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Erratum: Why Do the clients of georgian needleexchange programmes inject buprenorphine? (European Addiction Research (2010) 16 (1-8) DOI:10.1159/ 000253858)
... Opioid substitution therapy (OST) using buprenorphine and methadone has been introduced in some Former Soviet States including Ukraine (Bruce, Dvoryak, Sylla, & Altice, 2007; Dvoriak et al., 2013; Dvoryak & Grishayeva, 2008; Golovanevskaya, Vlasenko, & Saucier, 2012; Lawrinson et al., 2008) and Georgia (Gambashidze, Sikharulidze, Piralishvili, & Gvakharia, 2008; Otiashvili et al., 2010; Piralishvili, Gamkrelidze, Nikolaishvili, & Chavchanidze, 2012) and data are becoming available on its effectiveness in these cultural settings . Findings from the U.S., Western Europe, and Australia have consistently found that OST is associated with substantial reductions in illicit opioid use, criminal activity, and drug related mortality, and that it can play an important role in reducing the spread of HIV by reducing injection risk and improving adherence to antiretroviral therapy (Cornish, Macleod, Strang, Vickerman, & Hickman, 2010; Degenhardt et al., 2010; Gowing, Farrell, Bornemann, Sullivan, & Ali, 2011; Kimber et al., 2010; MacArthur et al., 2012; Malta, Strathdee, Magnanini, & Bastos, 2008; Mattick, Breen, Kimber, & Davoli, 2003; Mattick, Breen, Kimber, & Davoli, 2007; Suntharasamai et al., 2009; Tilson et al., 2007). ...
... Though HIV prevalence has been low in Georgia, the prevalence of Subutex® injection and sharing of injection equipment has been high during the last decade as Subutex® was commonly smuggled in from France (Gamkrelidze et al., 2004; Javakhishvili et al., 2006). In one survey, conducted in 2007, Subutex® was named as the most commonly injected drug in terms of lifetime (95.5%) and last-month (75%) prevalence although buprenorphine treatment was not legal until 2008 in Georgia (Otiashvili et al., 2010). The main reasons given by drug injectors for Subutex® use were selftreatment to cope with withdrawal from other opioids (Otiashvili et al., 2010), increased police activity with random urine drug testing at a time that buprenorphine was not part of the drug testing panel (Otiashvili, Srosi, & Somogyi, 2008), and its relatively long-lasting effect and less obvious signs of intoxication compared to other opioids. ...
... In one survey, conducted in 2007, Subutex® was named as the most commonly injected drug in terms of lifetime (95.5%) and last-month (75%) prevalence although buprenorphine treatment was not legal until 2008 in Georgia (Otiashvili et al., 2010). The main reasons given by drug injectors for Subutex® use were selftreatment to cope with withdrawal from other opioids (Otiashvili et al., 2010), increased police activity with random urine drug testing at a time that buprenorphine was not part of the drug testing panel (Otiashvili, Srosi, & Somogyi, 2008), and its relatively long-lasting effect and less obvious signs of intoxication compared to other opioids. Here we report data from a study in which opioid addicted Subutex® injectors were randomized to a 12-week course of dailyobserved Suboxone® or methadone and discuss possible reasons for the low level of drug use during OST in Georgia as compared to the U.S. Study details and the primary outcomes of opioid use and HIV risk have been reported elsewhere (Otiashvili et al., 2013). ...
... This limitation is common to other studies on buprenorphine abuse (e.g. Bazazi, Yokell, Fu, Rich, & Zaller, 2011; Moratti, Kashanpour, Lombardelli, & Maisto, 2010; Otiashvili et al., 2010; Winslow et al., 2006). Psychiatric symptoms and medical comorbidities were clinically diagnosed by specialist physicians in accordance with established criteria. ...
Abuse of prescription opioids is becoming increasingly widespread. This study compared the social, health and treatment-related factors associated with buprenorphine and amphetamine abuse in Finland. Structured clinical interviews were conducted with clients seeking treatment for buprenorphine (n = 670) or amphetamine (n = 557) abuse in Helsinki from January 2001 to August 2008. Unadjusted and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were computed for factors associated with buprenorphine compared to amphetamine abuse. In multivariate analyses, buprenorphine abuse was associated with male gender (OR 1.57, 95%CI 1.17-2.09), daily abuse (OR 5.45, 95%CI 4.14-7.18), no drug free months during the last year (OR 1.68, 95%CI 1.23-2.29), and inversely associated with increasing age (OR 0.95, 95%CI 0.93-0.97 per year) and psychotic symptoms (OR 0.33, 95%CI 0.24-0.45). Despite more intense abuse patterns, clients seeking treatment for buprenorphine abuse shared similar characteristics to amphetamine clients. These characteristics were different to characteristics of those who abuse prescription opioids in North America. This is important for developing and targeting intervention programs.
Al Al Al Al Alterna terna terna terna ternative Georgia tive Georgia tive Georgia tive Georgia tive Georgia 38 Executive Summary From the time of its creation in the 1970s, the system of registration of drug users and those dependent on drugs served as a form of extensive control for the State over this part of the population. As a result of legislative and administrative changes between 2004 -2007, the law on the books and actual practice differ greatly. The concept of registration of drug users has lost its formal public health function and moved under the full control of the law enforcement agencies. In 2006, The Ministry of Internal Affairs (MOIA) initiated a reform of drug testing and registration, -which has lead to the consolidation of its control in this sphere. The reforms were accompanied by legislative changes. In particular, administra-tive fines for those tested positive for drug use were increased dramatically following the transfer of the drug testing function to a special department under the supervision of the MOIA. The changes may have been accompanied by a verbal agreement with the law enforcement agencies to increase random drug testing. Whatever the cause, the number of people brought to testing has gone up considerably – 22,755 citizens were forced to be tested in the seven months after the law regarding administrative fines went into effect 1 . For the purpose of comparison, this is nearly equivalent to the total number of people registered (24,000) with the CIB from the period of 1985 to 2005 2 . With drug treatment severely limited and prohibitively expensive, forced drug testing of the population and restrictions on the civil liberties of drug users have become the pri-mary instrument of state drug policy in Georgia. Those who test positive for drug use, are not only subject to large fines, but are also denied certain rights such as the right to be employed in certain professions, the right to drive a car, the right to participate in an election as a candidate. This report examines the current practice of registration in Georgia and assesses its impli-cations for the health and human rights of people who use drugs as part of the state's broader strategy on the war on drugs.
The pharmacologie profile of sublingual and subcutaneous buprenorphine, a partial opioid agonist, indicates it may be useful as a maintenance drug in the treatment of opioid dependence. However, illicit intravenous self-administration suggests that it may have a greater abuse potential by this route of administration. Physiologic and subjective effects of intravenous buprenorphine (0.0, 0.3, 0.6, and 1.2 mg) were determined in a dose-escalation study in six nondependent volunteers with histories of opioid use. Buprenorphine caused miosis and decreased respiratory rate, increased diastolic blood pressure, and transiently increased heart rate. Buprenorphine increased positive responses on a "feel drug" question and scores on scales of "liking," "good effects," euphoria, and apathetic sedation. Physiologic and subjective responses were not consistently dose related, a finding compatable with the pharmacologie profile of a partial agonist. The findings indicate that buprenorphine has substantial potential for abuse when administered intravenously.
Background: Buprenorphine dependence is a new issue and to our knowledge no scientific papers have been published on treatment of buprenorphine dependency. The goal of this research was to characterize intrave-nous buprenorphine-dependent individuals with respect to socio-demographic and other background features, and to investigate the effect of methadone in the maintenance treatment of intravenous buprenorphine de-pendence in comparison with sublingual buprenorphine and also oral clonidine over a 12-week treatment pe-riod. Methods: Intravenous buprenorphine-dependent patients who met the DSM-IV criteria for opioid de-pendence were randomized to three groups. Results: The mean age was 29.4 years (range 19-46). The majority (86.1%) had a history of opium or heroin dependency before they were introduced to intravenous buprenor-phine. The mean duration of buprenorphine dependence was 1.8 years and the mean ampoule per day was 4.6 ampoules (1 ampoule contains 0.3 mg of buprenorphine in 1 ml). Completion rates by groups were 83.3% for the methadone group, 58.3% for the buprenorphine group and 11.1% for the clonidine group (p < 0.0001). Retention in treatment was significantly better in the methadone group than in the buprenor-phine group (p = 0.020) and the clonidine group (p < 0.0001). Retention in the buprenorphine group was significantly better than in the clonidine group (p < 0.0001). Conclusions: The results support the efficacy and safety of oral methadone and sublingual buprenorphine tablets for intravenous buprenorphine-dependent patients (German J Psychiatry 2003; 6: 23-29). Acknowledgements: We are very grateful to professor Robert Newman, and Professor Jude Ohaeri for their sci-entific comments. We are also thankful to Dr. Bahrami, Mr. Taghi Hidari, Mr. Taba Tabaee, and Dr. Mohammadsadegh Mohagheghzadeh for their assistance.
In most European countries, methadone treatment is provided to only 20– 30% of opiate abusers who need treatment due to regulations and concerns about safety. To address this need in France, all registered medical doctors since 1995 have been allowed to prescribe buprenorphine (BUP) without any special education or licensing. This led to treating approximately 65,000 patients per year with BUP, about ten times more than with more restrictive methadone policies. French physician compensation mechanisms, pharmacy services, and medical insurance funding all minimized barriers to BUP treatment. About 20% of all physicians in France are using BUP to treat about half of the estimated 150,000 problem heroin users. Daily supervised dosing by a phamacist for the first six months resulted in significantly better treatment retention (80% vs 46%) and lower heroin use. Intravenous diversion of BUP may occur in up to 20% of BUP patients and has led to various infections and relatively rare overdoses in combination with sedatives. Opiate overdose deaths have declined substantially (by 79%) since BUP was introduced in 1995. Newborn opiate withdrawal in mothers treated with buprenorphine compared to methadone was reported to be less frequent, less severe, and of shorter duration. Although some of the public health benefits seen during the time of buprenorphine expansion in France might be contingent upon characteristics of the French health and social services system, the French model raises questions about the value of tight regulations on prescribing BUP imposed by many countries throughout the world.
Illicit methamphetamine use continues to be a public health concern in the United States. The goal of the current study was to use a relatively inexpensive methodology to examine the prevalence and demographic correlates of nonmedical methamphetamine use in the United States.
The sample was obtained through an internet survey of noninstitutionalized adults (n = 4,297) aged 18 to 49 in the United States in 2005. Propensity weighting methods using information from the U.S. Census and the 2003 National Survey on Drug Use and Health (NSDUH) were used to estimate national-level prevalence rates.
The overall prevalence of current nonmedical methamphetamine use was estimated to be 0.27%. Lifetime use was estimated to be 8.6%. Current use rates for men (0.32%) and women (0.23%) did not differ, although men had a higher 3-year prevalence rate (3.1%) than women (1.1%). Within the age subgroup with the highest overall methamphetamine use (18 to 25 year olds), non-students had substantially higher methamphetamine use (0.85% current; 2.4% past year) than students (0.23% current; 0.79% past year). Methamphetamine use was not constrained to those with publicly funded health care insurance.
Through the use of an internet panel weighted to reflect U.S. population norms, the estimated lifetime prevalence of methamphetamine use among 18 to 49 year olds was 8.6%. These findings give rates of use comparable to those reported in the 2005 NSDUH. Internet surveys are a relatively inexpensive way to provide complimentary data to telephone or in-person interviews.
This study examined the correlates of injection drug use (IDU) in a community sample of psychostimulant users. Factors related to the cessation of illicit drug use and substance abuse service utilization were also determined among a subsample of stimulant users who reported IDU.
The study sample consisted of 3408 lifetime psychostimulant users from the National Household Survey on Drug Abuse. Logistic regression procedures were used to estimate independent associations of correlates of IDU.
Approximately one in seven lifetime stimulant users reported IDU in their lifetime. Stimulant users with a lifetime history of IDU were more likely than those who did not inject to be African-American, not have received a high school diploma, have a history of multiple drug use, and report an onset of stimulant use before age 18. Among recent stimulant users, being aged 26 or older, using stimulants at least weekly, and getting drunk in the past year were associated with increased odds of recent IDU. Only one-half of all injection drug users reported having ever used substance abuse services. Cessation of illicit drug use among injectors with a history of stimulant use is common (44%).
Further studies should clarify the natural history of IDU among stimulant users, including the cessation of drug use without participating in substance abuse treatment services.
Subutex is a sublingual formulation of buprenorphine that is used to treat opioid dependency. It may be abused parenterally with disastrous consequences.
We present 4 cases of parenteral abuse of Subutex resulting in severe upper limb complications.
Two vascular complications were treated with combinations of anticoagulants, vasodilators, brachial plexus bock and iloprostol. One severe hand abscess required surgical debridement, and 1 median nerve injury required neurolysis.
All patients had a poor outcome. Both patients with vascular complications required multiple amputations, the patient with a thenar abscess had severely impaired thumb function, and the patient with median nerve injury has ongoing neuralgic pain, numbness and thenar weakness.
The incidence of complications of parenteral abuse of Subutex is increasing in Singapore. These complications have a poor outcome despite adequate management, and are best prevented by education or legal means.
The Russian HIV-1 epidemic has been driven by injection drug use.
To determine HIV incidence and identify demographic and behavioral correlates of infection to facilitate the development of longitudinal HIV prevention programs.
In 2002, a cohort of 520 injection drug users (IDU) in St Petersburg, Russia were recruited and tested and counseled for HIV-1. HIV-seronegative IDU were enrolled and reevaluated at 6 and 12 months. HIV testing was performed and sociodemographic and behavioral data were collected during each study visit. The relationship of sociodemographic and behavioral factors to HIV-1 incidence was assessed.
Most enrolled subjects were young, male, living at home, educated, heroin users, and frequently shared needles and other injection paraphernalia. The retention rate at the 12 month follow-up was 80%. The HIV-1 incidence rate was 4.5/100 person-years. In univariate analysis, psychostimulant use, especially frequent use, three or more sex partners in the past 6 months, and females selling sex were associated with HIV seroconversion. In the multivariate analysis, psychostimulant use three or more times per week was the only factor still associated with HIV seroconversion.
The high incidence of HIV infection places St Petersburg among the worst IDU-concentrated epidemics in Europe. Interventions targeting psychostimulant and heroin users and their accompanying behaviors such as frequent injections and increased sexual activity are needed immediately.
The US Food and Drug Administration (FDA) approved buprenorphine or Subutex for the treatment of opiate dependence in October 2002. Buprenorphine is a partial agonist of the mu-opioid receptor; although initial animal research suggested a low abuse potential for buprenorphine, it was subsequently shown to have an abuse potential similar to that of morphine or hydromorphone. The objectives of this study were to establish the sociodemographic profile and help-seeking behaviour of buprenorphine abusers attending the deaddiction treatment clinics of the Community Addictions Management Programme.
One hundred and twenty subjects, all buprenorphine abusers fulfilling the diagnostic criteria for opiate dependence, who consented to the study, completed an interviewer-administered questionnaire.
The mean age of those participating in the study was 39.2 [standard deviation (SD) 8.0] years. The majority of the participants were male (90%), 52.5% were currently employed and 98% had at least primary education. A family history of drug abuse was reported by 27% of the subjects. Illicit drug abuse occurred at an early age with mean age of onset of illicit drug abuse being 16.9 (SD 4.8) years with gateway drugs like marijuana and glue.
It is vital for our medical profession to be aware of the trend in the local population to move from the abuse of illicit substances, to the abuse of prescriptive medications. It makes it necessary to increase the understanding of addictions both amongst our practising medical fraternity, and amongst those training to enter the profession. At the hospital level, it necessitates a higher level of vigilance among our emergency room physicians and those treating infectious diseases.
The aim of this study was to determine the prevalence and characteristics of benzodiazepine (BZD) abuse among intravenous opioid users in Singapore.
Eligibility criteria for inclusion in this study were all intravenous buprenorphine abusers, who presented to the Community Addictions Management Programme (CAMP) over a 1-year period from February 2005 to January 2006. One hundred and twenty subjects, who consented to the study, completed an interviewer-administered questionnaire and underwent blood test for blood-borne viral infections.
The age of the 120 subjects ranged from 20 to 64 years, with a mean age of 39.0 (SD 8.0) years. The majority of the participants were male (90.0%); 48.3% were Chinese. Ninety-eight (81.7%) patients were using BZDs concomitantly. Midazolam was the most commonly used BZD. Buprenorphine abusers who were concomitantly using BZDs were significantly younger and reported an earlier age of onset of illicit drug abuse as compared to those not using BZDs. Those abusing BZDs were more likely to share syringes (x 2 = 5.8, P = 0.02), and were more likely to be seropositive for hepatitis C virus (x 2 = 4.3, P = 0.04).
This study highlights the extreme caution that needs to be exercised in prescribing BZDs to all patients in general and patients with injecting drug use or histories of drug abuse in particular. At a public health level, general practitioners (GPs) who prescribe buprenorphine should have compulsory training which highlights the potential dangers of abuse and concomitant abuse of BZDs.
This study was designed to assess differences in drug and sex-related risk behaviors between injectors of opiates only, opiate/sedative mix only and stimulants only. Participants were current out-of-treatment injection drug users (IDUs), unaware of their HIV status, recruited through street outreach in Kiev, Odessa and Makeevka/Donetsk, Ukraine. Overall, 22% tested positive for HIV, including 39% among opiate/sedative injectors, 19% among opiate injectors and 17% among stimulant injectors. Despite these differences, stimulant injectors were at higher risk than other IDUs in sharing a used needle/syringe, always injecting with others, injecting a drug solution drawn from a common container, having an IDU sex partner, not using condoms during vaginal or anal sex and on composite measures of injection and sex risks. After controlling for age differences, stimulant injectors remained at higher risk in their needle and sex risk behaviors. Without intervention, it is likely that HIV will increase among stimulant injectors.
In January 1998 the authors conducted a rapid assessment of injecting drug use and HIV in the Republic of Georgia. We collected and analyzed information through a review of available documents, interviews with key informants, focus group interviews with injection drug users (IDUs), and observations of drug scenes. The guiding principles in our methodology were derived from the WHO manuals on Rapid Assessment Methodology (RAM). Although many information gaps remain in our findings, we did not find indications for an emerging HIV epidemic among IDUs, such as that occurring in other regions within the former USSR. On the other hand, a future HIV epidemic among IDUs cannot be precluded because of a high prevalence of injecting drug use and the common practices of needle sharing, 'front loading, 'and unprotected sex among IDUs. In order to maintain the relatively favorable situation regarding HIV infections among IDUs in Georgia, additional interventions are needed and should be targeted toward the general population as well as specific subgroups and situations posing high levels of risk behaviors (e.g., prisons). The limited opportunities for offering services directly to IDUs are an obstacle for targeted prevention. Since injecting at home for medical purposes is quite common in the general population, a mass media-based safe injection campaign and improved access to syringes and condoms through pharmacies are preferable and more feasible than setting up needle-exchange programs. In reflecting on the use of rapid assessment methodology, we see the need for evaluation of the approach. Its further development should aim at synthesizing social science methodology and practical knowledge on policy making and intervention development.
Buprenorphine was introduced as a potent analgesic with low abuse potential. Reports of buprenorphine abuse by opiate abusers have accumulated over the years, highlighting its use as a cheap alternative to heroin. The lower potency compared with heroin is being compensated by using a cocktail of buprenorphine with benzodiazepines or cyclizine. This study of 18 cases seen over 3 years broadly confirms these findings. Four cases reported haematemesis during acute withdrawal, a symptom not reported in earlier studies.
Research involving drug users and treatment evaluations continue to rely extensively on self-reports of drug use. This paper presents a meta-analytical review of 24 studies published since 1985 that examined the validity of drug self-reports in high risk populations. Only studies employing a biological criterion of validity (e.g., urinalysis, hair analysis) are included. Coefficients of chance-corrected agreement between self-reports and the validity criteria are calculated from published data to facilitate cross-study comparisons. The median conditional kappa (kappa c) was .42, considerably below the level of kappa c = .80 that represents acceptable reporting accuracy. The magnitude of drug use underreporting documented in this review could seriously bias prevalence estimates and treatment outcome studies.
The purposes of this study were to characterize the subjective, psychomotor and physiological effects of buprenorphine in nondrug-abusing volunteers and to compare and contrast the effects of equianalgesic doses of buprenorphine and morphine. Sixteen subjects without histories of opiate dependence were injected in an upper extremity vein with 0, 0.075, 0.15 or 0.3 mg/70 kg buprenorphine, or 10 mg/70 kg morphine, using a randomized, double-blind, cross-over design. The 0.3-mg buprenorphine dose and 10-mg morphine dose are considered to be equianalgesic and are doses commonly given for relief of postoperative pain. Buprenorphine increased scores on the Pentobarbital-Chlorpromazine-Alcohol Group scale and decreased scores on the Benzedrine Group scale of the Addiction Research Center Inventory, increased adjective checklist ratings of "nodding," "skin itchy," and "turning of stomach," and increased visual analogue scale ratings of "dizzy," "nauseous" and "sleepy." Buprenorphine (0.3 mg) in general had subjective effects of greater magnitude than that of 10 mg morphine. Buprenorphine produced impairment on five measures of psychomotor performance in a dose-related fashion. Ten mg morphine produced minimal psychomotor impairment. Both buprenorphine and morphine induced miosis, but buprenorphine (0.3 mg) had a larger and longer effect than that of 10 mg morphine. Buprenorphine, but not morphine, decreased respiration rate. The results of our study demonstrate that 0.075 to 0.3 mg buprenorphine had orderly, dose-related effects on subjective, psychomotor and physiological variables. Further, a clinically relevant dose of buprenorphine, 0.3 mg, produced a greater magnitude of subjective and psychomotor-impairing effects than did an equianalgesic dose of morphine.
To evaluate the safety and efficacy of an 8 mg/day sublingual dose of buprenorphine in the maintenance treatment of heroin addicts by comparison with a 1 mg/day dose over a 16-week treatment period. As a secondary objective, outcomes were determined concurrently for patients treated with two other dose levels.
Patients were randomized to four dosage groups and treated double-blind.
Twelve outpatient opiate maintenance treatment centers throughout the United States.
Two hundred and thirty-nine women and 497 men who met the DSM-III-R criteria for opioid dependence and were seeking treatment.
Patients received either 1, 4, 8 or 16 mg/day of buprenorphine and were treated in the usual clinical context, including a 1-hour weekly clinical counseling session.
Retention in treatment, illicit opioid use as determined by urine toxicology, opioid craving and global ratings by patient and staff. Safety outcome measures were provided by clinical monitoring and by analysis of the reported adverse events.
Outcomes in the 8 mg group were significantly better than in the 1 mg group in all four efficacy domains. No deaths occurred in either group. The 8 mg group did not show an increase in the frequency of adverse events. Most reported adverse effects were those commonly seen in patients treated with opioids.
The findings support the safety and efficacy of buprenorphine and suggest that an adequate dose of buprenorphine will be a useful addition to pharmacotherapy.
The use of behavioural self-reports of drug users is widespread among studies of illicit drug use. Despite widespread use, concerns about the accuracy of these reports continue to be raised. The current paper critically reviews the literature on the reliability and validity of self-reported drug use, criminality and HIV risk-taking among injecting drug users. The literature shows respectable reliability and validity of self-reported behaviours when compared to biomarkers, criminal records and collateral interviews. It concludes that the self-reports of drug users are sufficiently reliable and valid to provide descriptions of drug use, drug-related problems and the natural history of drug use.
The aim of this study was to compare the various clinical practices in four health care networks and to access how the variations in treatment effected the outcome in opiate-dependent patients.
A retrospective study was carried out with 71 participating general practitioners. These were chosen from a group of 354 practitioners from four health care networks. Each practitioner could enroll up to 5 patients who were currently undergoing treatment with high-dose buprenorphine(HDB). The patients treatment had to have been initiated between the 1(st) of February 1996 and the 31(st) of October 1996, and excluded any patients who had lapsed on their treatment during the first month. Patients were selected until a total of 75 cases were enrolled from each network. Data were then collected retrospectively between June and December 1997. Information collected concerned the initial stage of treatment, the stabilizing stage or level of treatment and followed up data on the most recent prescriptions.
The final patient maintenance totals were high for all four care networks (82.7 to 96% of patients were still being followed by their doctor at the final evaluation). A positive outcome as indicated by reduction of risk and decreased social vulnerability was also observed in all networks. Additionally, in each network there was a clear correlation between prescription practices and patient behavior. For example, the prescription of HDB at a daily dose of less than 6.2mg was associated with a higher rate of benzodiazepine use; and prescription of several daily doses of HDB was associated with a higher percentage of injecting patients.
This retrospective study provides evidence that general practitioner care of drug-dependent patients as outpatients, within a health care network helps to stabilize patient visits, allows treatment of associated comorbidities and favors social rehabilitation. The prescription of HDB as a single daily dose, individually adapted for each patient, optimizes the outcome and reduces misuse.
To evaluate the extent to which the introduction (February 1996) of ambulatory prescriptions of buprenorphine for drug maintenance treatment (DMT) has been associated with its intravenous illicit use by French injecting drug users (IDUs).
Cross-sectional survey (September 1997), using self-administered questionnaires, in a sample of IDUs recruited at 32 pharmacies, four needle exchange programmes and three syringe vending machines.
Thirty-nine sites where IDUs have access to sterile syringes in the city of Marseille (South-Eastern France).
Sample of IDUs attending community pharmacies, vending machines and needle exchange programs to obtain equipment.
To compare characteristics of IDUs who declared that they only injected buprenorphine in the prior 6 months versus the rest of the sample.
Among the 343 respondents (response rate = 70.7%), 33.8% were polydrug users who occasionally injected buprenorphine in parallel to heroin and/or cocaine, while 23.9% only injected buprenorphine in the previous 6 months. IDUs in this latter group were younger, injected more frequently, and were more frequently on buprenorphine DMT, but they were less likely to be HIV-infected and to declare HIV-related injecting risky behaviours.
Substantial risk of injecting misuse is associated with large-scale diffusion of buprenorphine DMT. A more stringent regulation for medical dispensation of buprenorphine than the current French general freedom of prescription for all physicians, including general practiioners in ambulatory care, may be necessary in other countries which are considering the diffusion of buprenorphine DMT.
Buprenorphine at high dosage became available in France in 1996, as a substitution treatment for heroin addicts. Since this date, numerous deaths were attributed to this drug. This paper reports two original series of 39 and 78 fatalities involving buprenorphine observed at the Institute of Legal Medicine of Strasbourg and at 13 other French forensic centers, respectively. The files were recorded from January 1996-May 2000. The first 20 fatalities that were previously published were excluded from this epidemiological study. From these 117 subjects, 96 were male (82%). Buprenorphine and its primary metabolite norbuprenophine were assayed in post-mortem blood by HPLC/MS (n=11 labs) or by GC/MS (n=3 labs). Blood levels for buprenorphine ranged from 0.5 to 51.0ng/ml (mean 10.2ng/ml) and 0.1 to 76ng/ml (mean 12.6ng/ml) in Strasbourg and the other centers, respectively. Blood levels for norbuprenorphine ranged from 0.2 to 47.1ng/ml (mean 8.2ng/ml) and <0.1 to 65ng/ml (mean 10.6ng/ml) in Strasbourg and the other centers, respectively. The mean values appear to be within the therapeutic range. Buprenorphine was identified in 24 of the 26 hair samples assayed in Strasbourg, at concentrations ranging from 10 to 1080pg/mg. Intravenous injection of crushed tablets, a concomitant intake of psychotropics (especially benzodiazepines and neuroleptics) and the high dosage of the buprenorphine formulation available in France appear as the major risk factors for such fatalities. In addition, two suicide-related deaths were also observed, with blood buprenorphine concentrations at 144 and 3276ng/ml.
Several sources indicate that intravenously administered buprenorphine may have significant abuse liability in humans. The present study evaluated the reinforcing effects of intravenously administered buprenorphine (0, 2, and 8 mg) in detoxified heroin-dependent participants during a 7.5-week inpatient study. Participants (n = 6) were detoxified from heroin over a 1.5-week period immediately after admission. Testing subsequently occurred in three 2-week blocks. During the first week of each 2-week block, the reinforcing effects of buprenorphine were evaluated. Participants first received a dose of buprenorphine and 20 during choice sessions. During the second week of each 2-week block, the direct effects of heroin were measured to evaluate potential long-lasting antagonist effects of buprenorphine. Progressive ratio break-point values were significantly higher after 2 and 8 mg of buprenorphine compared with placebo. Correspondingly, several positive subjective ratings increased after administration of active buprenorphine relative to placebo. Although there were few differences in peak effects produced by 2 versus 8 mg of buprenorphine, the higher buprenorphine dose generally produced longer-lasting effects. Heroin also produced dose-related increases in several subjective effects. Peak ratings produced by heroin were generally higher than peak ratings produced by buprenorphine. There was little evidence of residual antagonism produced by buprenorphine. These results demonstrate that buprenorphine served as a reinforcer under these conditions, and that it may have abuse liability in nonopioid-dependent individuals who abuse heroin.
In France, actually, around 70 000 drug addicts are treated with buprenorphine available as sublingual tablets. Clinical studies have demonstrated the clinical efficacity of buprenorphine for opiate addiction. But, it has been reported that some of them injected buprenorphine. Some inquiries have suggested measured with 10% to 40% injectors. To use buprenorphine tablets for injections have had heavy sanitary consequences (4).
To know the use buprenorphine context in our population and to analyse the circumstances and outcomes of buprenorphine injection for drug addicts.
In 1998-1999, we conducted a cross-sectional survey using a structured questionnaire. Information wax collected during a 30-minute face-to-face interview through an 69-item structured questionnaire administered by trained investigators. The questionnaire was composed of questions about social demographic data, the drugs taken before the first use of buprenorphine, the circumstances of the first buprenorphine experiment, the reasons for the first buprenorphine injection into drug addicts, the other substances used in the same time, the risks behaviors, the sensations seeking, the medical consequences. The questionnaire was first tested in a pilot study through ten patients. Drug addicts were followed-up in 8 drug abuse treatment centres among which 2 networks of general practitioners in Paris region, in Strasbourg region and in Nice region. The investigators were general practitioners, psychologists, psychiatrists, educators, nurses. All drugs addict which reported use buprenorphine were seen in treatment centre and were 18 years old or older, were eligible. Drugs addict with severe mental disorders, unable to answer the questions were excluded. Respondents received an assurance of confidentiality and informed consent was obtained. Standard descriptive statistics were used to analyse subjects characteristics: frequency, standard deviation. The study was funded by the Observatoire Français des Drogues et des Toxicomanies (OFDT).
Of the 779 consecutive drug addicts interviewed, 770 completed the questionnaire. The study has shown that the majority of subjects were male (77.2%), mean age was 31.3 (SD: 5.98). Most of them were unmarried (67.5%). They had no real employment (56.5%). The mean age at the first use opiate was 19.5 (SD: 4.5). The mean age at the first heroin injection was 20.7 (SD: 4.6). At the time of interview, most of drugs addict used more than two types of drugs (42.6%). Many associations with buprenorphine are described particularly associations to alcohol (41.2%), benzodiazepines (40%), cocaine (12.4%), heroin (7.8%), crack (7.2%); most of these subjects getting buprenorphine without any medical prescription. Most drug addicts had asked themselves for using buprenorphine (61.0%). Near fifty per cent (49.5%) injected buprenorphine. Among them, 39.6% injected this substance the first time they used it. Curiosity (72.8%), need for injection (69.0%), sensation seeking (49.0%) were reasons given by drug addicts for buprenorphine injection. Others reasons were given: an inadequate dosage of sublingual buprenorphine, to find buprenorphine in black market. Buprenorphine injection took place in the secure environment (57.5%). Drug addicts were not alone when they injected (53.6%). The introducer was an buprenorphine user (57%). The first buprenorphine injection sensation was not pleasant (61%), although injection of buprenorphine is usually performed by 80% of them. However, 93% had been informed that buprenorphine injection was contra-indicated.
Since six years, many French patients have received a treatment for opiate addiction. High dosage buprenorphine is actually the principal treatment for substitution medication in France. Some misappropriations and wrong uses have been seen, the most frequent and sever being using tablets for injections. The prevalence of buprenorphine injection is high among drug addicts. The results of the study show that the first buprenorphine Injection takes places place a few time after the first buprenorphine use. The codependance to other substances is one of risk markers for intravenous use of buprenorphine tablets and the dangers of polyintoxication were known. Curiosity, need for injection favour buprenorphine injection. But, the sensation seeking brings on the drug addict too. The rather loose frame of prescription, a lack of training among general practitioners, the fragility of the specialises network, the complexities in the care of drug users which not resumed by a substitution must take into consideration. The drug addict's career, the subject's environment and the circumstances of the buprenorphine injection have not been previously described. However their knowledge are of prime necessity to prevent this abnormal use and to find the best treatment for drug addicts.
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.
The study aimed to identify the range of buprenorphine doses required to comfortably alleviate symptoms in patients undergoing inpatient heroin withdrawal using a symptom-triggered titration dosing regime, and to identify the patient characteristics that impact upon the buprenorphine dose requirements. The study was conducted in two Australian inpatient withdrawal units, recruiting 63 dependent, injecting heroin users with no recent methadone treatment, dependence on other drugs, or other active medical or psychiatric conditions. In a single (patient) blinded case series, placebo or 2 mg sublingual buprenorphine tablets was administered four times a day according to severity of withdrawal (assessed with Subjective Opiate Withdrawal Scale). Up to 16 mg buprenorphine was available over the first 4 days of the admission, up to 8 mg on day 5, and placebo continued until day 6. Thirty-two subjects completed the dosing regime, with mean (+/-S.D.) daily doses of 3.8+/-2.8 on day 1, 5.8+/-3.2 on day 2, 4.8+/-3.3 on day 3, 2.3+/-2.6 on day 4, 0.8+/-1.3 on day 5, and a total dose of 17.4+/-9.7. Higher buprenorphine doses were required by those patients with more severe psychosocial dysfunction, women, those with more frequent heroin use, and those with more severe dependence on heroin at intake. A dosing regime using sublingual buprenorphine tablets for short inpatient heroin withdrawal is proposed.
Buprenorphine was approved in France for treating opiate dependence in July 1995 and can be prescribed by general practitioners (GPs). Most studies assessing buprenorphine maintenance treatment (BMT) outcomes have taken place in GP settings. An evaluation of BMT outcomes in patients already followed for their HIV-infection could supply additional information about the changes in addictive practices in a non-GP setting.
We assessed BMT discontinuations and the course of self-reported addictive behaviours and characteristics associated with buprenorphine-injection misuse in 114 HIV-infected patients on BMT who were followed in a hospital-based outpatient department.
The continuous series of follow-up visits at which these 114 patients reported regular buprenorphine prescriptions accounted for 237.5 person-years of observation, i.e. 475 follow-up visits. Of the 114 patients on BMT, 43% continued BMT throughout the follow-up, 40% stopped it, and results for 17% were not available either because they did not answer the self-administered questionnaire (5%) or because they were lost to follow-up (12%). Addictive behaviours declined but buprenorphine injection misuse remained stable. Depression measured by the CESD score (RR=1.04 95%CI [1.01-1.06]), cocaine use (RR=2.48 95%CI [1.31-4.68]) and alcohol consumption exceeding 4 alcohol units (AU) per day (RR=2.29, 95%CI [1.17-4.46]) were independently associated with buprenorphine injection misuse among stabilised BMT patients.
Despite the reduction in drug injection after starting BMT, buprenorphine injection misuse mainly involves patients with characteristics of severe addiction. Better monitoring of the illicit drug use patterns of patients on BMT may suggest new medical strategies for GPs to improve BMT outcomes.
To evaluate the associations between methadone and high-dose buprenorphine maintenance treatment and illicit drug use and injection among drug users in France.
A cross-sectional study. Data were gathered using a questionnaire administered containing closed-ended questions.
Drug dependence clinics (DDC) and general practitioners' (GPs) offices in three French cities.
Drug users undergoing maintenance treatment with methadone (n = 197) and buprenorphine (n = 142).
Interviews covered the use of illicit drugs (heroin, cocaine or crack) and injection practices (illicit drugs and/or substitution drugs) during the last month, current treatment modalities, socio-demographic and health characteristics. Bivariate analysis and multivariate logistic regressions were conducted.
Overall, 35.4% of respondents (34.5% in the methadone group, 36.6% in the buprenorphine group, P= 0.69) had used at least one illicit drug, 25.7% reported having injected drugs and 15.3% had injected the substitution drug. Injection was more common among buprenorphine-maintained individuals (40.1%) than among users on methadone (15.2%) (P < 0.01). Multivariate analyses indicate that the type of substitution drug (buprenorphine versus methadone) was not associated with illicit drug use (OR = 1.1; 95% CI = 0.7-1.8). In the buprenorphine group, injection was related independently to social situation, as measured by housing (unstable versus stable housing, OR = 4.3; 95% CI = 1.6-11.5), but this was not the case in the methadone group. The risk of injection increased with buprenorphine dosage (high/low dosage OR = 6.2; 95% CI = 2.0-19.7), but this association was not observed in the methadone group.
Further studies comparing the benefits of these two types of treatment should be carried out, taking outcomes such as physical health, mental health and social functioning into consideration.
Buprenorphine dependence is a relatively novel addiction.
To compare the treatment outcome in three groups over 12-weeks of treatment.
Two hundred and four intravenous (i.v.)-buprenorphine-dependent patients were randomised into three groups. Subjects received 50 mg oral methadone tablet, or 5 mg sublingual buprenorphine tablet, or 50 mg oral naltrexone, and a weekly 30-minute clinical counselling session.
The majority (80%) had a history of opium or heroin dependency before they were introduced to i.v. buprenorphine. The main source of buprenorphine for misusers was street sale (91%). The mean duration of buprenorphine dependence was 1.9 years and the mean dose per day was 3.9 ampoules (1 ampoule contains 0.3 mg of buprenorphine in 1 ml). Overall 59% of the patients completed the 12-week study. Retention in the 50 mg methadone group was significantly better than the 5 mg dose buprenorphine group (p=0.001) and the 50 mg dose naltrexone group (p=0.000). Retention in the 5 mg buprenorphine group was significantly better than the 50 mg naltrexone dose group (p=0.000).
These results support the efficacy and safety of oral methadone and sublingual buprenorphine tablets for injection buprenorphine-dependent patients.
Buprenorphine has become of increasing interest to be an alternative to methadone in the treatment of heroin addicts. The aim of the paper is to review, from a clinical perspective, the current status of what is known about the pharmacology of buprenorphine, with a particular emphasis on the issues of maintenance therapy in heroin addiction. A systematic review of published follow-up data, from observational and experimental studies was done. Electronic databases Medline and PSYNDEXplus were searched from their earliest entries. Buprenorphine appears to be a well-tolerated drug, with a benign overall side effect. Buprenorphine is an additional treatment option for heroin dependent patients, especially for those who do not wish to start or continue with methadone or for those who do not seem to benefit from adequate dosages of methadone.
The recent approval of office-based treatment for opioid addiction and US Food and Drug Administration approval of buprenorphine will expand treatment options for opioid addiction. Buprenorphine is classified as a partial micro opioid agonist and a weak kappa antagonist. It has a high affinity for the micro receptor, with slow dissociation resulting in a long duration of action and an analgesic potency 25 to 40 times more potent than morphine. At higher doses, its agonist effects plateau and it begins to behave more like an antagonist, limiting the maximal analgesic effect and respiratory depression. This "ceiling effect" confers a high safety profile clinically, a low level of physical dependence, and only mild withdrawal symptoms on cessation after prolonged administration. Suboxone contains a mixture of buprenorphine and naloxone. The naloxone is poorly absorbed sublingually and is designed to discourage intravenous use. Subutex, buprenorphine only, will also be available primarily as an initial test dose. Clinicians will be using this drug for detoxification or for maintenance of opioid addiction. Patients with recent illicit opioid use may develop a mild precipitated withdrawal syndrome with the induction of buprenorphine. Acute buprenorphine intoxication may present with some diffuse mild mental status changes, mild to minimal respiratory depression, small but not pinpoint pupils, and relatively normal vital signs. Naloxone may improve respiratory depression but will have limited effect on other symptoms. Patients with significant symptoms related to buprenorphine should be admitted to the hospital for observation because symptoms will persist for 12 to 24 hours.
This randomized clinical trial evaluated the relative efficacy of three buprenorphine dosing schedules. Opioid-dependent adults were randomly assigned to receive buprenorphine seven, 3 or 2 days per week for 24 weeks. Daily maintenance doses were 4, 8, 10, or 12 mg of the sublingual buprenorphine solution. Participants who attended the clinic daily received a maintenance dose of buprenorphine daily. Participants who attended the clinic thrice weekly received double their maintenance dose on Monday and Wednesday, followed by a triple dose on Friday. Participants who attended the clinic twice weekly received quadruple their maintenance dose of buprenorphine on Monday and triple their maintenance dose on Friday. Results demonstrated that all dosing regimens were of comparable efficacy in promoting treatment retention, opioid and cocaine abstinence, and reductions in HIV risk behavior (especially as related to drug use) and severity of life problems. Predictor analyses identified sub-populations of opioid-dependent individuals that may have a more positive treatment outcome under each buprenorphine dosing condition. Less-than-daily dosing schedules may provide the opportunity for treatment programs to serve a greater number of opioid-dependent patients and reduce the risk of medication diversion, which may, in turn, have a positive impact on community support of science-based treatment for opioid-dependence.
To examine indicators of buprenorphine diversion and injection among injecting drug users in Melbourne, Australia and to determine the factors associated with buprenorphine injection.
Melbourne arm of the 2002 Illicit Drug Reporting System (IDRS) cross-sectional study.
Five Needle and Syringe Programme sites in Melbourne, Australia.
A total of 156 current injecting drug users (IDU). Study eligibility criteria were at least monthly injection during the previous 6 months, and Melbourne residence for at least the preceding 12 months.
Structured questionnaire covering demographic characteristics, drug use history, the price, purity and availability of drugs, criminal activity, risk-taking behaviours, health-related issues and general drug use trends.
Over one-third (37%) of the study sample reported injecting buprenorphine in their life-time and 33% reported injecting the drug in the last 6 months. Recent buprenorphine injection was associated with the injection of other drug types (i.e. polydrug injectors), opioid substitution treatment, injection-related health problems and involvement in crime. Almost half (47%) of those who reported recent buprenorphine injection reported obtaining the drug illicitly at least once during that time.
Given the significant health harms associated with intravenous buprenorphine use (e.g. vein damage, abscesses and infections, precipitated withdrawal, blood-borne virus transmission, hospitalization and death), routine monitoring of the misuse of buprenorphine in Melbourne is warranted. These results suggest the need for development of effective countermeasures to address diversion and injection of buprenorphine in this setting.
The first case of HIV in Georgia was diagnosed in 1989. Through December 2002, a total of 375 cases of HIV infection were reported. However, the World Health Organization estimates that the true number of infections may be closer to 1700. In all, 70% of reported cases are among injection drug users. Based on the UNAIDS classification, Georgia is a 'low-level HIV country' with an HIV prevalence of less than 1% in all groups, including drug users. However, there is a high prevalence of hepatitis B and C, suggesting a significant risk for the spread of HIV. Georgia, a newly independent republic, is experiencing an increase in injection drug use, a rise in sexually transmitted infections and commercial sex trade that create a fertile soil for the potential rapid spread of HIV. However, it is also a country with a unique window of opportunity for limiting the spread of HIV.
Buprenorphine (Subutex) is widely abused in Finland. A combination of buprenorphine plus naloxone (Suboxone) has been available since late 2004, permitting a comparison of the abuse of the two products among untreated intravenous (IV) users. A survey was distributed to attendees at a Helsinki needle exchange program over 2-weeks in April, 2005, At least 30% were returned anonymously. Survey variables included: years of prior IV opioid abuse, years of buprenorphine abuse, frequency, dosage, route of administration and reasons for use, concomitant IV abuse of other substances and amount paid on the street for both buprenorphine and buprenorphine+naloxone. Buprenorphine was the most frequently used IV drug for 73% of the respondents. More than 75% said they used IV buprenorphine to self-treat addiction or withdrawal. Most (68%) had tried the buprenorphine+naloxone combination IV, but 80% said they had a "bad" experience. Its street price was less than half that of buprenorphine alone. The buprenorphine+naloxone combination appears to be a feasible tool, along with easier access to addiction treatment, for decreasing IV abuse of buprenorphine.
The confluence of the heroin injection epidemic and the human immunodeficiency virus (HIV) infection epidemic has increased
the call for expanded access to effective treatments for both conditions. Buprenorphine and methadone are now listed on the
World Health Organization's Model Essential Drugs List. In France, which has the most extensive experience, buprenorphine
has been associated with a dramatic decrease in deaths due to overdose, and buprenorphine diversion appears to be associated
with inadequate dosage, social vulnerability, and prescriptions from multiple providers. Other treatment models (in the United
States, Australia, Germany, and Italy) and buprenorphine use in specific populations are also reviewed in the present article.
In countries experiencing a dual epidemic of heroin use and HIV infection, such as former states of the Soviet Union and other
eastern European and Asian countries, access to buprenorphine and methadone may be one potential tool for reducing the spread
of HIV infection among injection drug users and for better engaging them in medical care.
IDUs are under the high risk of HIV and other blood born diseases. In Georgia injecting drug use is associated with two third of registered HIV/AIDS cases. Majority of them are also infected with B and C Hepatitis. One of the main components of HIV/AIDS prevention among drug users is considered to be harm reduction programs, among them syringe exchange program. We conducted observational cohort study and performed interviewing participants of syringe exchange program using structured questionnaire. The interviewing was conducted at intake, after 3 months and at the end of the program. During interviewing we used risk assessment questionnaire which we have little adapted (Risk Assessment Battery, Navaline, et al, 1994). The data were statistically analysed using SPPS-11, 5 program. The aim of the study was to assess the efficacy of outreach and needle exchange programs in terms of reduction of HIV risk behavior of injection drug users in Tbilisi. The results of the study show visible reduction in injection risk behavior for clients being in the program for at least three months. There was not seen any significant change in the level of sexual risk behavior, which might suggest the need for targeting this behavior during the further interventions. The results of the study suggest a visible potential benefit to drug users and communities that could be gained through the wide scale implementation of harm reduction programs in Georgia.
To examine concurrent buprenorphine and benzodiazepine consumption and to compare opioid toxicity symptoms induced by methadone and buprenorphine, examining factors associated with the reporting of these symptoms.
Self-report cross-sectional survey.
Five needle syringe programmes and five opioid substitution treatment services in Melbourne, Australia.
A total of 250 people who had experience with methadone or buprenorphine. Eligibility criteria were current or previous methadone or buprenorphine use.
Structured questionnaire covering: demographic characteristics; current treatment and drug use; concurrent use of buprenorphine and benzodiazepines, including route of administration and source of medications; and opioid toxicity symptoms reported in association with methadone and buprenorphine consumption.
Of those reporting buprenorphine use, two-thirds reported concurrent benzodiazepine use, with a median dose reported of 30 mg diazepam equivalents. A greater number of opioid toxicity symptoms were reported in relation to methadone consumption compared with buprenorphine. Those reporting opioid toxicity with buprenorphine were more likely to report intravenous use compared with those reporting opioid toxicity with methadone.
The risk of opioid toxicity appeared greater with methadone compared with buprenorphine, despite high levels of benzodiazepine consumption and injection being reported in relation to buprenorphine use. The prevalence of buprenorphine injection and the normalization of methadone-induced sedation are two findings that merit further investigation. Establishing recommendations as to the safest and most effective way to manage benzodiazepine-using people in opioid substitution treatment is necessary for the optimization of treatment for opioid dependence in polydrug-using individuals.
Buprenorphine misuse by injecting drug users was assessed in a survey of 350 needle exchangers, either amphetamine (57%) or heroin users (42%). 89% of heroin users and 24% of amphetamine users reported using buprenorphine at some time during the previous year. Most users reported illicit acquisition. Among illicit users, 87% of heroin users reported intake for withdrawal treatment or self-detoxification, and 11% for euphoria. Euphoria seeking was more common among amphetamine users (62%, p < 0.001). Intravenous misuse was reported by 43% of illicit users, and snorting by 29%. Sole sublingual intake was more common among heroin users than among amphetamine users (46 vs. 20%, p < 0.05), and less common among patients reporting euphoria seeking (20 vs. 46%, p < 0.05).
In France, all registered medical doctors have been allowed to prescribe buprenorphine without any special education or licensing since 1995. This has led to a rapidly increasing number of opiate-dependent users under buprenorphine treatment in primary care. French physician compensation mechanisms, pharmacy services, and medical insurance funding all have contributed to minimizing barriers to buprenorphine treatment. Approximately 20% of all physicians in France are prescribing buprenorphine to treat more than one half of the estimated 180,000 problem heroin users. Intravenous diversion of buprenorphine may occur in up to 20% of buprenorphine patients and has led to relatively rare overdoses in combination with sedatives, whereas total opiate overdose deaths have declined substantially. In France, buprenorphine maintenance treatment for problem opiate users was feasible and safe through office-based prescriptions in a relaxed regulatory environment.
To investigate the prevalence and associations of buprenorphine injection among a field-recruited cohort of injecting drug users.
Cross-sectional data from a prospective longitudinal cohort. Setting. Metropolitan Melbourne, Australia.
Current injecting drug users (IDUs).
Prevalence of buprenorphine injection, associations with location, buprenorphine as prescribed pharmacotherapy, markers of hepatitis C virus (HCV) exposure and risk behaviours for HCV.
More than 10% of our 316 participants reported buprenorphine as the drug they had most often injected, and 32% had injected buprenorphine at least once in the 3 months prior to interview. Primary buprenorphine injection was significantly more likely to be reported by IDUs recruited at one of our three research sites, and by those being prescribed buprenorphine for opioid dependence. Frequency of sharing a used needle was also associated with buprenorphine injection, but HCV exposure was not.
Buprenorphine injection has become entrenched among some groups of Victorian IDUs. The practice carries serious risks to health, including some related to microbiological contamination of buprenorphine during diversion. While measures can be taken to reduce the occurrence of buprenorphine diversion and injection and the associated harm, an alternative harm reduction measure would be to provide IDUs with an injectable pharmacotherapy.
Buprenorphine was approved in late 2004 for the treatment of opioid abuse and dependence in specially trained and certified physicians' offices. At the time of the approval, there was a regulatory concern that given the anticipated wide exposure there would be unexpectedly high levels of abuse in the high-risk population for which it was intended. To assess its abuse potential, the authors recruited more than 1000 individuals seeking treatment for prescription opioid abuse from 100 stand-alone (i.e., self-pay or insurance) drug abuse treatment programs around the country to determine whether they misused buprenorphine in the past 30 days to get high. The results indicate that there was a time-related increase in the number of subjects who used buprenorphine to get high, reaching 30-35 percent of individuals completing a questionnaire in the second quarter of 2006. At this time, it was equivalent to the misuse of methadone, both of which, however, were considerably lower than hydrocodone and oxycodone. Thereafter, the number of individuals using buprenorphine to get high dropped in a near linear fashion to less than 20 percent of those completing a questionnaire in the second quarter of 2007, significantly lower than that for methadone, oxycodone, and hydrocodone. The most likely interpretation of these data is that the poly-substance-abusing population, for whom buprenorphine is intended, experimented with this medication for its mood-altering effects for a period of time, but presumably because of its lack of euphorogenic properties, its use has now dissipated. Additionally, support for this conclusion is the very rare endorsement of buprenorphine as a primary drug (<3 percent of the total sample). Thus, the results indicate that it is unlikely that buprenorphine abuse will ever reach the epidemic that was feared by some regulatory groups and that its use in opioid detoxification and maintenance should continue.
This study aimed to investigate the prevalence of diversion and injection of methadone and buprenorphine among clients receiving opioid pharmacotherapy treatment at community pharmacies in New South Wales (NSW), Australia.
A multi-site cross-sectional survey design was utilised using a self-complete questionnaire. Participants were 508 clients receiving supervised methadone (n=442) and buprenorphine (n=66) at 50 community pharmacies. Participants were surveyed about whether they had diverted their currently prescribed pharmacotherapy, whether they had injected methadone or buprenorphine, the frequency, desirability and duration of action of injecting, and the ease of availability of street-purchased pharmacotherapies.
The prevalence of recent diversion was more than 10 times higher among those receiving buprenorphine compared to methadone, with 23.8% of buprenorphine-maintained participants reporting diverting their dose in the preceding 12 months. Seventeen percent of methadone clients had injected methadone in the preceding 12 months compared with 9.1% of buprenorphine clients over the same time period.
The higher prevalence of buprenorphine diversion compared to methadone diversion is likely to be due to its sublingual tablet formulation and difficulty associated with supervising its consumption compared to that of an oral liquid. Methadone diversion is also less prevalent likely due to the high levels of methadone take away provision, which also helps to explain the higher levels of recent methadone injecting compared to buprenorphine injecting. A clearer understanding of the motivations for diversion and injection of opioid pharmacotherapies, and the relationship between them is required.
Though the introduction of office-based buprenorphine has greatly contributed to stem the HIV epidemic since 1995, concerns have been raised about the intravenous use of buprenorphine even in patients on substitution treatment. The aim of this study was to identify which factors are predictive of buprenorphine injection in patients receiving office-based buprenorphine.
Subazur is a survey consisting of two longitudinal assessments of 111 stabilized patients receiving office-based buprenorphine in southeastern France.
Patients were interviewed by phone at enrolment and 6 months later about social characteristics, addictive behaviors, treatment experiences, overdoses and suicide ideation or attempt. A logistic regression based on generalized estimating equations (GEE) was used to identify factors associated with buprenorphine injection at any interview.
Among the 111 patients (32% women, mean age 38 years), 36 reported buprenorphine injection after having started treatment initiation in 40 interviews. After adjustment for time since first injection, individuals perceiving their prescribed dosage as inadequate (OR=2.6 95%CI[1.2-5.7]) and those reporting a history of suicide ideation or attempt (OR=2.7 95%CI[1.1-7.0]) had approximately a three-fold higher risk of injecting buprenorphine.
Providing adequate care for both drug dependence and psychiatric comorbidities in primary care is a major issue. Like heroin use during methadone treatment, buprenorphine injection should be regarded more as a response to inadequate care than simply as a "misuse". A re-assessment of the treatment efficacy through a possible dosage increase or a switch to methadone could potentially reduce diversion and assure sustained adherence to OST.
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