Illicit drug use and injection practices among drug users on methadone and buprenorphine maintenance treatment in France. Guichard A, Lert F, Calderon C, Gaigi H, Maguet O, Soletti J, Brodeur J-M, Richard L, Zunzunegui M-V. Addiction (2003) 98: 1585-1597
The November Addiction starts with a rather gauche exercise by Griffith Edwards et al. in which a hand-picked group of sub-editors, chosen for ‘their insight into Addiction’s ways of working’, are asked their suggestions for future directions in publication. It will come as no surprise to the reader that it is to be more of the same. While these distinguished folk come up with numerous worthy suggestions, the ‘uncomfortable’ issues are not raised to any level of prominence. These include the standard of opioid treatments; heroin prescription trials; controlled drinking; injecting centres; views direct from ‘consumers’; urine testing protocols; rapid opioid detoxification; naltrexone implants; medicinal uses of cannabis; the effects of criminal sanctions on the use of drugs, aka ‘drug law reform’; harm reduction philosophy and practice.
The authors congratulate themselves in advance by writing “the exercise has fulfilled its intentions”. They then concede that at some time in the future such an exercise may be repeated ‘with a wider sample’ and from ‘a younger generation’. We can only hope.
In spite of its current management, Addiction still attracts leading researchers, publishing key items of interest. An important item in this journal comes from France where in a three-city study, 340 addicts in maintenance treatment for at least 6 months were interviewed regarding illicit drug use, treatment characteristics and demographics. There were 200 on methadone while 140 were prescribed buprenorphine. About half the methadone patients and 80% of buprenorphine patients were treated in general practice, the remainder in specialist dependency treatment units.
The authors write that in France methadone can only be started in formal dependency treatment units. After stabilization, patients may attend pharmacies and receive up to a week’s supply of methadone on a GP prescription. In contrast, buprenorphine tablets (‘pure’, sub-lingual) can be prescribed for up to 28 days by any physician. Thus the latter has had a rather broader uptake even though both were introduced around the same time in France. This is especially so in regions without specialist units. The authors state that buprenorphine was generally considered the ‘first line’ drug in France.
This study found that methadone patients had been using drugs for longer and had been in treatment slightly longer than the buprenorphine recipients.
Mean daily dose for methadone was 67mg (SD 30) and for buprenorphine 10mg (SD 9).
The important finding of this study was a low rate of illicit drug use of around 35% of subjects (18% heroin, 25% cocaine, 7% crack). There was little significant difference between patients being cared for in specialist clinics or by GPs. It was noteworthy that 40% of the buprenorphine patients had injected their own substitution drug (ever) while only 15% of the methadone patients had done so. In addition, the higher dose buprenorphine cases were more likely to have injected, a trend which was not seen with the methadone patients.
About 80% of methadone patients received a prescription for two weeks or less. Two thirds of buprenorphine prescriptions were for 3 weeks or more.
About half of the subjects had a jail history. About 90% of patients had been tested for HCV and HIV. Around 50% were HCV positive while 22% HIV positive. These figures may relate to the late introduction of harm reduction measures in France compared with experience elsewhere (eg. Australia and Hong Kong). It is partly as a result of increasing HIV and overdoses that France took the bold step of making buprenorphine so widely available.
My ‘theory’ on the buprenorphine injecting is that a proportion of patients who do not do well initially on buprenorphine doses may increase their dose, still without suppressing cravings. Such unstable and unhappy patients may tend to inject their buprenorphine, thus defeating one of the main purposes of the treatment. Whether relapse to heroin use or buprenorphine injecting, such behaviour should indicate a consideration of transfer to methadone or another agonist drug such as long acting morphine if available.
With arbitrary regulations in some jurisdictions these options are not always available in the same treatment settings. This would be unlikely to occur in other fields, rather like banning some doctors or pharmacists from using certain antibiotics. The principles governing methadone treatment should be parallel to those for buprenorphine with emphasis on real risks and benefits, not implied or theoretical ones. Historical regulatory anomalies should be removed in the interests of all involved since agonist treatments are evidence based, cost-effective and can be simply delivered using existing resources and facilities. Fortunately, all Australian jurisdictions now permit (limited) take-away provisions for buprenorphine, including New South Wales (up to two per week as well as for emergencies and travel in suitably approved patients). South Australia allows up to 5 dispensed doses per week in stable patients who have been in treatment for over 18 months. Such dosing encourages retention and is recommended by the new Australian treatment guidelines. Intriguingly, both France and the US allow unlimited unsupervised doses even though these have not been researched to any degree. Such are the anomalies of our field.
This Addiction edition also has some largely reassuring information on buprenorphine in pregnancy with 13 cases reported from France. The authors state that no teratogenic effects have been reported, and that their cases had variable neonatal abstinence syndrome but of shorter duration than with methadone. Two cases (15%) had some motor abnormalities which did not resolve completely at follow-up. [Kayemba-Kay’s S et al.]
Another important recent comparative description is: Carrieri M-P, Reya D, Loundoua A, Lepeuc G, Sobeld A, Obadia Y .Evaluation of buprenorphine maintenance treatment in a French cohort of HIV-infected injecting drug users. Drug Alc Depend (2003) 72; 1:13-21
comments by Andrew Byrne ..
