Intravenous use of prescribed sublingual buprenorphine tablets by drug users receiving maintenance therapy in France

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Abstract

Background: In 1996, sublingual buprenorphine was authorized for prescription in France for maintenance therapy (MT). MT should facilitate the rehabilitation of opioid-dependent drug users and reduce the risks associated with injection. However, misuse and side effects have been reported. Objectives: To assess the frequency of buprenorphine injection in 404 subjects on buprenorphine MT and to determine the factors associated with the injection of buprenorphine. Methods: A cross-sectional survey was used to collect data from subjects on buprenorphine MT seeking treatment from health care networks, specialized structures, a prison and a hostel in three different regions of France (1998–1999). Information was collected by trained interviewers using a structured questionnaire. Results: About half (46.5%) of the subjects on MT (188/404) had ever injected buprenorphine; 67.2% of this subgroup had since used both injected and sublingual buprenorphine. Variables associated with buprenorphine injection were having injected a substance other than buprenorphine (odds ratio (OR): 13.18; 95% CI: 5.36–32.42), cannabis use (OR: 2.34; 95% CI: 1.51–3.63) and having a source of income other than a salary (OR: 1.58; 95% CI: 1.02–2.45) and heroin use (OR: 0.23; 95% CI: 0.09–0.61). Conclusions: To decrease buprenorphine injection, prescribers of buprenorphine should participate in networks with specialized centers, and social and professional rehabilitation programs should be implemented for subjects on buprenorphine MT.

Introduction

The benefits of methadone or buprenorphine maintenance therapy (MT) for the treatment of opioid dependence are well known (Farrell et al., 1994, O'Connor and Fiellin, 2000) preventing drug abusers from seeking illicit drugs, facilitating social and professional rehabilitation, reducing the number of injections, injection risk behaviors (Baker et al., 1995, Ball et al., 1988) and the risks of local infections and of HIV, HCV and HBV (Loo et al., 1993). However, some authors (Baker et al., 1995, Darke et al., 1994) found that over half of the subjects on methadone MT continue to inject drugs.

Methadone MT first became available in two drug abuse treatment centers in Paris in 1975 (Morel, 2000). Until 1993, only about 50 drug users (DUs) were receiving methadone. Since 1993, methadone has been available in most drug abuse treatment centers, but its distribution was strictly controlled, requiring daily prescriptions from specialized centers. The delivery regulations were simplified in 1996 and again in 2002; MT can now be prescribed by physicians and pharmacists in health care networks. Sublingual buprenorphine tablets were first marketed in France in 1996 as a means of MT for opioid-dependent DUs. Three doses are available (0.4, 2 and 8 mg). Buprenorphine should be administered via the sublingual route. France was the first European country to legalize buprenorphine tablets for MT. The ordering and delivery regulations remain specific to France and are subject to a moderate level of surveillance. Any opioid-dependent outpatient can be treated with buprenorphine by any physician, including general practitioners (Ministre délégué à la santé, 1995). The recommended daily dose is 8–10 mg, with a maximum of 16 mg for no more than 28 consecutive days and delivered by the same chemist for a maximum of 7 days at a time. However, some users may attend several institutions, meaning that each patient may have more than one prescriber. In 2000, between 67 377 and 89 836 DUs were estimated to be treated with buprenorphine (Morel, 2000).

Adverse effects, including deaths, have been reported following the use of buprenorphine. These effects are related to misuse (Decocq et al., 1997, Tracqui et al., 1998a, Tracqui et al., 1998b). Few data are currently available concerning the frequency and the circumstances of buprenorphine misuse (Obadia et al., 2001, Thirion et al., 2000). However, in a study carried out in France in 1997, 20% of the 300 DUs receiving buprenorphine MT declared that they had injected buprenorphine before entering the study (De Ducla et al., 2000). Furthermore, the risk factors for the misuse of buprenorphine in DUs have seldom been analyzed. However, Obadia et al. (2001) found that the DUs who had injected buprenorphine in the previous 6 months were younger, injected more frequently and were more frequently on buprenorphine MT than those who had not. The identification of further risk factors would make it possible to set up adapted measures to prevent misuse.

Therefore, the objectives of this study were to assess the frequency of buprenorphine injecting in DUs receiving buprenorphine MT and to determine which factors (sociodemographic or addictive behaviors) are associated with the intravenous injection of buprenorphine.

Section snippets

Study design

A survey of all consecutive admissions of opioid dependant patients for buprenorphine MT was carried out in three different areas of France. In this observational study, retrospective self-reported data were collected by face to face interviews. DUs were asked about their demographic status, the nature of drugs used and the characteristics of buprenorphine use. The first injection of buprenorphine was specifically explored.

Setting

DUs were recruited between July 1998 and June 1999 in three areas of

Sample characteristics

The mean (S.D.) age of the 404 buprenorphine-maintained DUs was 32.1 (5.6) years and 76% were male (Table 1); 80.3% of the DUs did not obtain their school leavers certificate; 66.1% were not living in a couple and 81.4% were living in a stable environment (in their own home or with their parents); 49.5% were unemployed and 51.4% were not earning a salary.

The mean age (S.D.) of the DUs was 20.1 (4.8) years when they first took opioids and 21.4 (5.0) years when they first injected a drug. They

Discussion

A high percentage of DUs receiving buprenorphine MT had injected buprenorphine at least once (46.4%). The injection of buprenorphine was independently associated with ongoing cannabis use, injecting substances other than heroin and markers of low social competence such as earning no salary. To our knowledge, only one other study (Barrau et al., 2001) comparing the characteristics of methadone and buprenorphine users in French care centres has previously analyzed some risk markers for

Acknowledgements

This study was funded by the Observatoire Français des Drogues et des Toxicomanies. We are greatly indebted to A. Coppel, I. Ferrand M.D., K.Illel M.D, X. Laqueille M.D., A. Mucchielli M.D., J.-P. Solal M.D, B. Tanche M.D. and the physicians from Espace MG (Strasbourg). We also want to thank the interviewers. We are grateful to the participating DUs.

References (26)

  • R.S. Schottenfeld et al.

    Community reinforcement approach for combined opioid and cocaine dependence. Patterns of engagement in alternate activities

    J. Subst. Abuse. Treat.

    (2000)
  • X. Thirion et al.

    Buprenorphine prescription by general practitioners in a French region

    Drug Alcohol Depend.

    (2002)
  • A. Baker et al.

    HIV risk-taking behaviour among injecting drug users currently, previously and never enrolled in methadone treatment

    Addiction

    (1995)
  • J.C. Ball et al.

    Reducing the risk of AIDS through methadone maintenance treatment

    J. Health Soc. Behav.

    (1988)
  • K. Barrau et al.

    Comparison of methadone and high dosage buprenorphine users in French care centres

    Addiction

    (2001)
  • D.C. Bell et al.

    Partner concordance in reports of joint risk behaviors

    J. Acquir. Immune Defic. Syndr.

    (2000)
  • S. Darke et al.

    Predictors of injecting and injecting risk-taking behaviour among methadone-maintenance clients

    Addiction

    (1994)
  • M. De Ducla et al.

    Follow-up of opioid addicts treated with high-dose buprenorphine in a health care network. National retrospective study. Experience of French general physicians

    Ann. Med. Interne. (Paris)

    (2000)
  • J. De Irala et al.

    Reliability of self-reported human immunodeficiency virus risk behaviors in a residential drug treatment population

    Am. J. Epidemiol.

    (1996)
  • G. Decocq et al.

    Local complications after intravenous injection of dissolved tablets of buprenorphine (letter)

    Presse. Med.

    (1997)
  • M. Farrell et al.

    Methadone maintenance treatment in opiate dependence: a review [see comments]

    BMJ

    (1994)
  • M.F. Goldstein et al.

    Self-reports of HIV risk behavior by injecting drug users: are they reliable?

    Addiction

    (1995)
  • H. Loo et al.

    Treatment of heroin addicts by substitution with methadone. Importance, limits and experience in France

    Bull. Acad. Natl. Med.

    (1993)
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