Intravenous use of prescribed sublingual buprenorphine tablets by drug users receiving maintenance therapy in France

Département de Santé Publique and service de Santé publique, AP-HP, CHU Cochin-Port Royal, Université René Descartes, Paris, France.
Drug and Alcohol Dependence (Impact Factor: 3.42). 04/2003; 69(2):175-81. DOI: 10.1016/S0376-8716(02)00312-5
Source: PubMed


In 1996, sublingual buprenorphine was authorized for prescription in France for maintenance therapy (MT). MT should facilitate the rehabilitation of opioid-dependent drug users and reduce the risks associated with injection. However, misuse and side effects have been reported.
To assess the frequency of buprenorphine injection in 404 subjects on buprenorphine MT and to determine the factors associated with the injection of buprenorphine.
A cross-sectional survey was used to collect data from subjects on buprenorphine MT seeking treatment from health care networks, specialized structures, a prison and a hostel in three different regions of France (1998-1999). Information was collected by trained interviewers using a structured questionnaire.
About half (46.5%) of the subjects on MT (188/404) had ever injected buprenorphine; 67.2% of this subgroup had since used both injected and sublingual buprenorphine. Variables associated with buprenorphine injection were having injected a substance other than buprenorphine (odds ratio (OR): 13.18; 95% CI: 5.36-32.42), cannabis use (OR: 2.34; 95% CI: 1.51-3.63) and having a source of income other than a salary (OR: 1.58; 95% CI: 1.02-2.45) and heroin use (OR: 0.23; 95% CI: 0.09-0.61).
To decrease buprenorphine injection, prescribers of buprenorphine should participate in networks with specialized centers, and social and professional rehabilitation programs should be implemented for subjects on buprenorphine MT.

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    • "Several studies have shown that with parenteral administration , Bup produces effects similar to full mu agonists and is self-administered (Strain et al. 1997; Zacny, Conley & Galinkin 1997; Bedi et al. 1998; Comer & Collins 2002; Comer, Sullivan & Walker 2005; Comer et al. 2010; Duke et al. 2010; Middleton et al. 2011). Consistent with laboratory findings suggesting that Bup does have abuse potential, several regions of the world have noted Bup abuse including: Australia (Jenkinson et al. 2005; Nielsen et al. 2007), Europe (Obadia et al. 2001; Vidal-Trecan et al. 2003; Auriacombe et al. 2004; Carrieri et al. 2006; Alho et al. 2007; Hakansson et al. 2007), South East Asia (Chua & Lee 2006; Lee 2006; Vicknasingam et al. 2010; Horyniak et al. 2011) and the United States. (Young, Havens & Leukefeld 2010; Nordmann et al. 2012). "
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    ABSTRACT: In spite of the clinical utility of buprenorphine, parenteral abuse of this medication has been reported in several laboratory investigations and in the real world. Studies have demonstrated lower abuse liability of the buprenorphine/naloxone combination relative to buprenorphine alone. However, clinical research has not yet examined the utility of the combined formulation to deter intranasal use in a buprenorphine-maintained population. Heroin-using volunteers (n = 12) lived in the hospital for 8–9 weeks and were maintained on each of three sublingual buprenorphine doses (2, 8, 24 mg). Under each maintenance dose, participants completed laboratory sessions during which the reinforcing and subjective effects of intranasal doses of buprenorphine (8, 16 mg), buprenorphine/naloxone (8/2, 8/8, 8/16, 16/4 mg) and controls (placebo, heroin 100 mg, naloxone 4 mg) were assessed. Intranasal buprenorphine alone typically produced increases in positive subjective effects and the 8 mg dose was self-administered above the level of placebo. The addition of naloxone dose dependently reduced positive subjective effects and increased aversive effects. No buprenorphine/naloxone combination dose was self-administered significantly more than placebo. These data suggest that within a buprenorphine-dependent population, intranasal buprenorphine/naloxone has reduced abuse potential in comparison to buprenorphine alone. These data strongly argue in favor of buprenorphine/naloxone rather than buprenorphine alone as the more reasonable option for managing the risk of buprenorphine misuse.
    Addiction Biology 08/2014; 20(4). DOI:10.1111/adb.12163 · 5.36 Impact Factor
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    • "Many do not have access to methadone because of a limited access to CSAPA. In addition, it has been shown that a proportion of buprenorphine patients, albeit marginal, administers the treatment by a non-indicated route, either intranasally [5] or intravenously [6]. Expanded access to methadone treatment for opioid dependent individuals through innovative models of care is a major challenge for the control of HIV and HCV infection. "
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    ABSTRACT: Background In France, the rapid scale-up of buprenorphine, an opioid maintenance treatment (OMT), in primary care for drug users has led to an impressive reduction in HIV prevalence among injecting drug users (IDU) but has had no major effect on Hepatitis C incidence. To date, patients willing to start methadone can only do so in a methadone clinic (a medical centre for drug and alcohol dependence (CSAPA) or a hospital setting) and are referred to primary care physicians after dose stabilization. This study aims to assess the effectiveness of methadone in patients who initiated treatment in primary care compared with those who initiated it in a CSAPA, by measuring abstinence from street opioid use after one year of treatment. Methods/Design The ANRS-Methaville study is a randomized multicenter non-inferiority control trial comparing methadone induction (lasting approximately 2 weeks) in primary care and in CSAPA. The model of care chosen for methadone induction in primary care was based on study-specific pre-training of all physicians, exclusion criteria and daily supervision of methadone during the initiation phase. Between January 2009 and January 2011, 10 sites each having one CSAPA and several primary care physicians, were identified to recruit patients to be randomized into two groups, one starting methadone in primary care (n = 147), the other in CSAPA (n = 48). The primary outcome of the study is the proportion of participants abstinent from street opioids after 1 year of treatment i.e. non-inferiority of primary care model in terms of the proportion of patients not using street opioids compared with the proportion observed in those starting methadone in a CSAPA. Discussion The ANRS-Methaville study is the first in France to use an interventional trial to improve access to OMT for drug users. Once the non-inferiority results become available, the Ministry of Health and agency for the safety of health products may change the the New Drug Application (NDA) of methadone and make methadone induction by trained primary care physicians possible. The trial is registered with the French Agency of Pharmaceutical Products (AFSSAPS) under the number 2008-A0277-48, the European Union Drug Regulating Authorities Clinical Trials. Number Eudract 2008-001338-28, the Identifier: NCT00657397 and the International Standard Randomised Controlled Trial Number Register ISRCTN31125511.
    BMC Public Health 06/2012; 12(1):488. DOI:10.1186/1471-2458-12-488 · 2.26 Impact Factor
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    • "Moreover, a recent study showed that opioid dependent individuals receiving heroin-assisted treatment were more likely to decrease their benzodiazepine use compared to those receiving methadone maintenance treatment [29]. Finally, heavy cannabis use also has been found to be correlated with buprenorphine injection [30]. Polydrug use should be considered more thoroughly not only for measuring the independent effects of multiple drug use but also for investigating the effects of drug use patterns on behavioural outcomes [31]. "
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    ABSTRACT: Opioid maintenance treatment (OMT) has a positive impact on substance use and health outcomes among HIV-infected opioid dependent patients. The present study investigates non-medical use of opioids by HIV-infected opioid-dependent individuals treated with buprenorphine or methadone. The MANIF 2000 study is a longitudinal study that enrolled a cohort of 476 HIV-infected opioid-dependent individuals. Data were collected in outpatient hospital services delivering HIV care in France. The sample comprised all patients receiving OMT (either methadone or buprenorphine) who attended at least one follow-up visit with data on adherence to OMT (N = 235 patients, 1056 visits). Non-medical use of opioids during OMT was defined as having reported use of opioids in a non-medical context, and/or the misuse of the prescribed oral OMT by an inappropriate route of administration (injection or sniffing). After adjusting for the non-random assignment of OMT type, a model based on GEE was then used to identify predictors of non-medical use of opioids. Among the 235 patients, 144 (61.3%) and 91 (38.9%) patients were receiving buprenorphine and methadone, respectively, at baseline. Non-medical use of opioids was found in 41.6% of visits for 83% of individual patients. In the multivariate analysis, predictors of non-medical use of opioids were: cocaine, daily cannabis, and benzodiazepine use, experience of opioid withdrawal symptoms, and less time since OMT initiation. Non-medical use of opioids was found to be comparable in OMT patients receiving methadone or buprenorphine. The presence of opioid withdrawal symptoms was a determinant of non-medical use of opioids and may serve as a clinical indicator of inadequate dosage, medication, or type of follow-up. Sustainability and continuity of care with adequate monitoring of withdrawal symptoms and polydrug use may contribute to reduced harms from ongoing non-medical use of opioids.
    Harm Reduction Journal 11/2011; 8(1):31. DOI:10.1186/1477-7517-8-31 · 1.26 Impact Factor
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