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Opioid Overdose Deaths with Buprenorphine Detected in Postmortem Toxicology: a Retrospective Analysis

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Abstract

Background

Buprenorphine is a unique μ-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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Acknowledgement

We would like to thank Yu Li, MD, MPH, PhD for help with statistical analysis.

Sources of Funding

This work was supported in part by the COBRE on Opioids & Overdose, funded by US National Institute of General Medical Sciences (P20-GM125507)

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Authors and Affiliations

  1. Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, 55 Claverick St, Providence, RI, 02903, USA

    Rachel S. Wightman

  2. Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Ground Silverstein, Rm. 260 3400 Spruce St, Philadelphia, PA, 19104, USA

    Jeanmarie Perrone

  3. Rhode Island Department of Health, 3 Capitol Hill, Cannon Building, Providence, RI, 02908, USA

    Rachel Scagos

  4. Department of Epidemiology, Brown University School of Public Health, 121 South Main St, Box G-S-121-2, Providence, RI, 02912, USA

    Maxwell Krieger & Brandon D.L. Marshall

  5. Rutgers New Jersey School of Medicine, Medical Science Building, 185 South Orange Avenue, Newark, NJ, 07103, USA

    Lewis S. Nelson

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  1. Rachel S. Wightman
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  2. Jeanmarie Perrone
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Contributions

Rachel S. Wightman, MD: Dr. Wightman was involved in study design, data analysis and interpretation, and manuscript creation.

Jeanmarie Perrone, MD: Dr. Perrone was involved in study creation, design, data analysis and interpretation, and manuscript editing.

Rachel Scagos, MPH: Rachel Scagos was involved in study design, data extraction, interpretation, and analysis as well as manuscript creation.

Maxwell Krieger, BSc: Maxwell Krieger was involved in study design, data extraction and acquisition, and data analysis and graphical representation of study findings.

Lewis S. Nelson, MD: Dr. Nelson was involved in data analysis and interpretation as well as manuscript editing.

Brandon D.L. Marshall, PhD: Dr. Marshall was involved in study creation, design, data analysis and interpretation and manuscript editing.

Corresponding author

Correspondence to Rachel S. Wightman.

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Supervising Editor: Trevonne Thompson, MD

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Wightman, R.S., Perrone, J., Scagos, R. et al. Opioid Overdose Deaths with Buprenorphine Detected in Postmortem Toxicology: a Retrospective Analysis. J. Med. Toxicol. 17, 10–15 (2021). https://doi.org/10.1007/s13181-020-00795-3

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  • DOI: https://doi.org/10.1007/s13181-020-00795-3

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