Mortality among clients seeking treatment for buprenorphine abuse in Finland

Buprenorphine deaths confirmed by toxicology reveal a low proportion of opioid agonist treatment before death in Finland

We studied opioid agonist treatment (OAT) status before buprenorphine-related death in Finland, where buprenorphine is the principal OAT medicine and also the most misused opioid, through a retrospective population-based study using medico-legal cause-of-death investigation and OAT patient records. The study included all death cases (N = 570) between 2018 and 2020 with a buprenorphine or norbuprenorphine finding in post-mortem toxicology and with known drug misuse history or concomitant findings of illicit drugs. Of the deceased, 10% had received OAT in the year before death. Less than 1% of individuals < 25 years had received OAT, whereas the proportion in individuals ≥ 25 years was 13% (p < 0.001). There were significantly more females and more fatal poisonings (p < 0.001) among those < 25 years than among those ≥ 25 years. OAT medication at the time of death was sublingual buprenorphine-naloxone in 74% and subcutaneous buprenorphine in 23%. Except for significantly fewer benzodiazepine findings among those receiving OAT, minimal differences were found in terms of age, gender, cause and manner of death, or concomitant substance use between the deceased in and outside of OAT. Concomitant misuse of benzodiazepines, psychostimulants, alcohol, and gabapentinoids was frequent both in and outside of OAT and likely contributed to the death. These results suggest that access to OAT especially for young people and treatment of multiple addictions should be improved. Comprehensive information from medico-legal cause-of-death investigation as a starting point, combined with subsequent ante-mortem patient records, proved to be a successful approach to shed light on the Finnish scene of buprenorphine mortality.

Concomitant drugs with buprenorphine user deaths

BACKGROUND

Buprenorphine is abused in several countries notwithstanding its benefits as an analgesic and as an opioid agonist treatment medication. Benzodiazepines and alcohol have previously been associated with buprenorphine toxicity. This study elucidates the role of emerging concomitant drugs in different groups of buprenorphine user deaths.

METHODS

All cases in the Finnish national post-mortem toxicology database from 2016-2019 in which buprenorphine or norbuprenorphine was a laboratory finding in any post-mortem specimen and age at death of 15-64 years were investigated for cause and manner of death, concurrent drug and alcohol findings, age, and gender.

RESULTS

There were 792 deaths with a buprenorphine finding, of which buprenorphine was implicated in poisoning without other opioids in 271 cases (34 %). In this group of buprenorphine poisoning deaths, concomitant benzodiazepines were found in 94 % (clonazepam 53 %), illicit drugs in 63 %, gabapentinoids in 50 % (pregabalin 41 %), alcohol in 41 %, antidepressants in 32 %, and antipsychotics in 28 % of cases; only three deaths showed no benzodiazepines, alcohol, or gabapentinoids. Polydrug use was common regardless of the cause of death. In the age group 15 to 24 years, concomitant use of benzodiazepines and illicit drugs, and buprenorphine poisoning were more prevalent than in the age group 25-64 years.

CONCLUSIONS

The unprecedentedly high concomitant use of benzodiazepines in buprenorphine user deaths obscures other possible pharmacological risk factors for buprenorphine poisoning that could be relevant for prevention. Higher mortality in the younger age group suggests particularly unsafe drug use patterns that should be addressed.

Suicide after contact with substance misuse services: a national registry study

BACKGROUND

People with substance use disorders have a well-known increased risk for taking their own life. Previous research has mainly focused on suicide in mental health services, whereas there is limited knowledge regarding suicide after contact with substance misuse services.

AIMS

The aim of the current study was to describe the utilisation of both mental health services and substance misuse services among people who have died by suicide within a year of contact with substance misuse services.

METHOD

We used an explanatory observational design, where all suicide deaths in the period from 2009 to 2016 were retrieved from the Norwegian Cause of Death Registry and linked with the Norwegian Patient Registry. The people who had been in contact with substance misuse services within a year before their death were included in the sample (n = 419). The analysis was stratified by gender, and variables with significant differences between men and women were entered into a multivariate logistic regression model.

RESULTS

More women (73.5%) than men (60.6%) had contact with mental health services in their last year (P = 0.01). In the adjusted logistic regression model, poisoning was more common among women (adjusted odds ratio (AOR) = 1.81, 95% CI 1.09-3.02) and women were more likely to be diagnosed with a sedative, hypnotic or anxiolytic use disorder (F14) in their last year (AOR = 2.77, 95% CI 1.37-5.68).

CONCLUSIONS

This study highlights gender differences for suicide in substance misuse services, and the importance of collaboration and cooperation between substance misuse services and mental health services.

Mortality and causes of death among people suspected of driving under the influence and testing positive for multiple substances

Aims: Understanding the mortality of drug users using multiple substances is helpful in preventing the harmful effects of polydrug use. We examined overall and cause-specific mortality and differences in mortality based on social background among people suspected of driving under the influence and testing positive for multiple substances (DUIMS) compared with the general Finnish population. Methods: Register data from 785 DUIMS during 2003-2006 were studied, with a reference population (n = 25,381) drawn from the general Finnish population. The effect of DUIMS on all-cause and cause-specific mortality was estimated using a Poisson regression model. Results: DUIMS had an increased risk of death compared with the general population (MRR 5.3, 95% CI 4.2-6.6). The most common causes of death in DUIMS were poisonings (37.9%) and suicides (13.6%), whereas in the reference population these were cardiovascular diseases (30.8%) and cancer (26.6%). The cause-specific risk of death among DUIMS was higher in all observed causes of death, except for cancer. The effect of DUIMS on mortality was modified by age, employment status and marital status; DUIMS was associated with an elevated risk of death especially in younger age groups and in singles. Conclusions: DUIMS indicates higher mortality, and DUIMS' profiles in causes of death differ from the general population. Elevated risk for, for instance, suicidal, accidental and violent death among those using multiple substances highlights the need to also pay attention to causes of death other than poisoning/overdose.

Opiate withdrawal syndrome in buprenorphine abusers admitted to a rehabilitation center in Tunisia

BACKGROUND

Illicit use of high dosage buprenorphine has been well documented in several countries, including Tunisia.

OBJECTIVES

The aim of this survey is to assess the buprenorphine withdrawal syndrome time course, and how it may be affected by the population characteristics among subjects admitted to a rehabilitation center in Tunisia.

METHODS

A prospective research has permitted study of the socio-demographic characteristics and assessment of buprenorphine withdrawal syndrome among 32 subjects admitted for buprenorphine dependence by using the clinical opiate withdrawal scale. An ANOVA was conducted to examine the effect of different factors on the withdrawal scores.

RESULTS

32 subjects were included. Among them 30 were males, 27 had been injecting buprenorphine, 16 were poly-drug abusers and 2 had a history of mental disorders. Buprenorphine withdrawal syndrome was of a mild intensity and had a delayed onset. Withdrawal mean scores varied between 0 and 9, and maximum values were reached at day 21. These scores varied significantly over time (p<0,001). The sex v time interaction and the mode of consumption of buprenorphine had significant effects on the withdrawal scores (p<0,001). The poly-drug consumption and the history of mental disorders did not have any significant effect on the withdrawal scores.

CONCLUSION

This study has permitted description of buprenorphine withdrawal syndrome among patients going through a detoxification treatment at a rehabilitation center. Understanding this syndrome would help elaborate effective and suitable buprenorphine dependence management plans.

Buprenorphine Prescribing: To Expand or Not to Expand

As a result of the prescription opioid epidemic in the United States, there has been an increasing need for effective treatment interventions, both pharmacological and nonpharmacological. Buprenorphine has emerged as a critical component of the treatment of opioid use disorder, yet its adoption has not been without some concerns. This article first reviews the pharmacology, clinical use, and US legislative action related to buprenorphine, followed by a discussion of the misuse and diversion of buprenorphine in the United States as well as internationally. We then explore the impact of buprenorphine abuse as well as discussing strategies for its reduction, including changes in policy, prescription and pharmacy monitoring, and continuing medical education for guiding and improving clinical practice.

Adolescents in a residential school for behavior disorders have an elevated mortality risk in young adulthood

BACKGROUND

Conduct problems during adolescence are associated with an elevated mortality risk. This study investigated the mortality rate, causes of death, and changes over time in a Finnish residential school (RS) population.

METHODS

All adolescents (N = 885, M/F = 594/291, age mean 15.2 years at baseline) residing in the RS system in 1991, 1996, 2001, and 2006 and matched controls were included in a register-based study with a follow-up time of up to 22 years.

RESULTS

The all-cause mortality rate for people with an RS background was 6.7 % compared to 1.0 % in the controls (Hazard Ratio HR = 6.95, 95 % 4.66-10.37, p < 0.001). 8.1 % of the RS boys had died compared to 2.2 % of the girls (HR = 2.2, p = 0.02). The HR for substance-related death was 24.31 (95 % CI 9.3-65.53, P < 0.001), for suicide 7.23 (95 % CI 3.24-16.11, P < 0.001) and for other external causes 5.45 (95 % CI 2.41-12.36, P < 0.001) compared to controls. Mortality peaked among RS boys at approximately 25 years, whereas for girls it peaked after 30 years.

CONCLUSIONS

Adolescents with severe disruptive behavior problems have a seven-fold risk for premature adult-age death compared to matched controls. The most common causes for death were avoidable, substance-related followed by suicide. Effective treatment of mental and substance use related problems during and after the placement is needed to reduce mortality.

A review of buprenorphine diversion and misuse: the current evidence base and experiences from around the world

Outpatient opioid addiction treatment with sublingual buprenorphine pharmacotherapy has rapidly expanded in the United States and abroad, and, with this increase in medication availability, there have been increasing concerns about its diversion, misuse, and related harms. This narrative review defines the behaviors of diversion and misuse, examines how the pharmacology of buprenorphine alone and in combination with naloxone influence its abuse liability, and describes the epidemiological data on buprenorphine diversion and intravenous misuse, risk factors for its intravenous misuse, and the unintended consequences of misuse and diversion. Physician practices to prevent, screen for, and therapeutically respond to these behaviors, which are a form of medication nonadherence, are discussed, and gaps in knowledge are identified. Outpatient opioid addiction treatment with sublingual buprenorphine pharmacotherapy experiences from other countries that have varied health care systems, public policies, and access to addiction treatment are shared to make clear that diversion and misuse occur across the world in various contexts, for many different reasons, and are not limited to buprenorphine. Comparisons are made with other opioids with known abuse liability and medications with no known abuse. The objective was to facilitate understanding of diversion and misuse so that all factors influencing their expression (patient and provider characteristics and public policy) can be appreciated within a framework that also recognizes the benefits of addiction treatment. With this comprehensive perspective, further careful work can help determine how to minimize these behaviors without eroding the current benefits realized through improved addiction treatment access and expansion.