Lack of Reduction in Buprenorphine Injection After Introduction of Co-Formulated Buprenorphine/Naloxone to the Malaysian Market

Yale University AIDS Program, New Haven, Connecticut, USA.
The American Journal of Drug and Alcohol Abuse (Impact Factor: 1.78). 02/2009; 35(2):68-72. DOI: 10.1080/00952990802585406
Source: PubMed


Diversion of buprenorphine (BPN) has been described in settings where it is legally prescribed and has resulted in increasing concern. To address this concern, co-formulation of buprenorphine/naloxone (BPN/NLX) replaced buprenorphine alone in Malaysia in December 2006.
To assess the significance of BPN/NLX introduction, 41 BPN/NLX injectors in Kuala Lumpur, Malaysia were recruited using a modified snowball recruitment technique.
In January 2007, all subjects had previously injected BPN alone. During the transition from injecting BPN alone to co-formulated BPN/NLX, the mean daily BPN injection dose increased from 1.88 mg (range 1.0-4.0 mg) to 2.49 mg/day (p < .001). Overall, 18 (44%) subjects increased their daily amount of injection while 22 (54%) had no change in dose; only one subject reduced the amount of injection. Development of opioid withdrawal symptoms was the primary outcome, however the only symptom that was significantly associated with BPN/NLX dosage was the report of "stomach pains" (p = .01). In logistic regression analysis, the development of opioid withdrawal symptoms was associated with increased benzodiazepine injection and increased syringe sharing.
These data suggests that the introduction of BPN/NLX did not reduce injection related risk behaviors such as syringe sharing and was associated with increased benzodiazepine use. Evidence-based approaches to treat BPN injection are urgently needed.

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Available from: Frederick Altice, Jan 09, 2014
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    • "A BNX combination product was developed in order to inhibit the IV abuse of buprenorphine and it was hoped that this would prevent diversion . However, several studies have shown that BNX is also diverted (Alho et al., 2007; Bruce et al., 2009; Degenhardt et al., 2009; Larance, Degenhardt, Lintzeris, Bell, et al., 2011). Another formulation , BNX soluble film, has been developed in order to further prevent diversion. "
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    ABSTRACT: Diversion (i.e. selling or giving away) of opioid maintenance treatment (OMT) medications is a challenge that concerns many units providing OMT worldwide and tools for prevention are needed. The object of this study was to examine the prevalence and predictors for diversion of the OMT medications buprenorphine-naloxone (BNX) and methadone (MET) among Finnish OMT patients. A cross-sectional study was conducted among all Finnish OMT patients of whom 60% (n=1508) participated. The data were collected by anonymous questionnaires distributed through all OMT units in Finland. To evaluate predictors for diversion, we used binominal regression analysis with unadjusted and adjusted ORs. Selling and/or giving away of OMT medication was used as a dependent variable and explanatory variables were gender, age, duration of OMT, type of OMT medication and dose, dispensation method of OMT medication, place of residence and intravenous use of any intoxicating drugs during the past six months. Of all 1508 respondents, 7% (n=100) had sold and 12% (n=169) had given their OMT medication to others, 57% for money and 23% in exchange for other drugs. In multivariate analysis, predictors associated with diversion were BNX as OMT medication (OR 2.76, 95% CI 1.76-4.33), low (<9.0mg/day) BNX dose (OR 1.74, 95% CI 1.01-2.98), intravenous use of intoxicating drugs during the past six months (OR 4.48, 95% CI 3.13-6.43) and increasing length of OMT (OR 1.01, 95% CI 1.01-1.02). Age, place of residence or unsupervised pharmacy distribution of BNX were not associated with diversion. In order to reduce diversion, more interventions are needed to support patients to stop concurrent substance abuse. Increasing control measures, for example, increased supervision, are unlikely to prevent diversion. Given that sub-optimal dosing of BNX increases the risk of diversion, more attention should be paid to providing patients with an optimal medical dose. Copyright © 2015 Elsevier B.V. All rights reserved.
    The International journal on drug policy 04/2015; 27(9). DOI:10.1016/j.drugpo.2015.03.007 · 2.54 Impact Factor
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    • "Buprenorphine is available for opioid addiction treatment as a sublingual tablet or a sublingual tablet or film composed of 4 parts buprenorphine to one part naloxone; one or more of these products is available in at least 44 countries (Carrieri et al., 2006). The buprenorphine-naloxone combination was developed to reduce diversion and injecting use and it appears to have had that effect (Simojoki et al., 2008), however, these problems continue to occur (Bruce et al., 2009; Vicknasingam et al., 2010). In the US, almost all addiction treatment is done using buprenorphinenaloxone and approximately 640,000 patients received it in 2009, mostly in office based settings (Clark, 2010). "
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    ABSTRACT: Determine the extent to which buprenorphine injectors continue treatment with buprenorphine-naloxone or methadone, and the impact of these treatments on substance use and HIV risk in the Republic of Georgia. Randomized controlled 12-week trial of daily-observed methadone or buprenorphine-naloxone followed by a dose taper, referral to ongoing treatment, and follow-up at week 20 at the Uranti Clinic in Tbilisi, Republic of Georgia. Eighty consenting treatment-seeking individuals (40/group) aged 25 and above who met ICD-10 criteria for opioid dependence with physiologic features and reported injecting buprenorphine 10 or more times in the past 30 days. Opioid use according to urine tests and self-reports, treatment retention, and HIV risk behavior as determined by the Risk Assessment Battery. Mean age of participants was 33.7 (SD5.7), 4 were female, mean history of opioid injection use was 5.8 years (SD4.6), none were HIV+ at intake or at the 12-week assessment and 73.4% were HCV+. Sixty-eight participants (85%) completed the 12-week medication phase (33 from methadone and 35 from buprenorphine/naloxone group); 37 (46%) were in treatment at the 20-week follow-up (21 from methadone and 16 from the buprenorphine/naloxone group). In both study arms, treatment resulted in a marked reduction in unprescribed buprenorphine, other opioid use, and HIV injecting risk behavior with no clinically significant differences between the two treatment arms. Daily observed methadone or buprenorphine-naloxone are effective treatments for non-medical buprenorphine and other opioid use in the Republic of Georgia and likely to be useful for preventing HIV infection.
    Drug and alcohol dependence 07/2013; 133(2). DOI:10.1016/j.drugalcdep.2013.06.024 · 3.42 Impact Factor
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    • "L'objectif attendu est essentiellement de réduire le taux de mésusage, effet qui a d'ailleurs e ´té observé dans des e ´tudes récentes [4] [5]. Malgré la présence d'un antagoniste aux opiacés dans sa composition, ce nouveau traitement semble avoir un niveau de sécurité global satisfaisant en usage standard [6], même si d'autres données suggèrent que chez les patients qui poursuivent des injections avec l'association BHD/NLX, certains risques pourraient e ˆtre aggravés, en particulier l'abus de benzodiazépines et le partage de seringues [7]. Le bénéfice médical attendu pour ce nouveau traitement est donc assez atypique, puisqu'il ne concerne, par rapport au traitement de référence, que les utilisations non médicales du produit. "
    Revue d Épidémiologie et de Santé Publique 03/2013; 61(2). DOI:10.1016/j.respe.2013.02.001 · 0.59 Impact Factor
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