The availability, diversion and injection of pharmaceutical opioids in South Asia

The Opioid Crisis, Preventing and Managing Substance Abuse in India: A Systematic Review

The opioid crisis has emerged as a significant public health concern globally, with India facing unique challenges in preventing and managing substance abuse. This systematic review aims to analyze the current state of the opioid crisis in India, evaluate existing prevention and management strategies, and propose evidence-based recommendations for addressing this complex issue. A comprehensive literature search was conducted across multiple databases, resulting in the inclusion of 30 studies meeting the predefined criteria. The review highlights the multifaceted nature of the opioid crisis in India, influenced by factors such as socioeconomic conditions, cultural norms, and healthcare accessibility. Key findings include the need for comprehensive prevention programs, improved access to evidence-based treatments, and integration of harm reduction strategies. The review also emphasizes the importance of addressing co-occurring mental health disorders and the potential of community-based interventions in managing substance abuse. Challenges identified include stigma, limited access to treatment, inadequate healthcare infrastructure, regulatory barriers, and lack of comprehensive policies. Recommendations for future directions include developing culturally appropriate prevention programs, assessing the long-term effectiveness of treatment modalities, exploring innovative approaches to reduce stigma, and investigating the role of technology in improving access to care. By implementing a multifaceted approach that considers the unique sociocultural context of India (including factors such as family structures, religious beliefs, economic disparities, and regional variations in drug use patterns), there is potential to significantly reduce the burden of opioid abuse and improve outcomes for affected individuals and communities.

Expanding single-venue services to better engage young people who inject drugs: insights from India

BACKGROUND

Over the last decade, India has had an alarming rise in injection of opioids across several cities. Although scale-up of public sector services for people who inject drugs (PWID) in India has occurred over decades, accessibility has been diminished by fragmented services across physical locations. To circumvent this barrier, and in alignment with the World Health Organization's guidelines to provide comprehensive care to key populations, Integrated Care Centers (ICCs) were established across 8 Indian cities as a public-private service delivery model for providing free single-venue services to PWID. ICCs have been very successful in expanding service availability and convenience for PWID generally. However, few studies from low- and middle-income countries (LMIC) have evaluated how well young PWID (defined as those ≤ 29 years of age) engage with single-venue service models like ICCs or specific services provided in such models. Young PWID are an important subpopulation in India, as they bear a disproportionate burden of new HIV infections because of greater risk and evidence of lower receipt of HIV testing and harm reduction services compared to older PWID. In this comment, we offer insights specific to young PWID drawn from multiple quantitative and qualitative studies examining the reach and effectiveness of ICCs, which may provide generalizable insights into limitations of services for young PWID more broadly in India and globally.

FINDINGS

Our studies suggest that while ICCs have expanded service availability, particularly in cities with emerging injection drug use epidemics, population-level reach to foster initial engagement among young PWID can be optimized. Additionally, young PWID who do engage with ICCs experience gaps in substance use treatment receipt and retention, and experience barriers to receipt of ICC services that are distinct from those experienced by older PWID. Notably, HIV incidence among ICC clients is concentrated in young PWID. Finally, ICCs were not intended to reach adolescent PWID, and new services are needed for this subpopulation.

CONCLUSIONS

In addition to co-locating services, iterative optimization of models such as ICCs should incorporate youth-specific differentiated interventions and be accompanied by policy changes that are critical to improving the reach and effectiveness of harm reduction and HIV services among young PWID in India.

Opioid use disorder and role of yoga as an adjunct in management (OUDARYAM): Study protocol for a randomized controlled trial

Background

The proposed research aims to test the effects and mechanisms of a six-month yoga-based intervention as an add-on to standard treatment in opioid use disorder (OUD) by conducting a randomized controlled study with the following primary outcome variables: 1) clinical: abstinence (opioid negative urine test), and reductions in pain and craving, and 2) mechanisms: reward circuit activation in response to opioid visual cue craving paradigm, activation in response to a cognitive control task, and resting state functional connectivity through fMRI, and plasma beta-endorphin levels. Secondary outcome variables are perceived stress, anxiety, sleep quality, cognitive performance, pain threshold, buprenorphine dosage and side effects, withdrawal symptoms, socio-occupational functioning, vedic personality traits, heart rate variability, serum cortisol, and brain GABA levels through magnetic resonance spectroscopy (MRS).

Methods

In this single-blinded, randomized, controlled, parallel-group superiority trial with 1:1 allocation ratio, 164 patients with OUD availing the outpatient/ inpatient clinical services at a tertiary mental healthcare hospital in India will be enrolled after giving informed consent. Consecutive consenting patients will be randomly allotted to one of the two groups - yoga arm (standard treatment + yoga-based intervention), or waitlist group (standard treatment alone). Allocation concealment will be followed, the clinicians, outcome assessors and data analysts will remain blind to subject-group allocation. A validated and standardized yoga program for OUD will be used as an intervention. Participants in the yoga arm will receive 10 supervised in-person sessions of yoga in the initial two weeks followed by tele-yoga sessions thrice a week for the next 22 weeks. The wait-list control group will continue the standard treatment alone for 24 weeks. Assessments will be done at baseline, two weeks, 12 weeks, and 24 weeks. Data from all randomized subjects will be analysed using intent-to-treat analysis and mixed model multivariate analysis.

Dissemination

Findings will be disseminated through peer-reviewed publication, conference presentations, and social media.

Trial registration number

The trial has been registered under Clinical Trials Registry-India with registration number CTRI/2023/03/050737.

Buprenorphine treatment receipt characteristics and retention among people who inject drugs at Integrated Care Centers in India

BACKGROUND

India is facing overlapping opioid injection and HIV epidemics among people who inject drugs (PWID) in several cities. Integrated Care Centers (ICCs) provide single-venue HIV and substance use services to PWID. We evaluated PWID engagement in daily observed buprenorphine treatment at 7 ICCs to inform interventions.

METHODS

We analyzed 1-year follow-up data for PWID initiating buprenorphine between 1 January - 31 December 2018, evaluating receipt frequency, treatment interruptions (no buprenorphine receipt for 60 consecutive days with subsequent re-engagement), and drop-out (no buprenorphine receipt for 60 consecutive days without re-engagement). Using descriptive statistics, we explored differences between ICCs in the opioid-endemic Northeast region and ICCs in the emerging opioid epidemic North/Central region. We used a multivariable logistic regression model to determine predictors of treatment drop-out by 6 months.

RESULTS

1312 PWID initiated buprenorphine (76% North/Central ICCs vs. 24% Northeast ICCs). 31% of PWID in North/Central, and 25% in Northeast ICCs experienced ≥ 1 treatment interruption in 1 year. Over 6 months, 48% of PWID in North/Central vs. 60% in Northeast ICCs received buprenorphine ≤ 2 times/week (p < 0.0001). A third of PWID in North/Central vs. half in Northeast ICCs experienced treatment drop-out by 6 months (p < 0.001). In the multivariable model, living in Northeast cities was associated with increased odds of drop-out while counseling receipt was associated with decreased odds.

CONCLUSIONS

Retention among PWID initiating buprenorphine at ICCs was comparable to global reports. However, regional heterogeneity in retention, and low daily buprenorphine receipt suggest patient-centered interventions adapted to regional contexts are urgently needed.

The association between the availability of over the counter codeine and the prevalence of non-medical use

PURPOSE

To investigate the prevalence of non-medical use (NMU) of codeine in Germany, Italy, Spain and the UK and whether availability of OTC codeine has any association with NMU of the drug.

METHODS

Data collected in the online Survey of Non-Medical Use of Prescription Drugs, in surveys launched in the second half of 2018 from (Germany (n = 14,969), Italy, (n = 9974), Spain (n = 9912) and the UK (n = 9819) were analysed. For each survey, the estimated prevalence and 95% confidence interval (CI) of respondents reporting NMU of prescription and/or OTC codeine within the last 12 months were calculated and compared.

RESULTS

The prevalence of last 12-month NMU in Spain was 12.6% (95% CI 11.7-13.6) for prescription codeine, 6.3% (5.6-7.0) for OTC codeine and 16.1% (15.1-17.3) for any codeine (prescription and/or OTC). The prevalence of last 12-month NMU in the UK was 5.4% (4.9-5.8) for prescription codeine, 4.5% (4.1-5.0) for OTC codeine and 8.3% (7.8-8.9) for any codeine (prescription and/or OTC). The prevalence of last 12-month NMU for prescription codeine was 2.1% (1.9-2.4) in Germany and 1.9% (1.7-2.2) in Italy.

CONCLUSION

The prevalence of last 12-month NMU of any codeine product is approximately eight times greater in Spain and four times greater in the UK compared to Germany and Italy where the drug is only available by prescription. While other factors may contribute, these findings suggest that availability of codeine OTC is associated with greater NMU.

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.

Buprenorphine abuse and health risks in Iran: A systematic review

INTRODUCTION

Buprenorphine maintenance treatment (BMT) is widely used in Iran, and its use is growing continuously. We reviewed studies on buprenorphine use, non-prescribed use, use disorder and treatment-seeking for it, buprenorphine-associated poisoning, and mortality in Iran in the current systematic review.

METHODS

An Iranian database (Scientific Information Database; SID) and three International electronic databases (PubMed, Scopus, and Web of Science) were searched for publications up to August 2020 for the relevant data. Opportunistic methods (Contact with experts and backward citation tracking) were also used for this purpose. Identified records were screened for eligibility criteria, and data of included studies were extracted. For context, the trend of BMT in the country was also examined.

RESULTS

Ten studies were found on the prevalence of non-prescribed buprenorphine use, seven were on the regular use and use disorder, and two studies on buprenorphine poisoning. The last 12-month prevalence of non-prescribed use was lower than 0.5 % in the general population, university, and high school students. The indicator was 2.5 % among persons who use drugs in a 2018 national study. The proportion of buprenorphine poisoning was 4.9 % among all illicit substance poisoning cases admitted to a hospital. The proportion of buprenorphine poisoning cases among all acute pediatric drug poisoning cases increased from 1.2 % to 2.5 % in a 3-year study.

CONCLUSION

Despite the expansion of BMT in Iran in the last decade, the adverse health consequences associated with buprenorphine are infrequent, when compared to other opioids used in Iran, suggesting the safety of BMT for future expansion.

Cost-Effectiveness of an Opioid Abuse-Prevention Program Using the Narcotics Information Management System in South Korea

OBJECTIVES

To assess the cost-effectiveness of an opioid abuse-prevention program embedded in the Narcotics Information Management System ("the Network System to Prevent Doctor-Shopping for Narcotics") in South Korea.

METHODS

Using a Markov model with a 1-year cycle length and 30-year time horizon, we estimated the incremental cost-utility ratio (ICUR) of implementing an opioid abuse-prevention program in patients prescribed outpatient opioids from a Korean healthcare payer's perspective. The model has 6 health states: no opioid use, therapeutic opioid use, opioid abuse, overdose, overdose death, and all-cause death. Patient characteristics, healthcare costs, and transition probabilities were estimated from national population-based data and published literature. Age- and sex-specific utilities of the general Korean population were used for the no-use state, whereas the other health-state utilities were obtained from published studies. Costs (in 2019 US dollars) included the expenses of the program, opioids, and overdoses. An annual 5% discount rate was applied to the costs and quality-adjusted life-years (QALYs). Parameter uncertainties were explored via deterministic and probabilistic sensitivity analyses.

RESULTS

The program was associated with 2.27 fewer overdoses per 100 000 person-years, with an ICUR of $227/QALY. The ICURs were generally robust to parameter changes, although the program's effect on abuse reduction was the most influential parameter. Probabilistic sensitivity analysis showed that the program reached a 100% probability of cost-effectiveness at a willingness-to-pay threshold of $900/QALY.

CONCLUSIONS

The opioid abuse-prevention program appears to be cost-effective in South Korea. Mandatory use of the program should be considered to maximize clinical and economic benefits of the program.

Pattern and prevalence of substance use and dependence in two districts of Union Territory of Jammu & Kashmir: Special focus on opioids

Background:

Kashmir has been at the centre of conflict between India and Pakistan after partition of erstwhile British India in 1947. While research suggests that conflict exposure may result in increased substance use, the prevalence of substance use disorders has remained an under-searched area in Kashmir.

Method:

We employed respondent-driven sampling (RDS) for recruiting substance users from two districts of Kashmir. Estimation of substance dependence was done using benchmarkmultiplier method.

Results:

Prevalence of any substance dependence was estimated to be 1.95% while as for any opioids, it was 1.80%. Heroin was the most common opioid with last year use by 84.33% respondents. Current prevalence of injection drug use was 0.95% and heroin was the most common opioid among Injection Drug User (IDU), being used by 91.12% IDUs followed by Pentazocine (5.92%).

Conclusion:

Our results indicate that RDS was a feasible and acceptable sampling method for recruiting 'difficult to reach 'participants like illicit substance users including IDUs. Our results further demonstrate that opioids are highly prevalent in Kashmir and heroin injection is not uncommon. All these findings call for attention from policy makers as opioids are one of the important contributors to mortality and morbidity related to substances.

Compliance of private pharmacies in Uganda with controlled prescription drugs regulations: a mixed-methods study

Background

Controlled prescription drug use disorders are a growing global health challenge in Sub-Saharan Africa. Effective supply chain regulations on dispensing and stock control are important for controlling this epidemic. Since compliance with these regulations in resource-limited countries is poor, there is need to understand its predictors in order to reduce the risk of prescription drug use disorders.

Methods

A mixed-methods study utilizing a structured questionnaire and a simulated client guide was undertaken in Kampala and Mbale towns in Uganda. The questionnaire recorded self-reported dispensing and verified stock control practices and their covariates from 101 private pharmacies. The guide recorded actual dispensing practices from 27 pharmacies. Snowball sampling was done to enrich the sample with pharmacies that stock opioids. The mean compliance with good dispensing and stock control practices was calculated. Multivariate logistic regression analyses were applied to identify predictors of compliance.

Results

The mean compliance with dispensing and stock control requirements was 82.9% and 23%, respectively. Twenty percent and 40% of the pharmacies dispensed pethidine without a prescription and with invalid prescriptions, respectively. Having a pharmacist on duty (OR = 5.17; p = 0.02), prior in-service training on narcotics regulations (OR = 3.51; p = 0.04), and previous narcotics audits by the regulator (OR = 5.11; p = 0.01) were independent predictors of compliance with stock control requirements. Pharmacies with a previous history of poor compliance with dispensing requirements were less likely to demonstrate good compliance (OR = 0.21; p = 0.01).

Conclusions

There is suboptimal compliance to controlled prescription drug regulations among Uganda’s pharmacies. A previous history of poor compliance to dispensing requirements predicted low compliance in subsequent assessments. Training and regulatory audits increased compliance in stock control but not dispensing. Expansion of training and audits to more pharmacies and/or incentives for compliance are necessary.

Correlates of Non-Medical Prescription Drug Misuse Among a Treatment-Seeking Population: A Comparison with Illicit Drug Users

Prescription drugs (PD) undoubtedly help people with various physical or psychiatric ailments. Nevertheless, they are often diverted and misused (use without prescription or for purposes/in ways not intended by the prescriber). This study compared the sociodemographic and clinical correlates of those who misused PDs, used illegal drugs and co-ingested both, to identify those who were at a high risk of misusing these drugs. Retrospective analysis of the treatment outcome monitoring (TOM) data for the period of 2013–2017 identified 1369 subjects for the study; 295 patients presented with PD use disorder (PDUD alone), 811 with illegal drug use disorder (IDUD alone), and 263 had both PDUD and IDUD. The study sample included treatment seeking population (Singaporeans and permanent residents). TOM data included data collected through direct interviews (addiction severity, quality of life) and from the clinical case notes (diagnosis, co-morbidities, socio demographic information, etc.). The most commonly misused prescription and illegal drugs were benzodiazepines (63.1%) and heroin (63.4%), respectively. Those who co-ingested both PD and illegal drugs (PDUD+IDUD) had a significantly higher addiction severity score, lower quality of life and higher psychiatric co-morbidities than that of IDUD alone at baseline. When compared to Chinese patients, Malay and Indian patients had lower odds (p < 0.05) of PDUD alone and PDUD+IDUD than Chinese patients; divorcees had higher odds of PDUD+IDUD than those who were married. Those with primary and secondary qualifications had higher odds (2.1 and 2.9 times, respectively) of PDUD+IDUD than those with tertiary qualification and those in managerial or professional roles had higher odds of PDUD alone than those who were unemployed. Gender, ethnicity, marital status, education and occupational classes were associated with PDUD and IDUD. These characteristics can be helpful to identify those who are at the risk of PDUD and incorporate strict prescription monitoring to their care.

Buprenorphine-based opioid substitution therapy in India: A few observations, thoughts, and opinions

The most evidence-based treatment for opioid dependence is opioid agonist maintenance treatment also known as opioid substitution therapy (OST). However, there are some critical, yet unaddressed issues of buprenorphine-based substitution therapy, especially in the Indian context. These comprise of generalizability of the evidence for OST, especially for natural and pharmaceutical opioids and for all age groups, optimum dose and duration of OST, and mode of treatment delivery including the frequency of dispensing. Notwithstanding the use of buprenorphine-naloxone combination, abuse and diversion are serious but often underreported problems. There is an urgent need for health services research in India on OST, focusing on these aspects. Rather than directly copying from Western models, it is important to try to understand the useful and safe program and policy options likely to be applicable in the Indian setting, with our own assets as well as vulnerabilities.

Should Antibiotics Be Controlled Medicines? Lessons from the Controlled Drug Regimen

This study aimed to identify the antibiotic-relevant lessons from the controlled drug regimen for narcotics. Whereas several elements of the United Nations Single Convention on Narcotic Drugs (1961) could be advantageous for antibiotics, we doubt that an international legally binding agreement for controlling antibiotic consumption would be any more effective than implementing stewardship measures through national AMR plans.

Nalbuphine for analgesia after fracture surgery and its effect on circulating inflammatory factors

The present study evaluated the use of nalbuphine for analgesia after fraction reduction surgery. Eighty lower limb fracture patients needing open reduction and internal fixation were selected in the First People's Hospital of Jingzhou from January 2015 to December 2015. Patients were randomly divided into observation and control groups (with 40 cases in each). After surgery, the patients in the observation group were treated with nalbuphine (2 mg/kg) for patient-controlled intravenous analgesia (PCIA), while sufentanil (2.5 µg/kg) was used for patients in the control group. The analgesia treatment lasted for 48 h after surgery. Changes in inflammatory factors and catecholamine hormones during the observation period were determined and compared between the groups. Pain, sedation scores and the number of times the analgesia pump was used were recorded at different time-points. Additionally, the life and sleep qualities and any adverse reactions were also recorded. Our results showed that after the operation, the levels of interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), interleukin-1 (IL-1), high-sensitivity CRP (hs-CRP) cortisol, adrenaline epinephrine (AD) and norepinephrine (NE) were significantly lower in the observation group than in the control group (P<0.05). Pain and sedation scores of patients in the observation group were better than those in the control group at all time-points after operation (P<0.05). Life and sleep qualities of patients in the observation group were also better than those in the control group (P<0.05). Finally, the rates of nausea, vomiting, dizziness, lethargy, urinary retention, skin itch and constipation were significantly lower in the observation group than in control group (P<0.05). Based on our findings, the application of nalbuphine for analgesia in patients with fracture surgeries can reduce the levels of inflammatory cytokines, improve the analgesic effect, bring beneficial sedative effects and reduce the occurrence of adverse reactions.

The effect of a potentially tamper-resistant oxycodone formulation on opioid use and harm: main findings of the National Opioid Medications Abuse Deterrence (NOMAD) study

BACKGROUND

Escalation of pharmaceutical opioid use and harm in North America is well-documented, with similar issues emerging in Australia. One response is the development of tamper-resistant formulations of opioids. A potentially tamper-resistant formulation of controlled-release oxycodone was introduced in Australia in April, 2014, rapidly replacing the non-tamper-resistant formulation. Our study is the most systematic and comprehensive examination of the impact of a new opioid formulation to date, assessing the effect of tamper-resistant formulation of controlled-release oxycodone on population-level opioid use and opioid-related harm (ie, overdose, help-seeking, and treatment-seeking); and opioid use, tampering, and preference for the tamper-resistant formulation of controlled-release oxycodone compared with other drugs or formulations among sentinel populations likely to tamper with pharmaceutical opioids.

METHODS

We conducted interrupted time-series analyses of opioid sales data and multiple routinely collected health datasets, followed up a cohort of people who tamper with pharmaceutical opioids before and after the introduction of the tamper-resistant formulation of controlled-release oxycodone, and analysed annual surveys of people who inject drugs. Data were collected from several Australian states: New South Wales, South Australia, and Tasmania. Meta-analyses (weighted Z tests) were conducted to synthesise across data sources providing evidence for a given indicator.

FINDINGS

At the population level, we found reduced sales of higher strengths of controlled-release oxycodone and increased sales of other oxycodone formulations. No significant effect was observed among population-level indicators of opioid overdose, or help or treatment-seeking. Mortality data were not available for inclusion at the time of our study. Meta-analyses across sentinel populations (ie, prospective cohort, surveys of people who inject drugs, and clients of supervised injecting facilities or needle and syringe programmes) indicated reduced controlled-release oxycodone use via tampering (mainly injection), with no evidence of switching to heroin or other drug use.

INTERPRETATION

This formulation of controlled-release oxycodone reduced tampering with pharmaceutical opioids among people who inject drugs, but did not affect population-level opioid use or harm.

FUNDING

Mundipharma Australia, the Australian Government, and the National Health and Medical Research Council.

Prevalence and correlates of prescription opioid residue injection

BACKGROUND

There is growing evidence of intravenous administration of prescription opioids (POs) in several countries. Preparation of POs for injection may leave residues in containers and filters used by people who inject drugs and may lead to adverse health outcomes if they are injected.

METHODS

This exploratory study used cross-sectional data from the COSMO study, a prospective cohort of out-of-treatment cocaine users carried out in Montréal (Canada) between October 2010 and August 2015. For this analysis, only one visit per participant was selected, that is, the first time the participant reported PO injection during the study. The outcome of interest, "injection of PO residues", was defined as having injected PO residues from a filter and/or a container in the last month. Correlates of this outcome were identified using logistic regression analyses.

RESULTS

Of the 122 participants who reported PO injection during the study period, 41.8% had injected PO residues. Reporting an unstable source of income (AOR=4.26; 95% CI: 1.03-17.69), a recent overdose (AOR=5.45; 95% CI: 1.50-19.88) and a preponderant use of opiates (mostly opiate use versus other drugs excluding alcohol and cannabis) (AOR=2.46; 95% CI: 1.08-5.63) increased the risk of PO residue injection. The odds of reporting PO residue injection rose by 7% per unit increase in the score of psychological distress (AOR=1.07 per unit increase; 95% CI: 1.01-1.12).

CONCLUSIONS

The findings of this study suggest that PO residue injection is associated with markers of vulnerability. Further investigation is needed in order to better understand this understudied drug injection practice.

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.

Sharing of Needles and Syringes among Men Who Inject Drugs: HIV Risk in Northwest Bangladesh

Introduction

Injection drug use is prevalent in northwestern Bangladesh. We sought to explore the context of needle/syringe sharing among persons who inject drugs (PWID), examining risk exposures to blood-borne infections like the human immunodeficiency virus (HIV) and hepatitis in a region where these dual epidemics are likely to expand.

Methods

We used a qualitative research approach to learn about injection practices, conducting 60 in-depth interviews among PWID. We then conducted 12 focus group discussions (FGDs) that generated a checklist of salient issues, and followed up with personal observations of typical days at the drug-use venues. Content and interpretative frameworks were used to analyze qualitative information and socio-demographic information, using SPSS software.

Results

We found that needle/syringe-sharing behaviours were integrated into the overall social and cultural lives of drug users. Sharing behaviours were an central component of PWID social organization. Sharing was perceived as an inherent element within reciprocal relationships, and sharing was tied to beliefs about drug effects, economic adversity, and harassment due to their drug user status. Carrying used needles/syringes to drug-use venues was deemed essential since user-unfriendly needle-syringe distribution schedules of harm reduction programmes made it difficult to access clean needles/syringes in off-hours. PWID had low self-esteem. Unequal power relationships were reported between the field workers of harm reduction programmes and PWID. Field workers expressed anti-PWID bias and judgmental attitudes, and also had had misconceptions about HIV and hepatitis transmission. PWID were especially disturbed that no assistance was forthcoming from risk reduction programme staff when drug users manifested withdrawal symptoms.

Conclusion

Interventions must take social context into account when scaling up programmes in diverse settings. The social organization of PWID include values that foster needle-syringe sharing. Utilization and impact of risk reduction programmes might be improved with expanded clean needle/syringe distribution at times and venues convenient for PWID, better trained and non-judgmental staff, and medical assistance for health problems, including drug withdrawal symptoms.

Health outcomes associated with illicit prescription opioid injection: A systematic review

Prescription opioid injection is a growing concern among people who use illicit drugs. Little is known about the potential health-related harms of injecting prescription opioids. Therefore, the authors undertook a systematic review to identify health outcomes associated with injecting prescription opioids. PubMed, Ovid MEDLINE®, EMBASE, Journals@Ovid, CINAHL, PsycInfo, Web of Science® Core Collection, CAB Direct, and ERIC databases were searched to identify English articles published between January 1990 and February 2015 that matched the inclusion criteria. Potentially relevant articles were those examining a clinical health outcome among people who use illicit drugs, in which a sub-group injects prescription opioids. The International Classification of Diseases (ICD-10) was used to clinically classify health outcomes. In total, 31 studies that met the inclusion criteria were identified and summarized. A modified version of the Downs and Black checklist was used to assess individual study quality and identify sources of bias. Findings supported associations between prescription opioid injection and hepatitis C infection, substance dependence and other mental health indicators, and lower general health. Associations with human immunodeficiency virus, overdose, and cutaneous infection were less consistent and varied according to prescription opioid type(s). Several potential sources of bias were identified as well as a need for more longitudinal research and more rigorous confounding adjustment. The current findings highlight a need to consider the growing popularity of prescription opioid injection in efforts to reduce drug-related harm among people who inject drugs.

Changes in non-opioid substitution treatment episodes for pharmaceutical opioids and heroin from 2002 to 2011

BACKGROUND

There has been a well-documented increase in the non-medical use of pharmaceutical opioids (PO) worldwide. However, there has been little detailed examination of treatment demand, or the characteristics of those presenting for treatment, particularly for treatments other than opioid substitution.

METHODS

Data from closed drug and alcohol treatment episodes from the Alcohol and Other Drug Treatment Services National Minimum Data Set (AODTS-NMDS, representing non-opioid substitution treatment) in Australia for 2002-2003 to 2010-2011 were examined. In the four jurisdictions where detailed data were available, episodes where heroin was the principal drug of concern were compared to episodes for the four most frequently reported pharmaceutical opioids (morphine, codeine, fentanyl and oxycodone).

RESULTS

In 2002-2003, most (93%) opioid treatment was related to heroin with seven percent of all opioid treatment episodes reporting a PO as the principal drug of concern. In 2010-2011, 20% of all opioid treatment episodes were attributed to POs. Distinct changes over time were observed for different opioids. There was an increase in the average age at the start of treatment for heroin and oxycodone episodes, and a reduction in the proportion of females for codeine episodes, with 67% in 2002-2003 compared with 44% in 2010-2011. Codeine and oxycodone episodes had the lowest current or past injection rates.

CONCLUSIONS

Clear differences were observed over time and between different opioids. Monitoring these emerging patterns will be important to inform treatment needs, particularly in light of different patterns of poly drug use, different routes of administration and changing demographic characteristics.

Prescription opioid abuse based on representative postmortem toxicology

Opioids are important medications for pain and opioid maintenance treatment. Increasing use and abuse of prescription opioids has, however, caused worldwide concern. Our aim was to estimate the ratio between prescription opioid abuse and total use, based on representative postmortem toxicology. Our material included all the medico-legally examined deaths in Finland during 2010-2011 involving positive findings involving buprenorphine, codeine, fentanyl, methadone, oxycodone, or tramadol. We studied drug abuse by age group, with "abuse" meaning licit opioids used illicitly as narcotics. Drug-abuse history, drug injecting, or laboratory findings of illicit drugs defined an abuser case. We then compared abuser cases and other opioid-related cases between the opioids with the number of fatal poisonings, accidents, suicides, alcohol findings, concomitant opioid use, and median postmortem blood opioid concentrations. Opioid findings numbered 2499 in 2088 cases. Drug abuse involved 545 opioid-positive cases, which in Finland represented 0.5% of those deceased. The proportion of abuser cases among all opioid-related cases for buprenorphine was 85.5%, for methadone 82.4%, for tramadol 29.4%, for codeine 16.3%, for fentanyl 14.5%, and for oxycodone 6.9%. Abuse in age-groups >60 was rare. Concomitant other opioid findings were more frequent in abuser- than in other cases for codeine, oxycodone, and tramadol, whereas alcohol findings were more frequent in buprenorphine, codeine, and fentanyl abuse. Buprenorphine and methadone were most often related to drug abuse. Every other opioid studied involved some abuse, and especially tramadol. Abuse and fatal poisonings were concentrated in men aged 20-49.

Type of opioids injected: does it matter? A multicentric cross-sectional study of people who inject drugs

INTRODUCTION AND AIMS

Injecting pharmaceutical opioids for non-medical purposes is a major concern globally. Though pharmaceutical opioids injection is reported in India, the exact proportion of people who inject drugs (PWID) using pharmaceutical opioids is unknown. The objectives of this study were to describe the various types of drugs that are injected by people in India and to analyse the differences between the commonly injected drugs.

DESIGN AND METHODS

A cross-sectional, multicentric study covering 22 harm-reduction sites from different regions of the country was conducted. First 50 subjects, chosen randomly from a list of PWIDs accessing services from each site and fulfilling study criteria, were interviewed using a structured questionnaire. Data from 902 male subjects are presented here.

RESULTS

Pharmaceutical opioid injectors (POI) accounted for 65% of PWIDs (buprenorphine: 30.8%, pentazocine: 21.8% and dextropropoxyphene: 11.9%). Heroin, injected by 34.3%, was prevalent in most states surveyed. Buprenorphine and pentazocine were not injected in the north-east region, whereas dextropropoxyphene was injected in the north-east alone. Univariate and multivariate logistic regression showed that, compared with heroin injectors, the POI group was more likely to consume alcohol and pharmaceutical opioids orally, inject frequently, share needle/syringes and develop injection-site complications. Among individual POIs, buprenorphine injectors had significantly higher proportion of subjects injecting frequently, sharing needle/syringes and developing local complications. Irrespective of the opioid type, majority of subjects were opioid dependent.

DISCUSSION AND CONCLUSIONS

Pharmaceutical opioids are the most common drugs injected in India currently and have greater injection-related risks and complications. Significant differences exist between different pharmaceutical opioids, which would be important considerations for interventions.

Confidence interval estimation in R-DAS

BACKGROUND

Roughly 25 years ago, the United States National Institute on Drug Abuse (US NIDA) initiated the creation of public use datasets for its National Household Survey on Drug Abuse, since re-named the National Survey on Drug Use and Health (NSDUH). The Substance Abuse and Mental Health Services Administration (SAMHSA), which assumed responsibility for the survey in 1992, has continued and expanded this effort to make the survey data available to researchers. During 2012, SAMHSA created a "Restricted-Use Data Analysis System" (R-DAS) to provide researchers with the capability to create tabulations using restricted NSDUH variables not otherwise available on the public-use files.

METHODS

This methods focused article is intended to help potential users of R-DAS-like online data analysis systems by (i) clarifying statistical issues involving approximation of confidence intervals (CI), (ii) providing a way to estimate CI when tabular output is suppressed with an 'error message' based on confidentiality restrictions, and (iii) showing how to make pairwise comparisons of estimates not otherwise allowed.

RESULTS

For illustration purposes, some empirical estimates are presented on a topic of continuing of public health concern in the US namely, extra-medical use of pain relievers (generally opioids), where the drugs are being used to get high and otherwise outside the boundaries intended by prescribing clinicians.

CONCLUSION

The R-DAS makes it possible to derive state-level estimates of male-female and age-related differences in incidence of extra-medical prescription pain reliever (EMPPR) use, not previously reported in peer-reviewed articles, and not available without research approaches described here.

An inevitable wave of prescription drug monitoring programs in the context of prescription opioids: pros, cons and tensions

Background

In an effort to control non-medical use and/or medical abuse of prescription drugs, particularly prescription opioids, electronic prescription drug monitoring programs (PDMP) have been introduced in North-American countries, Australia and some parts of Europe. Paradoxically, there are simultaneous pressures to increase opioid prescribing for the benefit of individual patients and to reduce it for the sake of public health, and this pressure warrants a delicate balance of appropriate therapeutic uses of these drugs with the risk of developing dependence. This article discusses pros and cons of PDMP in reducing diversion of prescription opioids, without hampering access to those medications for those with genuine needs, and highlights tensions around PDMP implementation.

Discussion

PDMPs may help alleviate diversion, over-prescription and fraudulent prescribing/dispensing; prompt drug treatment referrals; avoid awkward drug urine test; and inform spatial changes in prescribing practices and help designing tailored interventions. Fear of legal retribution, privacy and data security, potential confusion about addiction and pseudo-addiction, and potential undue pressure of detecting misuse/diversion - are the major problems. There are tensions about unintended consequence of excessive regulatory enforcements, corresponding collateral damages particularly about inadequate prescribing for patients with genuine needs, and mandatory consultation requirements of PDMP.

Summary

In this era of information technology PDMP is likely to flourish and remain with us for a long time. A clear standard of practice against which physicians’ care will be judged may expedite the utilisation of PDMP. In addition, adequate training on addiction and pain management along with public awareness, point-of-supply data entry from pharmacy, point-of-care real-time access to data, increasing access to addiction treatment and appropriate regulatory enforcement preferably through healthcare administration, together, may help remove barriers to PDMP use.

Personally prescribed psychoactive drugs in overdose deaths among drug abusers: a retrospective register study

INTRODUCTION AND AIMS

Psychoactive prescription drug (PPD) abuse-related overdose deaths have increased in many countries in recent decades. We aimed to investigate the role of personally prescribed psychoactive drugs in abuse-related overdose mortality and explore any associations with level of social disadvantage.

DESIGN AND METHODS

This register linkage study included all 243 people who had died of abuse-related drug-induced poisoning in Finland in 2000 and 2008. Data on registered purchases of psychoactive drugs within one and three years of death were linked to data on the psychoactive drug/s contributing to death in each case. Social disadvantage was measured by receipt of income support, long-term unemployment and disability pension.

RESULTS

Thirty-six percent of those abusers who had died of a drug overdose had purchased a similarly acting drug within three years of death. In all overdoses, the proportion increased from 20% in 2000 to 49% in 2008 (P < 0.001). A similar increase was seen in purchases within one year of death; from one-tenth in 2000 to one-third of all cases in 2008 (P < 0.001). The majority (83%) of the deceased had received income support, while only 13-14% were long-term unemployed or on disability pension. Disability pension recipients had significantly more prescribed psychoactive drug purchases than non-recipients (P < 0.001 for three and one years within death).

DISCUSSION AND CONCLUSIONS

Personally prescribed PPDs pose a potential threat to people who abuse drugs. Health-care services should invest greater effort in identifying people who abuse drugs and in monitoring their drug prescriptions.

'South Asian cocktail'--the concurrent use of opioids, benzodiazepines and antihistamines among injecting drug users in Nepal and associations with HIV risk behaviour

Background

Data of the Central Bureau of Statistic of Nepal from 2008 show a total of more than 46,000 illegal drug users, out of which 61% are injecting drug users (IDU). An injecting mix of medicines like opioids, benzodiazepines and antihistamines (the so-called South Asian cocktail) was prevalent. Furthermore, it is estimated that about 70,000 people are living with human immunodeficiency virus (HIV). The government of Nepal has started realizing and recognizing drug use and HIV as significant health and social issues. Harm reduction programs such as needle syringe exchange and opioid substitution treatment are being implemented.

Methods

The aim of this study is to obtain specific knowledge on the drug use behaviour and the health status of drug users with a focus on HIV in drug users with concurrent injection of opioids, benzodiazepines and antihistamines. After an initial mapping of Kathmandu Valley, 300 drug users in contact with different treatment and counselling centres were randomly chosen for the interviews. The research questionnaire was designed according to the European Addiction Severity Index (EuropASI) and Maudsley Addiction Profile standards.

Results

Ninety-one percent of the respondents are male and 9% female. Mean age is 28.7 years. Ninety-five percent are injecting drug users with a mean of 8.7 years of drug use history. Eighty-six percent are injecting different ‘cocktails’, usually made of buprenorphine, diazepam, promethazine and/or other substances (30-day prevalence). Similarly, 48% use heroin, whereas only 2% take cocaine/crack. Among those tested for HIV (N = 223), 33% are positive (25% of the sample population). Compared to the other drug users (mainly heroin), the cocktail users show a higher HIV infection rate and more co-infections. Furthermore, risk behaviour, as e.g. needle sharing, is much more common among the cocktail users.

Conclusion

Currently, the mixture of medicines, opioids, benzodiazepines and antihistamines, is the predominant drug in Nepal; the pharmaceutical drugs needed to prepare the cocktail are less expensive than heroin and relatively easy to acquire. The cocktail users show a higher risk behaviour regarding the transmission of HIV than heroin drug users. It needs to be considered which HIV prevention measures are necessary to target the specific needs of drug users who inject a mixture of opioids, benzodiazepines and antihistamines, since the available services (such as needle syringe exchange) do not seem to cover their specific needs (high percentage of needle sharing).

Substance use disorders among treatment naïve first-episode psychosis patients

OBJECTIVES

To examine the prevalence of substance use among treatment naïve patients with first episode psychosis presenting to a psychiatry outpatient clinic in India.

METHODS

The study sample consisted of 139 first episode treatment naïve patients with psychosis from in and around Bangalore, a city in South India. Self as well as informant-reported data on type, use and duration of substance use as well as the severity of psychotic symptoms were collected using structured instruments. Urine toxicology screen was also conducted for six common drugs of abuse. Breath alcohol analysis was performed in all patients.

RESULTS

Acute and transient psychosis was the most common diagnosis (42.4%). Overall, 20% of the population reported current substance use disorder (excluding nicotine). Current alcohol dependence was diagnosed among 17.3%, whereas cannabis dependence in 3.6%. Life time as well as current use of cannabis was less than 6%. While one patient reported inhalant abuse none reported use of amphetamine or opioids. There was very high concordance between reported drug use and urine toxicology screen.

CONCLUSION

The use of illicit drugs is substantially less among first episode drug naïve patients with psychosis in an Indian urban clinical setting compared to rates reported from developed countries like North America, Canada and UK.

High HIV incidence among persons who inject drugs in Pakistan: greater risk with needle sharing and injecting frequently among the homeless

Background

The incidence of HIV among persons who inject drugs (PWIDU) has fallen in many nations, likely due to successes of clean needle/syringe exchange and substance abuse treatment and service programs. However in Pakistan, prevalence rates for PWID have risen dramatically. In several cities, prevalence exceeded 20% by 2009 compared to a 2003 baseline of just 0.5%. However, no cohort study of PWID has ever been conducted.

Methods

We enrolled a cohort of 636 HIV seronegative PWID registered with three drop-in centers that focus on risk reduction and basic social services in Karachi. Recruitment began in 2009 (March to June) and PWID were followed for two years. We measured incidence rates and risk factors associated with HIV seroconversion.

Results

Incidence of HIV was 12.4 per 100 person-years (95% exact Poisson confidence interval [CI]: 10.3–14.9). We followed 474 of 636 HIV seronegative persons (74.5%) for two years, an annual loss to follow-up of <13 per 100 person years. In multivariable Cox regression analysis, HIV seroconversion was associated with non-Muslim religion (Adjusted risk ratio [ARR] = 1.7, 95%CI:1.4, 2.7, p = 0.03), sharing of syringes (ARR = 2.3, 95%CI:1.5, 3.3, p<0.0001), being homeless (ARR = 1.7, 95%CI:1.1, 2.5, p = 0.009), and daily injection of drugs (ARR = 1.1, 95%CI:1.0, 1.3, p = 0.04).

Conclusions

Even though all members of the cohort of PWID were attending risk reduction programs, the HIV incidence rate was very high in Karachi from 2009–2011. The project budget was low, yet we were able to retain three-quarters of the population over two years. Absence of opiate substitution therapy and incomplete needle/syringe exchange coverage undermines success in HIV risk reduction.

A comparison of buprenorphine taper outcomes between prescription opioid and heroin users

OBJECTIVES

Dependence on prescription opioids (PO) is a growing problem. Although most research with buprenorphine has focused on heroin-dependent populations, we hypothesize that individuals dependent on PO display characteristics that may predict different outcomes in treatment, particularly in short-term taper procedures in which comorbidities such as pain conditions may complicate taper.

METHODS

This secondary data analysis examined differences in outcomes between PO users (n = 90) and heroin users (n = 426) after a buprenorphine taper. Data were collected in a multisite randomized clinical trial conducted by the National Drug Abuse Treatment Clinical Trials Network at 11 study sites across the United States. After a 4-week buprenorphine induction/stabilization phase, 516 opioid-dependent individuals were randomized into 1 of 2 taper lengths (7 vs 28 days) to assess the association between taper length and outcome. The primary outcome was measured by urine drug test for opioids at the end of the taper period. Craving, withdrawal, and buprenorphine dose were also examined.

RESULTS

After controlling for baseline demographic and drug use differences between the opioid use groups, results indicate that a higher percentage of the PO group (49%) provided an opioid-free urine drug specimen at the end of taper compared with the heroin group (36%; χ(2)(1) = 6.592, P < 0.010).

CONCLUSION

Short-term taper is not recommended as a stand-alone treatment; however, patients may taper from buprenorphine as part of a treatment plan. Despite greater comorbidity, PO users seem to have favorable taper outcomes compared with heroin users. Further studies are required to examine longer-term treatment outcomes.

Pharmacological therapies for maintenance treatments of opium dependence

BACKGROUND

Pharmacologic therapies for maintenance treatment of heroin dependence have been used and studied widely. Systematic reviews have demonstrated the effectiveness of such therapies. Opium dependence is associated with less problems and impairments and is less likely to be used by injecting, with consequent reductions in risk of overdose and blood-borne diseases. Although it is a common substance use disorder in many countries, a systematic review of the literature is lacking on the maintenance treatment for opium dependence.

OBJECTIVES

To evaluate the effectiveness and safety of various pharmacological therapies on maintenance of opium dependence (alone or in combination with psychosocial interventions) compared to no intervention, detoxification, different doses of the same intervention, other pharmacologic interventions and any psychosocial interventions.

SEARCH METHODS

We searched the following sources up to February 2012: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, PsycINFO, regional databases (IMEMR and ASCI), national databases (Iranmedex and Iranpsych), main electronic sources of ongoing trials and reference lists of all relevant papers. Also, we contacted known investigators from some Asian countries to obtain details about unpublished trials.

SELECTION CRITERIA

Randomised controlled clinical trials (RCTs) comparing any maintenance pharmacologic intervention versus no intervention, other pharmacologic or non-pharmacologic intervention for opium dependence.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed the risks of biases and extracted data, independently.

MAIN RESULTS

Three RCTs recruiting 870 opium dependents were included. The studies made different comparisons so it was not possible to pool data. Only retention rate was assessed by the studies. Two studies compared different doses of buprenorphine: in one study, 4 mg/day of buprenorphine was compared with doses of 2 mg/day and 1 mg/day and in another study, 8 mg/day of buprenorphine was compared with doses of 3 mg/day and 1 mg/day. Comparisons showed a statistically significant difference between groups; higher doses of buprenorphine increased the probability of retention in treatment. The studies had high risks of biases. In the third study, after a process of detoxification, baclofen (60 mg/day) was compared with placebo for maintenance treatment. The difference in retention rate between groups was high, but it was not statistically significant.

AUTHORS' CONCLUSIONS

It is not possible to conclude about the use of any kind of pharmacologic therapies for maintenance treatment of opium dependence.

Twelve-year trend in treatment seeking for buprenorphine abuse in Finland

BACKGROUND

Buprenorphine abuse is becoming increasingly common worldwide. However, large-scale long-term studies of buprenorphine abuse are lacking. The objective of this study was to examine the trend in characteristics of clients seeking treatment for buprenorphine abuse and compare them to those seeking treatment for heroin and amphetamine abuse.

METHODS

A 12-year descriptive study was conducted at the Helsinki Deaconess Institute (HDI), a public utility foundation responsible for providing treatment for substance abuse in the greater Helsinki area. All clients seeking treatment between 31 January 1997 and 31 August 2008 received a structured clinical interview concerning demographic characteristics and abuse patterns. Characteristics of clients who reported that their primary drug of abuse was buprenorphine (n=780) were compared to those whose primary drug of abuse was either heroin (n=598) or amphetamine (n=1249).

RESULTS

The annual proportion of buprenorphine clients increased from 3.0% in 1998 to 38.4% in 2008. Daily abuse (73.8%) and intravenous administration (80.6%) were common among buprenorphine clients. Concurrent abuse of prescription medications (p<0.001), stimulants (p=0.001) and alcohol (p<0.001) increased from 1997 to 2008. Treatment seeking for heroin abuse declined to approximately 1% of clients annually after 2002. Buprenorphine clients were more likely to be daily users of their primary drug (p<0.001), abuse prescription medications (p<0.001) and administer drugs intravenously (p=0.001 from 1997 to 2001) compared to heroin and amphetamine clients.

CONCLUSIONS

Our results highlight the increasing abuse of buprenorphine in Finland. Buprenorphine clients had risky abuse patterns in terms of daily use and intravenous administration. Concurrent substance abuse increased during the study period.

Substance dependence treatment interventions: why we continue to fail people who use drugs in Asia

INTRODUCTION

Substance use disorders contribute to a large number of preventable deaths in Asia; a majority of the negative health consequences are associated with opioid use. User friendly and effective drug dependence treatment is limited.

SCOPE

Factors mediating drug user treatment outcomes in Asia are explored, with a focus on opioid use. Individual, programmatic, and legal/political issues which reduce the impact of drug user treatment are noted.

DISCUSSION

Criminalization of drug users, inadequate insurance, chronic underinvestment, and an overall lack of therapeutic options create structural barriers for treatment for users and providers. The practice of detention as drug treatment serves to fracture the treatment alliance. At the individual level, extreme poverty and the lack of a social protection network mediate against the achievement of treatment goals.

CONCLUSIONS

A range of factors has a bearing on processes and outcomes of drug user treatment. Acknowledging and addressing them, at each level, is fundamental to delivering useful interventions for people who use drugs.

Agonist treatment in opioid use: advances and controversy

Opioid dependence is a chronic relapsing condition which requires comprehensive care; pharmacological agents form the mainstay of its long term treatment. The two most popular approaches are the harm reduction method using agonists and the complete abstinence method using antagonists. Currently, particularly from the harm minimization perspective and the low feasibility of an abstinence based approach, there is an increasing trend toward agonist treatment. The use of buprenorphine has gained popularity in view of its safety profile and the availability of the buprenorphine-naloxone combination has made it popular as a take-home treatment. This review outlines the pharmacological advances and controversies in this area.