The global diversion of pharmaceutical drugs: opiate treatment and the diversion of pharmaceutical opiates: a clinician's perspective

Estimated effectiveness and cost-effectiveness of opioid use disorder treatment under proposed U.S. regulatory relaxations: A model-based analysis

AIM

To assess the effectiveness and cost-effectiveness of buprenorphine and methadone treatment in the U.S. if exemptions expanding coverage for substance use disorder services via telehealth and allowing opioid treatment programs to supply a greater number of take-home doses of medications for opioid use disorder (OUD) continue (Notice of Proposed Rule Making, NPRM).

DESIGN SETTING AND PARTICIPANTS

Model-based analysis of buprenorphine and methadone treatment for a cohort of 100,000 individuals with OUD, varying treatment retention and overdose risk among individuals receiving and not receiving methadone treatment compared to the status quo (no NPRM).

INTERVENTION

Buprenorphine and methadone treatment under NPRM.

MEASUREMENTS

Fatal and nonfatal overdoses and deaths over five years, discounted lifetime per person QALYs and costs.

FINDINGS

For buprenorphine treatment under the status quo, 1.21 QALYs are gained at a cost of $19,200/QALY gained compared to no treatment; with 20% higher treatment retention, 1.28 QALYs are gained at a cost of $17,900/QALY gained compared to no treatment, and the strategy dominates the status quo. For methadone treatment under the status quo, 1.11 QALYs are gained at a cost of $17,900/QALY gained compared to no treatment. In all scenarios, methadone provision cost less than $20,000/QALY gained compared to no treatment, and less than $50,000/QALY gained compared to status quo methadone treatment.

CONCLUSIONS

Buprenorphine and methadone OUD treatment under NPRM are likely to be effective and cost-effective. Increases in overdose risk with take-home methadone would reduce health benefits. Clinical and technological strategies could mitigate this risk.

Assessing the impact of public funding in alleviating participant reduction and improving the retention rate in methadone maintenance treatment clinics in Taiwan: an interrupted time series analysis

BACKGROUND

Given the steady decline in patient numbers at methadone maintenance treatment (MMT) clinics in Taiwan since 2013, the government initiated Patients' Medical Expenditure Supplements (PMES) in January 2019 and the MMT Clinics Accessibility Maintenance Program (MCAM) in September 2019. This study aims to evaluate the impact of the PMES and MCAM on the enrollment and retention of patients attending MMT clinics and whether there are differential impacts on MMT clinics with different capacities.

METHODS

The monthly average number of daily participants and 3-month retention rate from 2013 to 2019 were extracted from MMT databases and subjected to single interrupted time series analysis. Pre-PMES (from February 2013 to December 2018) was contrasted with post-PMES, either from January 2019 to December 2019 for clinics funded solely by the PMES or from January 2019 to August 2019 for clinics with additional MCAM. Pre-MCAM (from January 2019 to August 2019) was contrasted with post-MCAM (from September 2019 to December 2019). Based on the monthly average number of daily patients in 2018, each MMT clinic was categorized as tiny (1-50), small (51-100), medium (101-150), or large (151-700) for subsequent stratification analysis.

RESULTS

In terms of participant numbers after the PMES intervention, a level elevation and slope increase were detected in the clinics at every scale except medium in MMT clinics funded solely by PMES. In MMT clinics with subsequent MCAM, a level elevation was only detected in small-scale clinics, and a slope increase in the participant numbers was detected in tiny- and small-scale clinics. The slope decrease was also detected in medium-scale clinics. In terms of the 3-month retention rate, a post-PMES level elevation was detected at almost every scale of the clinics, and a slope decrease was detected in the overall and tiny-scale clinics for both types of clinics.

CONCLUSIONS

Supplementing the cost of a broad treatment repertoire enhances the enrollment of people with heroin use in MMTs. Further funding of human resources is vital for MMT clinics to keep up with the increasing numbers of participants and their retention.

Prescribing safe supply: ethical considerations for clinicians

The COVID-19 pandemic has exacerbated the drug poisoning epidemic in a number of ways: individuals use alone more often, there is decreased access to harm reduction services and there has been an increase in the toxicity of the unregulated drug supply. In response to the crisis, clinicians, policy makers and people who use drugs have been seeking ways to prevent the worst harms of unregulated opioid use. One prominent idea is safe supply. One form of safe supply enlists clinicians to prescribe opioids so that people have access to drugs of known composition and strength. In this paper, we assess the ethical case for clinicians providing this service. As we describe, there is much that is unknown about safe supply. However, given the seriousness of the overdose death epidemic and the current limited evidence for safe supply's efficacy, we argue that it is ethically permissible for clinicians to begin prescribing opioids for some select patients.

Provider experiences with relaxing restrictions on take-home medications for opioid use disorder during the COVID-19 pandemic: A qualitative systematic review

BACKGROUND

Historical restrictions on take-home medications for opioid use disorder have generated considerable debate. The COVID-19 pandemic shifted the perceived risks and benefits of daily clinic attendance and led to widespread policy reform, creating an unprecedented opportunity to explore the impact of more flexible prescribing. We conducted a qualitative systematic review to synthesize the evidence on providers' experiences with relaxing restrictions on take-home doses of medications prescribed for opioid use disorder during the COVID-19 pandemic.

METHODS

The protocol for this systematic review was registered in PROSPERO (CRD42022360589; https://www.crd.york.ac.uk/prospero/). From Sept.-Nov. 2022, we searched Medline, Embase, CINAHL, PsycInfo, Web of Science, the Cochrane Register of Controlled Trials, and the grey literature from 2020 onward. Studies were eligible for inclusion if they used qualitative methods to investigate providers' experiences with relaxed restrictions on take-home medications for opioid use disorder during the COVID-19 pandemic. We appraised study quality using the CASP qualitative checklist and used thematic synthesis and GRADE-CERQual to synthesize the results.

RESULTS

We retrieved 13 articles representing 11 studies. Six were conducted in the United States and most focused on changes to methadone treatment. Providers' experiences with increased flexibilities around take-homes were broadly positive, despite widespread initial concern over client safety and the potential for medication misuse. For a small number of providers, concerns about diversion were a specific manifestation of more general unease with loss of control over clients and the treatment process. Most providers appreciated increased flexibilities and described them as enabling more individualized, person-centered care.

CONCLUSION

Our findings support the continuation of flexibilities around take-homes and demonstrate that regulations and policies that reduce flexibility around take-homes conflict with person-centered approaches to care. Stronger guidance and support from professional regulatory agencies may help increase uptake of flexibilities around take-homes.

Bridging the Macro-micro Divide: A Qualitative Meta-synthesis on the Perspectives and Experiences of Health Care Providers on the Extramedical Use and Diversion of Buprenorphine

OBJECTIVES

Opioid agonist therapy using buprenorphine is one of the most effective treatments for opioid use disorder. However, concerns regarding its extramedical use and diversion, such as adverse patient outcomes and damage to the legitimacy of addictions practice, are persistent. The aim of this review is to synthesize the perspectives and experiences of health care providers around the extramedical use of buprenorphine.

METHODS

A qualitative meta-synthesis was conducted based on a systematic search of 8 databases. All primary qualitative and mixed-methods studies relating to the views of health care providers on the extramedical use of buprenorphine were included. A qualitative analysis informed by the constant comparative method was conducted, using NVivo for data management.

RESULTS

Sixteen studies were included in this review. Findings were organizedunder 2 key themes: (1) Harm-producing versus harm-reducing effects of extramedical buprenorphine use and (2) driving forces of and responses to extramedical buprenorphine use.

CONCLUSIONS

The studies included in our review identified a disconnect-health care providers noted that macro, health care system-level challenges drove extramedical use whereas the recommended solutions for prevention and management were primarily aimed at the micro, individual level. This study emphasizes the critical role that health care providers can play, in partnership with patients, in informing appropriate policies and health care system design to optimize the care for people with opioid use disorder.

Experiences with take-home dosing in heroin-assisted treatment in Switzerland during the COVID-19 pandemic-Is an update of legal restrictions warranted?

Heroin-assisted treatment comprises the use of diacetylmorphine (pharmaceutical heroin) for individuals with severe opioid use disorder. In Switzerland, take-home doses in heroin-assisted treatment are more strictly regulated as compared to conventional opioid agonist treatment. In light of the COVID-19 pandemic, the Swiss Federal Council provisionally adapted its policy, allowing for longer prescriptions of take-home diacetylmorphine. Before the beginning of the pandemic, take-home doses only occurred in exceptional circumstances and under strict criteria for patient eligibility. Following the legislative adaptations, we critically revised our internal centre policies as well. We report our experiences with oral take-home diacetylmorphine from a Swiss outpatient university centre specialising in heroin-assisted treatment. An additional 45 patients received take-home doses following the first lockdown. While some patients wished to return to their previous treatment regimen, most patients managed their medication well and showed good adherence. We also noticed an increase of treatment admissions that are likely related to the relaxed regulations. Previously, the strict therapeutic framework of visiting a HAT centre twice a day for supervised dispensing seemed to have discouraged these individuals from seeking medical treatment. From a medical point of view, the politically driven restrictions on take-home doses in heroin-assisted treatment are questionable and do not support the goal of harm reduction.

The impact of Taiwan's implementation of a nationwide harm reduction program in 2006 on the use of various illicit drugs: trend analysis of first-time offenders from 2001 to 2017

Background

After implementing a nationwide harm reduction program in 2006, a dramatic decline in the incidence of human immunodeficiency virus (HIV) infection among people with injection drug use (IDU) was observed in Taiwan. The harm reduction program might have sent out the message discouraging the choice of IDU among illicit drug users in early stage. Based on the yearly first-time offense rates from 2001 to 2017, this study aimed to examine (1) whether the nationwide implementation of the harm reduction program in 2006 led to changes in first-time offenders’ use of heroin; (2) whether the intervention had a similar effect on the use of other illicit drugs; and (3) whether the effect of the intervention was limited to the first-time offenders of young age groups.

Methods

Yearly first-time illicit-drug offense rates from 2001 to 2017 in Taiwan were derived from two national databases for drug arrests that were verified using urine tests: the Criminal Record Processing System on Schedule I/II Drugs and the Administrative Penalty System for Schedule III/IV Substances. A hierarchy of mutually exclusive categories of drug uses was defined by the drug with the highest schedule level among those tested positive in an arrest. Segmented regression analyses of interrupted time series were used to test for the impact of the 2006 intervention.

Results

There was a decrease of 22.37 per 100,000 in the rate for heroin but no detectable level changes in that for methamphetamine or ecstasy after the 2006 intervention in Taiwan. There were baseline decreasing trends in the first-time offense rate from 2001 to 2017 for heroin and ecstasy and an increasing trend for methamphetamine, with the slopes not altered by the 2006 intervention. The postintervention decrease in the first-time offense rate for heroin was detectable among offenders less than 40 years old.

Conclusions

Our results indicate a diffusion effect of the 2006 intervention on decreasing heroin use among young offenders and have policy implications for better prevention and treatment for different age groups.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12954-021-00566-5.

Beyond harm-producing versus harm-reducing: A qualitative meta-synthesis of people who use drugs' perspectives of and experiences with the extramedical use and diversion of buprenorphine

INTRODUCTION

This review synthesizes the literature on the perspectives and experiences of people who use drugs to better understand motivations and behaviors related to the extramedical use and diversion of buprenorphine. Given the particular social construction of buprenorphine against methadone, and the centrality of concerns around extramedical use in delivering opioid agonist therapies, a focus on extramedical buprenorphine use can provide an important lens through which to analyze treatment for opioid use disorder. This review is framed within persistent tensions between potential harm-producing versus harm-reducing effects of extramedical use that have long been described for opioid agonist therapies.

METHODS

The research team conducted a qualitative meta-synthesis based on a systematic search of eight databases as well as hand searching. The review includes all primary qualitative and mixed-methods studies related to the perspectives and experiences of people who use drugs on extramedical buprenorphine use. The study team carried out three rounds of qualitative coding using NVivo 12, and constructivist grounded theory and the constant comparative method informed the synthesis.

RESULTS

The review includes twenty-one studies. Findings are organized into the following three themes: 1) the experiences of people who use drugs (PWUD) with extramedical use of buprenorphine and their motivations to engage in it (including the desire to self-medicate and achieve "stability", to manage ongoing use of other opioids, and to "get high"); 2) the relationship between extramedical use and formal medical opioid agonist therapy programs; and 3) the established drug economy of extramedical buprenorphine.

CONCLUSIONS

The review identified varied and often divergent perspectives and experiences with extramedical buprenorphine use. An examination of the reported "normalizing" effects of extramedical buprenorphine suggests this practice as extending medicalized discipline beyond the clinical environment. Taken together, these findings identify a need to move beyond the tension of harm-reducing versus harm-producing effects toward forms of health care and promotion that focus on the needs, perspectives, and priorities of people who use drugs.

Recent advances in the treatment of opioid use disorders-focus on long-acting buprenorphine formulations

Oral methadone or sublingual buprenorphine are first-line medications for pharmacotherapy of opioid use disorders (OUDs). Three long-acting buprenorphine depot or implant formulations are currently available for the treatment of OUDs: (1) CAM 2038 (Buvidal) for subcutaneous weekly and monthly application; (2) RBP-6000 (Sublocade™) as a monthly depot formulation; and (3) A six-month buprenorphine implant [Probuphine™]. The pharmacology, clinical efficacy and prospects of these medications are discussed.

Medicolegal Considerations in the Management of Opioid Use Disorder With Buprenorphine in the Correctional Setting

Buprenorphine-based medication-assisted treatment is a long-term strategy for individuals with opioid use disorder (OUD), a condition observed at disproportionate rates among incarcerated populations. Individuals with OUD are also at higher risk of overdose and death upon community reentry, necessitating effective interventions and care modalities targeted at this high-risk population. As support for buprenorphine in correctional health care increases, so do concerns surrounding personal liability for prescribers. This article seeks to identify problematic events related to prescribing buprenorphine to incarcerated individuals, clarify medicolegal implications, and provide recommendations for safe prescribing and administration within this unique setting.

Factors influencing engagement and utilisation of opium tincture-assisted treatment for opioid use disorder: A qualitative study in Tehran, Iran

INTRODUCTION

In response to a high burden of opioid use disorder (OUD), Iran established a network of opioid agonist treatment (OAT) centres beginning in 2002. To increase treatment diversity, particularly for patients who use opium as their drug of choice, opium tincture (OT)-assisted treatment was introduced to the network. This study aimed to explore factors influencing OT-assisted treatment selection for OUD in Tehran, Iran.

METHODS

We conducted 54 in-depth interviews with patients with OUD (n = 33), family members of patients (n = 9) and drug treatment providers (n = 12). Participants were recruited from 12 drug treatment centres across Tehran, between September and November 2019. All interviews were audio-recorded, transcribed and coded in OpenCode 4.02 software and analysed using thematic analysis.

RESULTS

Study participants more commonly reported individual-level factors as facilitators (e.g. to reduce harms associated with illicit opioid use, achieve recovery through a gradual dose reduction regimen combined with Congress 60 recovery program) and structural level factors (e.g. low adoption by OAT system and lack of familiarity of treatment providers) as barriers for utilisation of OT-assisted treatment regimens. OT was perceived to produce lower levels of physiological dependence than methadone, but the requirement for twice supervised dosing was restrictive. Low familial and community acceptance were also seen as barriers to access.

DISCUSSION AND CONCLUSIONS

This research identified a range of perceived benefits for OT-assisted treatment ranging from harm reduction to an intermediate step to achieve recovery. However, several structural-, individual-, familial- and community-level barriers impede its availability and acceptability.

Novel Long-Acting Buprenorphine Medications for Opioid Dependence: Current Update

Opioid maintenance treatment with oral methadone or sublingual buprenorphine is the first-line treatment in opioid dependence. Three novel long-acting buprenorphine formulations have been approved or will be available soon: for subcutaneous weekly and monthly application, the depot formulations CAM 2038 (Buvidal^®), the monthly depot formulation RBP-6000 (Sublocade™), and a 6-month buprenorphine implant (Probuphine™). Clinical data available so far on the efficacy of these 3 medications are given, and possible clinical implications are discussed.

Therapy without a prescription: buprenorphine/naloxone diversion and the therapeutic assemblage in Taiwan

Buprenorphine/naloxone (B/N) therapy is a prescription pharmacotherapy for opioid dependence. For certain health service providers, when B/N escapes supervision and diverts into the hands of people for whom it is unintended, it can pose serious risks even if it may still have therapeutic benefits. The line between therapy and diversion is thus a problematic one. By qualitatively analysing archival review and in-depth interviews, this study uses the concept of a therapeutic assemblage to understand the relationships among government, knowledge, and professionals that surround the regulation of B/N in Taiwan. The therapeutic assemblage is characterised by the partitioning of administration, the loose regulation of prescription, the exclusion of addiction treatment from National Health Insurance (NHI), and the materiality and technicality of therapies. These elements contribute to the therapeutic assemblage's different territorial modes as reflected in the substance schedules that allow for diversion. This is the first grounded work in Asia that empirically examines and theoretically explains the diversion of B/N from an assemblage perspective. It suggests establishing new associations by incorporating addiction treatment into NHI. Lastly, it addresses the analytic purchase of the assemblage approach in unveiling and problematising unintended outcomes of an intervention.

Medication Treatment of Opioid Use Disorder

Opioid use disorder (OUD) is a chronic, relapsing condition, often associated with legal, interpersonal, and employment problems. Medications demonstrated to be effective for OUD are methadone (a full opioid agonist), buprenorphine (a partial agonist), and naltrexone (an opioid antagonist). Methadone and buprenorphine act by suppressing opioid withdrawal symptoms and attenuating the effects of other opioids. Naltrexone blocks the effects of opioid agonists. Oral methadone has the strongest evidence for effectiveness. Longer duration of treatment allows restoration of social connections and is associated with better outcomes. Treatments for OUD may be limited by poor adherence to treatment recommendations and by high rates of relapse and increased risk of overdose after leaving treatment. Treatment with methadone and buprenorphine has the additional risk of diversion and misuse of medication. New depot and implant formulations of buprenorphine and naltrexone have been developed to address issues of safety and problems of poor treatment adherence. For people with OUD who do not respond to these treatments, there is accumulating evidence for supervised injectable opioid treatment (prescribing pharmaceutical heroin). Another medication mode of minimizing risk of overdose is take-home naloxone. Naloxone is an opioid antagonist used to reverse opioid overdose, and take-home naloxone programs aim to prevent fatal overdose. All medication-assisted treatment is limited by lack of access and by stigma. In seeking to stem the rising toll from OUD, expanding access to approved treatment such as methadone, for which there remains the best evidence of efficacy, may be the most useful approach.

Public Policy: An Analgesia for Opioid Diversion

Although opioids are a commonly prescribed form of analgesics among the armamentarium for their efficacy and safety when used responsibly, societal problems of drug diversion are highly prevalent. This review seeks to examine the importance of opioids and the extent of diversion and its impact, drawbacks, and controversies in law, public policies, and strategies. In particular, the law has skewed its focus toward the regulation of opioid suppliers (as compared to consumers), giving rise to a chilling effect where physicians are hesitant to prescribe opioids to patients with legitimate needs. This has downplayed the importance of medically treating pain, especially in the context of palliative care. This article recommends the intelligent use of public policy to alleviate the opioid diversion problem while acknowledging the importance of appropriate pain management. Concurrently, this article recommends providing continuous education and support for physicians, dispensers, and the like and adoption of soft law approaches by legislators and enforcement bodies to prevent relentless clamping down on opioid abusers. In conclusion, appropriate policies and guidelines are necessary to support the entire health care body in executing a coordinated approach and exercising vigilance to better manage the opioid diversion problem.

The complex relation between access to opioid agonist therapy and diversion of opioid medications: a case example of large-scale misuse of buprenorphine in the Czech Republic

Opioid agonist therapy (OAT) has been available in a standard regime in the Czech Republic since 2000. Buprenorphine is the leading medication, while methadone is available only in a few specialised centres. There is an important leakage of buprenorphine onto the illicit market, and the majority of Czech opioid users are characterised by the misuse (and injecting) of diverted buprenorphine medications. Most prescribed buprenorphine for OAT is not covered by current national health insurance schemes, and patients have to pay considerable prices to afford their treatment. This affordability barrier together with limited accessibility is likely the leading factor of limited coverage of OAT and of recent stagnation in the number of patients in the official treatment programmes in the Czech Republic. It also encourages doctor shopping and the re-selling of parts of their medication at a higher price, which represents the main factor that drives the Czech illicit market for buprenorphine, but at the same time co-finances the medication of clients in official OAT programmes. Improving access to OAT by making it financially affordable is essential to further increase OAT coverage and is one of the factors that can reduce the illicit market with OAT medications.

The Impact of an Automated Dispensing System for Supplying Narcotics in a Surgical Unit: The Experience of the National Cancer Institute Foundation of Milan

Objective: An automated dispensing system for narcotic drugs was introduced in a surgical unit to be compliant with the Italian narcotic drugs regulation. The aim of this study was to evaluate the impact of this automated dispensing system on the incidence of registry errors and corrections and on staff time and hospital costs. Methods: In 2014, Pyxis MedStation 3500 was introduced in a surgical unit of the National Cancer Institute of Milan, to improve the effectiveness of narcotics dispensing and avoid potential errors. Two different time periods of 8 months were compared, respectively, before and after the introduction of the automated dispensing system. In the pre-Pyxis period, drug movements were recorded through paper registries, while in the post-Pyxis period, electronic reports were automatically created from the system. For each period, the number of load/unload registry entries and corrections, the number of registry errors, the staff time dedicated to dispensing and registry activities, and stock and expired drug quantities were recorded. Results: Load and unload errors were reduced by 100% from the pre-Pyxis period to the post-Pyxis period, while registry corrections were lowered by 95%. Time dedicated from nurses to dispensing registration activities was reduced from 36 to 2 hours/month, while pharmacist time lowered from 9 to 1 hours/month. These time savings correspond to an economic saving of ~€4,120 and ~€3,730, respectively. In the post-Pyxis period, average operating room stock quantities were reduced versus the pre-Pyxis period, with wastage being 100% avoided. The reduction in stock drug quantities could correspond to an economic saving of ~€22,300 over the examined 8-month period, while the impact of drug wastage avoidance is modest (~€650). Conclusion: The overall economic impact of Pyxis use, over the 8-month time horizon in analysis, was around €31,000 saved or possibly converted into resource cost dedicated to other added value activities.

Drug diversion

Prescription drug diversion has significant health, legal and social implications. Deaths from misuse of prescription drugs account for a significant proportion of overdose deaths. The drugs most commonly involved are analgesics, particularly opioids, and psychoactive drugs, particularly benzodiazepines. Diverted drugs are most often sourced from a family member or friend, but are also sourced from overseas pharmacies or laboratories, or bought from drug dealers. Drug diversion can be mitigated by good prescribing practices. Systems for monitoring the prescribing and dispensing of medicines are being instituted across Australia.

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.

Factors contributing to the rise of buprenorphine misuse: 2008-2013

OBJECTIVE

The purpose of the present study was to examine the motivations underlying the use of buprenorphine outside of therapeutic channels and the factors that might account for the reported rapid increase in buprenorphine misuse in recent years.

METHODS

This study used: (1) a mixed methods approach consisting of a structured, self-administered survey (N=10,568) and reflexive, qualitative interviews (N=208) among patients entering substance abuse treatment programs for opioid dependence across the country, centered on opioid misuse patterns and related behaviors; and (2) interviews with 30 law enforcement agencies nationwide about primary diverted drugs in their jurisdictions.

RESULTS

Our results demonstrate that the misuse of buprenorphine has increased substantially in the last 5 years, particularly amongst past month heroin users. Our quantitative and qualitative data suggest that the recent increases in buprenorphine misuse are due primarily to the fact that it serves a variety of functions for the opioid-abusing population: to get high, manage withdrawal sickness, as a substitute for more preferred drugs, to treat pain, manage psychiatric issues and as a self-directed effort to wean themselves off opioids.

CONCLUSION

The non-therapeutic use of buprenorphinehas risen dramatically in the past five years, particularly in those who also use heroin. However, it appears that buprenorphine is rarely preferred for its inherent euphorigenic properties, but rather serves as a substitute for other drugs, particularly heroin, or as a drug used, preferable to methadone, to self-medicate withdrawal sickness or wean off opioids.

The accuracy of self-reported drug ingestion histories in emergency department patients

Inaccuracies in self-reports may lead to duplication of therapy, failure to appreciate non-compliance leading to exacerbation of chronic medical conditions, or inaccurate research conclusions. Our objective is to determine the accuracy of self-reported drug ingestion histories in patients presenting to an urban academic emergency department (ED). We conducted a prospective cohort study in ED patients presenting for pain or nausea. We obtained a structured drug ingestion history including all prescription drugs, over-the-counter medication (OTC) drugs, and illicit drugs for the 48 hours prior to ED presentation. We obtained urine comprehensive drug screens (CDS) and determined self-report/CDS concordance. Fifty-five patients were enrolled. Self-reported drug ingestion histories were poor in these patients; only 17 (30.9%) of histories were concordant with the CDS. For the individual drug classes, prescription drug-CDS was concordant in 32 (58.2%), OTC-CDS was concordant in 33 (60%), and illicit drug-CDS was concordant in 45 (81.8%) of subjects. No demographic factors predicted an accurate self-reported drug history. Sixteen patients had drugs detected by CDS that were unreported by history. Nine of these 16 included an unreported opioid. In conclusion, self-reported drug ingestion histories are often inaccurate and resources are needed to confirm compliance and ensure unreported drugs are not overlooked.

Self-management of buprenorphine/naloxone among online discussion board users

BACKGROUND

Buprenorphine/naloxone is an effective medication used to treat opioid dependence. Patients in treatment and those using it illegally without prescriptions have discussed using buprenorphine/naloxone anonymously on Internet discussion boards. Their beliefs about self-treatment and efforts to self-treat are not well known.

OBJECTIVES

To identify facilitators of self-treatment by online buprenorphine/naloxone users.

METHODS

A qualitative, retrospective study of discussion board postings from September 2010 to November 2012 analyzed 121 threads from 13 discussion boards using grounded theory.

RESULTS

Facilitators of self-management themes that emerged included: (1) a ready supply of buprenorphine/naloxone from a variety of sources; (2) distrust of buprenorphine prescribers and pharmaceutical companies; (3) the declaration that buprenorphine/naloxone is a "bad-tasting" medicine; (4) the desire to adopt a different delivery method other than sublingually; and (5) a desire to become completely "substance-free." The sublingual film formulation appears to be an important facilitator in self-treatment because it can more easily be apportioned to extend the medication because of limited supply, cost, or to taper. CONCLUSIONS/IMPORTANCE: The findings indicate a range of self-management activities ranging from altering the amount taken to modifying the physical medication composition or changing the administration route; some of these behaviors constitute problematic extra-medical use. Contributors to discussion boards seem to trust each other more than they trust pharmacists and prescribing physicians. The shared knowledge and behaviors of this understudied online community are important to healthcare providers because of the previously unknown precautions and risks taken to self-treat.

Patterns of non-compliant buprenorphine, levomethadone, and methadone use among opioid dependent persons in treatment

Background

The non-compliant use of opioid substitution treatment (OST) medicines is widespread and well-documented. However, less is known about characteristics of non-compliant OST medicine use and the factors that predict it. The two main goals of this study are to compare characteristics of non-compliant levomethadone, methadone, and buprenorphine use and to explore factors that may differentially predict it among opioid dependent persons in treatment.

Methods

Data from 595 opioid dependent patients with non-compliant OST medicine use were analyzed. Characteristics of use between substances were compared using chi-squared tests and predictive factors were explored through multinomial logistic regressions.

Results

Non-compliant levomethadone and methadone use was characterized by more frequent parallel consumption of other psychoactive substances and intravenous use, whereas buprenorphine was more often procured without a prescription. Regarding predictive factors, methadone was perceived to relieve withdrawal symptoms better than buprenorphine and levomethadone was perceived as being better at modulating the effects of other substances and worst at enhancing mood.

Conclusions

Patterns of non-compliant use differ according to OST medicine. These patterns are considered with the reduction of non-compliant use and the improvement of treatment in mind.

[Chronic non-cancer-related pain. Long-term treatment with rapid-release and short-acting opioids in the context of misuse and dependency]

Annually published data show a continual increase in the volume of opioid prescriptions in Germany, thus indicating an intensification of opioid therapy. The majority of opioids are prescribed to treat chronic non-cancer-related pain. On the basis of current guidelines, as well as in terms of the lack of data regarding long-term use of opioids and their effectiveness beyond a period of 3 months, this development must be viewed critically. With reference to four case reports, we discuss and evaluate opioid therapy in relation to medication misuse and the development of drug dependency. Particular emphasis is placed on the administration of rapid-release and short-acting opioid preparations, which we consider to be particularly problematic.

Prevalence and correlates of street-obtained buprenorphine use among current and former injectors in Baltimore, Maryland

OBJECTIVES

There are few systematic assessments of street-obtained buprenorphine use from community-based samples in the United States. The objective of this study was to characterize the prevalence, correlates, and reasons for street-obtained buprenorphine use among current and former injection drug users (IDUs) in Baltimore, Maryland.

METHODS

In 2008, participants of the ALIVE (AIDS Linked to the IntraVenous Experience) study, a community-based cohort of IDUs, were administered a survey on buprenorphine. Street-obtained buprenorphine represented self-reported use of buprenorphine obtained from the street or a friend in the prior three months.

RESULTS

Six hundred and two respondents were predominantly male (65%), African-American (91%), and 30% were HIV-positive. Overall, nine percent reported recent street-obtained buprenorphine use, and only 2% reported using to get high. Among active opiate users, 23% reported recent use of street-obtained buprenorphine. Use of buprenorphine prescribed by a physician, injection and non-injection drug use, use of street-obtained methadone and prescription opiates, homelessness, and opioid withdrawal symptoms were positively associated, while methadone treatment, health insurance, outpatient care, and HIV-infection were negatively associated with recent street-obtained buprenorphine use in univariate analysis. After adjustment, active injection and heroin use were positively associated with street-obtained buprenorphine use. Ninety-one percent reported using street-obtained buprenorphine to manage withdrawal symptoms.

CONCLUSIONS

While 9% reported recent street-obtained buprenorphine use, only a small minority reported using buprenorphine to get high, with the majority reporting use to manage withdrawal symptoms. There is limited evidence of diversion of buprenorphine in this sample and efforts to expand buprenorphine treatment should continue with further monitoring.

'Diversion' of methadone or buprenorphine: 'harm' versus 'helping'

Background

'Non-compliant’ individuals in opioid maintenance treatment, OMT, are often met with tight control regimes to reduce the risk of 'diversion’, which may lead to harm or death among persons outside of OMT. This article explores reported practices of, and motivations for, diversion of methadone and buprenorphine, in a group of imprisoned individuals in OMT.

Findings

28 in-depths interviews were conducted among 12 OMT-enrolled, imprisoned individuals, most of whom were remand prisoners. All had experienced tight control regimes prior to imprisonment due to varying degrees of 'non-compliance’ and illicit drug use during treatment. Their acquired norm of sharing with others in a drug using community was maintained when entering OMT. Giving one’s prescription opioids to an individual in withdrawal was indeed seen as an act of helping, something that takes on particular significance for couples in which only one partner is included in OMT and the other is using illicit heroin. Individuals enrolled in OMT might thus be trapped between practicing norms of helping and sharing and adhering to treatment regulations. ’Diversion’, as this term is conventionally used, is not typically understood as practices of giving and helping, but may nevertheless be perceived as such by those who undertake them.

Conclusions

As we see it, the need to sustain oneself as a decent person in one’s own eyes and those of others through practices such as sharing and helping should be recognized. Treatment providers should consider including couples in which both individuals are motivated for starting OMT.

QTc interval screening for cardiac risk in methadone treatment of opioid dependence

BACKGROUND

Methadone represents today the gold standard of efficacy for the pharmacological treatment of opioid dependence. Methadone, like many other medications, has been implicated in the prolongation of the rate-corrected QT (QTc) interval of the electrocardiogram (ECG), which is considered a marker for arrhythmias such as torsade de pointes (TdP). Indications on the association between methadone, even at therapeutic dosages, and TdP or sudden cardiac death have been reported. On these bases, consensus and recommendations involving QTc screening of patients receiving methadone treatment have been developed to identify patients with QTc above the thresholds considered at risk for cardiac arrhythmias, and they provide these individuals with alternative treatment (reduction of methadone dosage; provision of alternative opioid agonist treatment; treatment of associated risk factors).

OBJECTIVES

To evaluate the efficacy and acceptability of QTc screening for preventing cardiac-related morbidity and mortality in methadone-treated opioid dependents.

SEARCH METHODS

We searched MEDLINE, EMBASE, CINAHL (to April 2013), the Cochrane Central Register of Controlled Trials (CENTRAL), The Cochrane Library Cochrane Drug and Alcohol Review Group Specialised Register (Issue 3, 2013), main electronic sources of ongoing trials, specific trial databases and reference lists of all relevant papers.

SELECTION CRITERIA

Randomised controlled trials (RCTs), controlled clinical trials (CCTs) and non-randomised studies (cohort studies, controlled before and after studies, interrupted time series studies, case control studies) examining the efficacy of QTc screening for the prevention of methadone-related mortality and morbidity in opioid addicts.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened and extracted data from studies.

MAIN RESULTS

The search strategy led to the identification of 872 records. Upon full-text assessment, no study was found to meet the quality criteria used for this review.

AUTHORS' CONCLUSIONS

It is not possible to draw any conclusions about the effectiveness of QTc screening strategies for preventing cardiac morbidity/mortality in methadone-treated opioid addicts. Research efforts should focus on strengthening the evidence about the effectiveness of widespread implementation of such strategies and clarifying the associated benefits and harms.

The prescription drug abuse epidemic

In the United States, the nonmedical use of prescription drugs is the second most common illicit drug use, behind only marijuana. This article discusses the abuse issues with three of the most widely abused prescription drugs: opioids, central nervous system (CNS) depressants (eg, benzodiazepines), and stimulants (eg, amphetamine-dextroamphetamine and methylphenideate) in the United States. Efforts to deal with the problem are described as well.

The effect of an electronic medicine dispenser on diversion of buprenorphine-naloxone-experience from a medium-sized Finnish city

Providing unobserved opioid substitution treatment (OST) safely is a major challenge. This study examined whether electronic medicine dispensers (EMDs) can reduce diversion of take-home buprenorphine-naloxone (BNX) in a medium-sized Finnish city. All BNX treated OST patients in Kuopio received their take-home BNX in EMDs for 4months. EMDs' effect on diversion was investigated using questionnaires completed by patients (n=37) and treatment staff (n=19), by survey at the local needle exchange service and by systematic review of drug screen data from the Kuopio University Hospital. The majority of patients (n=21, 68%) and treatment staff (n=11, 58%) preferred to use EMDs for the safe storage of tablets. Five patients (16%) declared that EMDs had prevented them from diverting BNX. However, EMDs had no detectable effect on the availability or origin of illegal BNX or on the hospital-treated buprenorphine-related health problems. EMDs may improve the safety of storage of take-home BNX, but their ability to prevent diversion needs further research.

Aberrant drug-related behaviors: unsystematic documentation does not identify prescription drug use disorder

OBJECTIVE

No evidence-based methods exist to identify prescription drug use disorder (PDUD) in primary care (PC) patients prescribed controlled substances. Aberrant drug-related behaviors (ADRBs) are suggested as a proxy. Our objective was to determine whether ADRBs documented in electronic medical records (EMRs) of patients prescribed opioids and benzodiazepines could serve as a proxy for identifying PDUD.

DESIGN

A cross-sectional study of PC patients at an urban, academic medical center.

SUBJECTS

Two hundred sixty-four English-speaking patients (ages 18-60) with chronic pain (≥3 months), receiving ≥1 opioid analgesic or benzodiazepine prescription in the past year, were recruited during outpatient PC visits.

OUTCOME MEASURES

Composite International Diagnostic Interview defined Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnoses of past year PDUD and no disorder. EMRs were reviewed for 15 prespecified ADRBs (e.g., early refill, stolen medications) in the year before and after study entry. Fisher's exact test compared frequencies of each ADRB between participants with and without PDUD.

RESULTS

 Sixty-one participants (23%) met DSM-IV PDUD criteria and 203 (77%) had no disorder; 85% had one or more ADRB documented. Few differences in frequencies of individual behaviors were noted between groups, with only "appearing intoxicated or high" documented more frequently among participants with PDUD (N = 10, 16%) vs no disorder (N = 8, 4%), P = 0.002. The only common ADRB, "emergency visit for pain," did not discriminate between those with and without the disorder (82% PDUD vs 78% no disorder, P = 0.6).

CONCLUSIONS

EMR documentation of ADRBs is common among PC patients prescribed opioids or benzodiazepines, but unsystematic clinician documentation does not identify PDUDs. Evidence-based approaches are needed.

Medical marijuana use among adolescents in substance abuse treatment

OBJECTIVE

To assess the prevalence and frequency of medical marijuana diversion and use among adolescents in substance abuse treatment and to identify factors related to their medical marijuana use.

METHOD

This study calculated the prevalence and frequency of diverted medical marijuana use among adolescents (n = 164), ages 14-18 years (mean age = 16.09, SD = 1.12), in substance abuse treatment in the Denver metropolitan area. Bivariate and multivariate analyses were completed to determine factors related to adolescents' use of medical marijuana.

RESULTS

Approximately 74% of the adolescents had used someone else's medical marijuana, and they reported using diverted medical marijuana a median of 50 times. After adjusting for gender and race/ethnicity, adolescents who used medical marijuana had an earlier age of regular marijuana use, more marijuana abuse and dependence symptoms, and more conduct disorder symptoms compared with those who did not use medical marijuana.

CONCLUSIONS

Medical marijuana use among adolescent patients in substance abuse treatment is very common, implying substantial diversion from registered users. These results support the need for policy changes that protect against diversion of medical marijuana and reduce adolescent access to diverted medical marijuana. Future studies should examine patterns of medical marijuana diversion and use in general population adolescents.

The nature of methadone diversion in England: a Merseyside case study

Background

Methadone maintenance treatment (MMT) is a key element in treatment for opiate addiction; however concerns about the diversion of methadone remain. More current empirical data on methadone diversion are required. This research investigated the market for diverted methadone in Merseyside, UK, in order to provide a case study which can be transferred to other areas undertaking methadone maintenance treatment on a large scale.

Methods

Questionnaires were completed (in interview format) with 886 past year users of methadone recruited both in and out of prescribing agencies. Topic areas covered included current prescribing, obtaining and providing methadone, reasons for using illicit methadone and other drug use.

Results

Large proportions of participants had obtained illicit methadone for use in the past year with smaller proportions doing so in the past month. Proportions of participants buying and being given methadone were similar. Exchange of methadone primarily took place between friends and associates, with 'dealers' rarely involved. Gender, age, whether participant's methadone consumption was supervised and whether the aims of their treatment had been explained to them fully, influenced the extent to which participants were involved in diverting or using diverted methadone.

Conclusion

Methadone diversion is widespread although drug users generally do not make use of illicit methadone regularly (every month). The degree of altruism involved in the exchange of methadone does not negate the potential role of this action in overdose or the possibility of criminal justice action against individuals. Treatment agencies need to emphasise these risks whilst ensuring that treatment aims are effectively shared with clients to ensure adherence to treatment.

Opioid replacement therapy: a wait unmanaged

There has been a rapid increase in members of the Australian population using opioids in recent years. The flow-on effect has been an increase in demand for treatments, particularly opioid replacement therapy (ORT), but the availability of treatments has not increased. This has frequently resulted in delays before treatment can be commenced. Outcomes could improve if health-care professionals had clearer guidelines on how to prioritize access to ORT. This review investigates the triage of consumers in ORT within Australia. Information on triage in ORT was not available, and an understanding of how consumer needs are managed when they present for ORT triage was not identified. In the absence of research to guide this practice, the body of evidence regarding ORT treatment access is weighted on government policies. Triage, as applied in general health and mental health-care service delivery, was reviewed to consider the components of triage and how these might pertain to triage in ORT. Failure to facilitate the needs of consumers accessing ORT can result in further harm to consumers and increased social and financial costs for society. Research is required to investigate how this issue is currently being managed and to lead the way for needed improvements in service delivery.