authority. Those centers are modeled on the The Healing Place program and offer the same latitude and restrictions regarding Medication Assisted Treatment. All data for the pilot study and for the expanded study are collected and analyzed by the Recovery Center Outcome Study (RCOS), conducted by the Center or Drug and Alcohol Research at the University of Kentucky under the direction of T.K. Logan, Ph.D. The RCOS study holds the Institutional Review Board approval for human-subject research. Both THP and Recovery Kentucky accept participants by self-referral and from the Department of Corrections resulting in an approximate 4-to-5 ration on non-DOC to DOC for all RCOS subjects. The male-to-female split is about 1-to-1 for all RCOS subjects. Neither the pilot study nor this expanded study sets as a goal any determination of the efficacy of the The Healing Place or the Recovery Kentucky locations. The sites were chosen because anecdotes reported by program staff indicated that many participants report experiences with buprenorphine prior to entering those recovery communities. The locations, therefore, offer a naturally occurring pool of this population of interest.

Study History (Continued) Directors of two other drug programs heard of the pilot study in late 2015 and asked to use the question-set for their programs. One program is Kentucky Drug Courts, a diversion program for people charged with illicit drug and alcohol use and who are not in any residential treatment or recovery community. The other is Project UNITE, a regional Appalachian out-patient support program with strong federal funding. The population characteristics across the three different populations cannot be assumed to be the same. The research team (called RCOS) which originated the pilot study and continues the expanded study within the The Healing Place and Recovery Kentucky Centers have enjoyed considerable control over training staff in the face-to-face interview use of the protocol questions. Such similar control for the other two locations cannot be assumed. The RCOS team also added a final item to the question set (essentially, “Did buprenorphine, help, hurt, or make no difference in your recovery from drug problems?”) This additional item remained unknown to the other two locations and, therefore, unasked. In view of these conditions, all data from all three populations is reported here but no attempt is made to compare results across the three samples.

Drug Ct (n = 849) UNITE (n = 117) RCOS (n = 1,674) If all drugs and alcohol would have been equally available to you, what were your three preferred substances:   Listed as preferred drug: Alcohol 33.5% 23.1% 39.7% Marijuana 44.8% 26.5% 40.2% Opiates, prescription pain killers 56.2% 58.1% 57.5% Methadone 4.8% 6.0% 8.5% Suboxone 18.9% 35.9% 15.7% Heroin 27.2% 14.5% 42.2% Sedatives, tranquilizers, barbiturates 25.8% 34.2% 15.9% Stimulants, methamphetamine 40.0% 49.6% 37.1% Cocaine 18.3% 19.7% Other drugs (hallucinogens, inhalants, synthetic drugs) 8.6% 6.8% 6.2% The problems in my life caused by substance use are primarily due to: Alcohol use 4.1% 4.3% 7.6% Drug use 70.3% 75.0% 54.6% Both 24.7% 20.7% 37.8% Percentage of the total who had ever used buprenorphine: 67.1% 74.4% 60.7%

Of those who have used buprenorphine: If all drugs and alcohol would have been equally available to you, what were your three preferred substances: Drug Ct (n = 569) UNITE (n = 87) RCOS (n = 1,016) Listed as preferred drug:   Alcohol 24.1% 12.6% 29.7% Marijuana 36.3% 21.8% 31.9% Opiates, prescription pain killers 67.2% 63.2% 66.0% Methadone 6.2% 5.7% 11.3% Suboxone 28.1% 47.1% 23.7% Heroin 32.1% 18.4% 54.5% Sedatives, tranquilizers, barbiturates 30.7% 39.1% 17.2% Stimulants, methamphetamine 38.0% 48.3% 36.0% Cocaine 17.9% 4.6% 18.6% Other drugs (hallucinogens, inhalants, synthetic drugs) 8.0% 4.5%

If ever used buprenorphine, a) how did you obtain it and b) how long did you stay on it? Drug CT (n =569) UNITE (n = 87) RCOS (n = 985) By Prescription Only 8.5% 12.6% 5.6% By Illegal Access Only 48.9% 33.3% 62.6% By both Prescription and Illegal Access 42.7% 54.0% 31.8% How long did you take buprenorphine (average): 302 days 942 days 496 days

Of those prescribed by a doctor: Drug CT (n=209) UNITE (n = 58) RCOS (n = 368) Doctor recommended use:   For detox from other drugs only 11.8% 17.5% 7.9% For long-term use in order to stay away from other drugs 29.5% 49.1% 36.4% For both detox and long-term use to stay away from other drugs 34.7% 15.8% 37.8% The doctor did not discuss a purpose and time length 15.9% 12.3% 9.0% I do not remember 8.1% 5.3%

When thinking about your conversations with the doctor or about your use of buprenorphine: Drug CT (n=209)   UNITE (n = 58) RCOS (n = 368) The doctor advised you to attend recovery support meetings 53.4% 93.0% 59.2% The doctor advised you to get counseling from a substance abuse treatment professional 56.9% 77.2% 60.6% The doctor gave you counseling about substance use in addition to prescribing the medication 54.6% 44.4% 62.8% You took others drugs or alcohol to get high while taking the prescribed buprenorphine 56.3% 64.3% 76.4% You sold, traded, or gave away any of the buprenorphine that was prescribed to you 53.5% 57.9% 78.3%

When you were using the drug buprenorphine under a doctor’s care: Drug CT (n=209)   UNITE (n = 58)  RCOS (n = 368) It stopped your craving 79.5% 81.0% 71.7% It prevented withdrawal symptoms 89.3% 93.1% 92.1% It gave you a satisfactory high 43.1% 72.4% 53.5% It made other drugs feel more powerful 21.7% 34.5% 28.5% It made other drugs have less effects on you 47.6% 48.3% 72.3% It freed you up from having to hustle for drugs 72.8% 86.2% 68.5% It helped you in any way at all Not asked 78.0%

  Drug CT (n =290 ) UNITE (n = 58) RCOS (n = 1,016) What are the main reasons you stopped using buprenorphine: The cost was too great 25.8% 41.2% 27.0% Treatment program did not allow the drug 23.5% 5.9% 13.3% The drug was not helping 9.8% 39.4% Could not easily get to the clinic or doctor where it was prescribed 25.0% 33.3% 20.4% Went to jail Not asked

  Drug CT (n = 569) UNITE (n=) RCOS (n=1,016) Ever bought or received buprenorphine from someone without having a prescription 91.4% 87.4% 94.4%

Of those who used without a prescription: Drug CT (n =519) UNITE (n = 76) RCOS (n = 930) When thinking about your use of buprenorphine without a prescription:   Used buprenorphine to get through rough days until you could get preferred drug of choice 77.4% 93.3% 87.1% Used buprenorphine to get high, to get a buzz, or to feel euphoria 64.6% 73.7% 79.2% Found you could get higher by increasing the amount of buprenorphine you took 51.7% 67.1% 60.6% Used information you got from other people about how you could increase the high from using buprenorphine 37.7% 56.6% 60.9% Used information from the internet to learn how you could increase the high from using buprenorphine 11.0% 16.0% 34.9% Ever overdosed when combining buprenorphine with another drug or alcohol 8.4% 8.2%

  Drug CT Not asked UNITE Not asked RCOS (n=1,016) Overall, do you think your use of buprenorphine: (Forced choice of the three options.) Helped you treat your drug problems ? 24.9% Had no effect on your drug problem 36.5% Made your drug problem worse 38.6%

CONCLUSIONS While these self-reports about the uses of buprenorphine do not refute the effectiveness of buprenorphine in controlled settings, they raise questions about how the drug using community understands and uses buprenorphine. The findings also suggest, at least for this sample of person in drug free recovery, that buprenorphine is experienced much like any other euphoria-inducing drug and that its illicit use may continue rather than attenuate problematic opioid use.