Research paperDiversion of methadone and buprenorphine by patients in opioid substitution treatment in Sweden: Prevalence estimates and risk factors
Introduction
Dependence on heroin or other opiates is a condition which is difficult to treat. Research has been unable to point to any clear evidence of lasting effects of medication-free treatment. The dominant treatment method is opioid substitution treatment (OST) with methadone or buprenorphine, the latter often combined with naloxone. Metastudies show that OST is effective in light of factors such as mortality, morbidity, illicit drug use, and criminality (Amato et al., 2011, Mattick et al., 2009, Mattick et al., 2008). OST also carries risks. Methadone is a strong respiratory depressant, potentially fatal for individuals without sufficient tolerance (Fugelstad et al., 2007, Milroy and Forrest, 2000). Buprenorphine is less potent, but if mixed with alcohol or sedatives there is a risk of polydrug intoxication (Mégarbane, Hreiche, Pirnay, Marie, & Baud, 2006). Both medications have high abuse potential and are sought after on the illicit drug market. Diversion—here defined as patients selling or sharing part or all of their medication—is therefore a significant risk. In several countries diversion has been linked to an increase in methadone-related fatalities and in extensive illicit use of buprenorphine (Obadia et al., 2001, Otiashvili et al., 2010, Piercefield et al., 2010, Strang et al., 2010). Measures have been taken to reduce these risks, such as developing safer versions of the medications (Fudala & Johnson, 2006). The first one to reach the market was Suboxone©, a sublingual tablet where buprenorphine was combined with the opioid antagonist naloxone, which reduces the potential for abuse. Buprenorphine–naloxone is now also available as a sublingual film.
In the research on diversion and illicit, three main strands emerge. One strand concerns illicit use, and the demand for methadone and buprenorphine on the illicit market. Illicit use of methadone and buprenorphine is common among opioid-dependent individuals. Lifetime prevalence of illicit methadone use among intravenous drug users outside treatment has varied between 17% and 95% in different studies, but high prevalence is the rule rather than the exception (Davis and Johnson, 2007, Hall et al., 2013, Roche et al., 2008, Vlahov et al., 2007). Illicit buprenorphine use is prevalent, as well (Håkansson et al., 2007, Yokell et al., 2011) and in some countries this substance has become the most common opioid on the illicit market (Aalto et al., 2011, Moatti et al., 2001, Yokell et al., 2011). Methadone and buprenorphine typically enter a user's drug career at a late stage, and they are rare among younger people, unless they have already developed severe drug problems (Richert & Johnson, 2013). The substances are mainly used by people with a long-standing opioid addiction. Very often these users are not in treatment, and employ them to avoid withdrawal symptoms, or as a means of performing self-detoxification, or managing substitution treatment on their own (Gwin et al., 2009, Håkansson et al., 2007, Monte et al., 2009, Richert and Johnson, 2013, Roche et al., 2008, Schuman-Olivier et al., 2010, Spunt et al., 1986). However, among them are also OST patients dissatisfied with their prescribed doses (Schmidt et al., 2013, Spunt et al., 1986). In addition, the substances are used for euphoria-inducing purposes, typically as part of a polydrug use (Richert & Johnson, 2013).
The second strand of research is looking at the negative consequences of illicit use, mainly in the form of methadone- and buprenorphine-related mortality among users not in treatment (Auriacombe et al., 2004, Fugelstad et al., 2010, Madden and Shapiro, 2011, Mégarbane et al., 2006, Morgan et al., 2006, Seldén et al., 2012, Seymour et al., 2003, Strang et al., 2010, Wikner et al., 2014). The majority of such fatalities are caused by polyintoxication involving a broad array of different substances, often sedatives and alcohol (Fugelstad et al., 2010, Mégarbane et al., 2006, Seldén et al., 2012, Wikner et al., 2014). Such deaths have made up a significant percentage of the opioid-related mortality in some countries, not least Sweden; since 2011 the combined number of methadone- and buprenorphine-related fatalities have exceeded heroin-related deaths.
Nevertheless, potential advantages to illicit use have been indicated, particularly in connection with heroin use. Harris and Rhodes argued that illicit methadone use may serve as a ‘protection strategy’ enabling people with an opioid dependence to control their drug use, improve social relations, and protect themselves against hepatitis C (Harris & Rhodes, 2013). This is the case also for buprenorphine (Bridge et al., 2003, Yokell et al., 2011).
The third and final strand concerns the supply side; how the substances end up on the illicit market, and how common it is for OST patients to sell or share their medication. This is also the main subject for our study, and therefore we will start by discussing previous research in greater detail.
Empirical evidence on the extent of diversion among OST-patients is not, however, available to any significant degree. In our research review we have identified only five peer-reviewed cross-sectional studies (Dale-Perera et al., 2012, Duffy and Baldwin, 2012, Spunt et al., 1986, Winstock and Lea, 2010, Winstock et al., 2008) (see Table 1).
All the studies are self-report studies in which structured interviews or questionnaires were used. The proportion of patients who reported that they had at some point sold or shared varies from 9.6% to 34% in these studies. The one-year prevalence varies from 4.3% to 23.8%. Only one study measured diversion in the past month. There, 4% admitted to having shared, 2% to having sold, and 1% to having traded their methadone (Duffy & Baldwin, 2012). No study accounts for how great a proportion of the medication was diverted, but Spunt and colleagues categorized 10% of the patients as ‘regular diverters’ (Spunt et al., 1986).
The research accounts for few demographic and treatment-related factors associated with self-reported diversion. In two studies comparing substances, prevalence was markedly higher for buprenorphine than for methadone (Winstock and Lea, 2010, Winstock et al., 2008). Strict collection routines and supervised dosing were associated with lower levels of diversion in two studies (Dale-Perera et al., 2012, Winstock and Lea, 2010), whereas two other studies found no such link (Spunt et al., 1986, Winstock et al., 2008). Personal experience of illicit use of methadone or buprenorphine was associated with an increased risk in two studies (Winstock and Lea, 2010, Winstock et al., 2008). One study found significant differences in the levels of diversion between countries (Dale-Perera et al., 2012).
Methodologically there is reason to question some of the aforementioned findings. Admitting use of methadone or buprenorphine outside treatment is unproblematic for most drug users, and as we have seen the prevalence of such use is often very high. However, the low numbers which have been reported for diversion may indicate disadvantages with this type of self-reported data. To tell a researcher that you have diverted your medication may be a delicate issue, even if you trust the researcher's promises of confidentiality. Where the interviews take place may also influence the answers—Duffy and Baldwin (2012) discovered that interviewees who had been recruited in clinics reported significantly lower diversion (11% in the past year) than those recruited elsewhere (28%). Written questionnaires also constitute a problematic data-gathering method, partly because of the risk of biased selection, as well as respondents’ doubts regarding confidentiality since the honorarium is paid out afterwards.
The aim of this study is to examine the prevalence of self-reported diversion of methadone and buprenorphine in OST programs in the south of Sweden. We also investigate if demographic, treatment-related, or social factors can be linked to an increased risk of diversion. In order to assess the reliability of previous research we have used two different data-gathering methods: on-site interviews carried out by the researchers and peer interviews done by specially trained patients, so called ‘privileged access interviewing’. The hypothesis is that the peer-interviewers, by virtue of being ‘insiders’ with personal experience of both drug use and treatment, may be able to obtain more honest answers to sensitive questions.
Section snippets
Participants and recruitment
A total of 411 participants (219 on methadone and 192 on buprenorphine) were recruited from nine public and two private OST programs in five cities and towns in southern Sweden. Structured interviews were conducted between May and December of 2012. The inclusion criterion was that participants had been enrolled in OST for at least four weeks.
We utilized two different data-gathering methods: on-site interviews carried out by researchers and peer interviews done by patients. The on-site
Levels of diversion
Of the 411 patients, 24.1% (n = 99) stated that they had diverted part of their medication in the past month. Giving it away was most common (16.1%, n = 66), followed by selling (13.6%, n = 56) and trading it for other substances (3.4%, n = 14). The median extent of diversion activities (number of days in the past month) was two days for giving away and trading and four days for selling. A smaller group of patients, 8.5% (n = 35), stated that they had diverted (giving away, selling and/or trading) more
Discussion
Diversion of methadone and buprenorphine may be significantly more common than has been indicated by previous research. The levels we present for patients who have sold or shared at some point in their lives, are two to three times higher than in previous cross-sectional studies. The prevalence of current diversion (DPM) is significantly higher than the one-year prevalence rates hitherto reported. The differences become even greater when accounting for the strong interviewer effects we have
Contributors
BJ planned the original project. BJ and TR designed the study, developed the interview questionnaire and did most of the researcher interviews. BJ and TR conducted the analysis jointly. BJ wrote the first draft. Final revisions were made jointly by BJ and TR. Both authors read and approved the final manuscript.
Acknowledgements
This research was supported by FORTE, The Swedish Research Council for Health, Working Life and Welfare (grant no. 2010-1144). We wish to thank all participants in the study, as well as our peer interviewers. We also wish to thank Robert Svensson for statistical aid and Anders Håkansson, Johan Nordgren, and Frida Petersson for their close readings and suggestions for this article.
Conflict of interest
We wish to confirm that there are no known conflicts of interest associated with this
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