Drug and Alcohol Review (2003) 22;4:471-2
Muhleisen P, Spence J, Nielsen S. Crushing buprenorphine tablets.
In Australia, as in most of the research reports, buprenorphine is generally given under supervision of the nurse or pharmacist. As with methadone, there is more supervision for new and unstable patients with take-away dosing permitted to some degree for stable patients after periods in treatment. For example in South Australia up to 5 days may be dispensed in a week with 2 supervised doses after 18 months in stable treatment. In NSW up to two doses may be given per week for those needing daily doses under certain conditions, and for emergencies, travel, etc. Reports from France show that a proportion of doses there are also given under supervision although this is not by regulation but just �good practice�. The issue of whether tablets should be given whole, bisected or crushed is debated.
A report in this month's Drug and Alcohol Review covers this area from a practical perspective from a team which has been using the drug for over 5 years (originally running a trial). This group in Melbourne initially crushed tablets for some patients who they suspected were diverting the drug. Others requested crushed tablets to reduce administration time. Then the Victorian Health authorities, who are not known for their liberal attitudes, nor strong evidence base, advised all buprenorphine to be 'substantially broken or crushed'. Too fine crushing, however, is reported by these authors to sometimes result in a 'powder' which may be swallowed and thus remain largely unabsorbed. Thus crushing can cause problems in the attempt to avoid them.
These authors quote reports of about a quarter of buprenorphine patients attempting to inject their drug on at least one occasion but only less than 5% continuing to do so when they could. This is probably not too different from rates of injecting of methadone syrup.
"Merely crushing doses does not stop diversion or injecting..." <snip>
"Adequate supervision is still the basis of good treatment in this field, and is not replaced by dose-crushing. All professionals involved in the treatment should be diligent in their responsibilities in ensuring that the treatment is safe and effective. Clients who continue to misuse their buprenorphine could be considered unsuitable for treatment with this more expensive and time-consuming drug and an option to minimize potential harm to the client and the treatment itself is to suggest transfer to dosing with methadone, which is still the gold standard opioid substitution treatment."
My personal feeling is that the drug was approved by the TGA in the current tablet forms and most patients should receive the doses in that form. The tablets should only be crushed for good clinical reasons, and then only with the consent and understanding of the patients involved. Otherwise it could be seen as another paternalistic manoeuvre perpetuating the 'them and us' attitude so prevalent in drug clinics around the world.
