Research paperDiversion of opioid maintenance treatment medications and predictors for diversion among Finnish maintenance treatment patients
Introduction
Diversion and abuse of the medications used in opioid maintenance treatment (OMT) – methadone (MET), mono-buprenorphine (BUP) and buprenorphine-naloxone (BNX) – have been documented in countries around the world, for example in France (Auriacombe et al., 2004, Nordmann et al., 2012, Obadia et al., 2001, Roux et al., 2008a, Roux et al., 2008b, Vidal-Trecan et al., 2003), Australia (Aitken et al., 2008, Degenhardt et al., 2009, Horyniak et al., 2011, Jenkinson et al., 2005, Larance et al., 2011a, Winstock and Lea, 2010), USA (Bazazi et al., 2011, Cicero et al., 2007, Dasgupta et al., 2010, Johanson et al., 2012, Lofwall and Havens, 2012, Monte et al., 2009, Schuman-Olivier et al., 2010), Malaysia (Bruce et al., 2008, Bruce et al., 2009, Vicknasingam et al., 2010), Finland (Alho et al., 2007, Simojoki and Alho, 2013, Uosukainen et al., 2013) and Sweden (Hakansson et al., 2007, Johnson and Richert, 2014a). Diversion is defined as selling or trading, sharing or giving away of medications to others (Larance, Degenhardt, Lintzeris, Winstock, & Mattick, 2011). Unlike some more inclusive definitions, diversion in this study does not include injection of own medication or other forms of non-adherence, but is used to describe selling and/or giving away of own medication. In this paper, the term ‘abuse’ is used when referring to any substance use that is harmful to self or others.
Both diversion and abuse of OMT medications are linked to public health concerns relating to dependence, overdose and mortality, particularly when OMT medications are used together with sedatives or alcohol (Bretteville-Jensen et al., 2014, Degenhardt et al., 2008, Iwersen-Bergmann et al., 2014). Diversion of OMT medications contributes to the burden of disease and the social costs of opioid dependence, jeopardizing the reputation, outcomes and integrity of OMT (Larance et al., 2014, Mammen and Bell, 2009). It has also been associated with an increased incidence of addiction (Bell, 2010, Yokell et al., 2011). However, several studies have identified that diversion may also have benefits. For example, diverted BUP may help opioid-dependent people to decrease the illicit use of other opioids, to self-treat opioid dependence, to manage withdrawal symptoms and to reduce the level of harm associated with intravenous use (Yokell et al., 2011). Nonetheless, these benefits are likely to have more significance in countries where there is a large unmet demand for treatment. There remains therefore a need to better understand the extent of diversion and its predictors, if treatment policies and outcomes are to be improved, and public confidence in OMT is to be maintained.
Previous studies on prevalence of diversion among patients attending OMT are limited, most of them being conducted in Australia (Larance et al., 2011a, Larance et al., 2014, Winstock and Lea, 2010, Winstock et al., 2008) and the latest one in Sweden (Johnson & Richert, 2014a). Comparing different studies is not straightforward since diversion is defined differently in different studies, e.g. the more inclusive definition also covers diversion for personal use and for intravenous (IV) use. In addition, comparison of diversion potential between different medications is difficult since treatment practices vary between countries and clinics, e.g. policies regarding take-home allowances. However, some studies have focused on differences in OMT treatment policies and the extent of misuse of OMT medications by country (Bell, 2010, Dale-Perera et al., 2012, Yokell et al., 2011). The most recent of these shows that the rates of diversion and misuse differ significantly between European countries (Dale-Perera et al., 2012).
One Australian study (Larance, Degenhardt, Lintzeris, Bell, et al., 2011) found that 28% of current OMT patients had diverted (sold or given away) their medication during the past six months with no differences between medication types (MET/BUP/BNX). Two other Australian studies (Winstock and Lea, 2010, Winstock et al., 2008), which focused on diversion under supervised settings, found 15.3–24% of BUP clients and 2–4.3% of MET clients had diverted their dose during the past 12 months. In these two studies, the more inclusive definition of diversion was used and previous injection (ever) of BUP and MET was found to be significant predictor for diversion. The Swedish study reported that the prevalence of diversion (including strictly selling or giving away of medication) among Southern Swedish OMT patients was 24.1% during the past month. Risk factors for diversion were found to be BUP as OMT medication (as opposed to MET), concurrent illicit drug use, social interactions with other drug users and previous trading of drugs with OMT patients. When peer interviewers were used as opposed to professional interviewers, more diversion was reported (Johnson & Richert, 2014a).
Motivations for diversion (including IV use of own medication) have been found to include stockpiling medication for later use, discarding medication, giving it to another person or helping a friend in withdrawal, selling, or injecting (Larance et al., 2011a, Winstock et al., 2009). When referring to diversion strictly as selling or giving away of medication, the following motivations have been described: helping a friend or a partner, need for money, not needing the entire dose, and cutting down the dose (Johnson & Richert, 2014b). Unsupervised dosing and low availability of heroin have also been assumed to be associated with diversion (Bell, 2010). In addition, if there is an unmet demand for treatment, there will inevitably be more street demand for illicit opioids (Bell, 2010, Yokell et al., 2011).
BUP is the most widely abused opioid in Finland and it has almost completely replaced heroine on the illegal market. In 2012, BUP was the main reason for seeking treatment for 32% of all clients with substance use disorders (Varjonen, Tanhua, & Forsell, 2014). The majority (88%) of those who reported BUP as their primary drug of abuse reported using BUP mainly IV (Varjonen et al., 2014). Among needle exchange program participants in the Helsinki metropolitan area BUP was the most frequently used illicit drug (77%) in 2010 (Simojoki & Alho, 2013). BUP abuse can also be reflected through drug-related fatalities: BUP was the most common finding in drug-related deaths and caused 46 fatal poisonings in Finland in 2010. In poisonings, BUP has typically been used IV or by snorting, and taken together with alcohol and benzodiazepines (Vuori, Ojanperä, Launiainen, Nokua, & Ojansivu, 2012). Abused BUP in Finland is mainly smuggled from abroad (e.g. France, Belgium, Germany, Sweden) according to the latest seizure statistics (Varjonen et al., 2014).
Due to concerns about BUP abuse, BNX (Suboxone®, Reckit-Benckiser) was introduced in Finland in 2004. In 2008 BUP (Subutex®, Reckit-Benckiser) was withdrawn and placed under special licence (pregnancy only). Since then, only MET and BNX have been used as primary drugs in OMT in Finland. Despite its presumably lower abuse potential, BNX abuse has been documented (Simojoki & Alho, 2013) and its abuse can also be seen in fatal poisonings. In Finland, between 2010 and 2011, the proportion of parenteral BNX use among BUP-related drug fatalities was 12.4% compared to 18.6% for parenteral BUP use (Hakkinen, Heikman, & Ojanpera, 2013). However, the extent to which BNX is diverted from OMT into the street market is unclear.
Both pharmacological and restriction efforts have been made in order to deter the IV abuse of OMT medications. A BNX combination product was developed in order to inhibit the IV abuse of buprenorphine and it was hoped that this would prevent diversion. However, several studies have shown that BNX is also diverted (Alho et al., 2007, Bruce et al., 2009, Degenhardt et al., 2009, Larance et al., 2011a). Another formulation, BNX soluble film, has been developed in order to further prevent diversion. So far only a few studies have looked into the diversion and abuse of this formulation among OMT patients (Larance et al., 2014, Lavonas et al., 2014). These have reported diversion of BNX film, although to a lesser extent than for other OMT medications.
In Finland, provision of OMT is highly regulated. According to Finnish clinical guidelines, take-home allowances of OMT medications are only granted to stable and motivated patients. MET and BUP are mostly dispensed by addiction treatment units and take-home doses of MET are often diluted with water to discourage injecting. Pharmacy distribution of BNX is possible, though it is restricted to stable patients who agree to sign a contract compelling them to collect their BNX from one pharmacy only. However, practices relating to supervision and dispensing of OMT medications vary between different regions and treatment units. At the end of 2011, a total of 2439 patients were receiving OMT. The most commonly used medication was BNX tablet (58%) followed by oral liquid MET (38%) and BUP (4%). The majority (66%) of patients received rehabilitative OMT and collected their medication at the treatment unit, while 7% of patients received their BNX unsupervised from a pharmacy (Partanen, Vorma, Alho, & Leppo, 2014).
Previous studies on diversion have had relatively small samples of OMT patients as compared to the total population of OMT patients in each country. Also, there are very few studies focusing strictly on predictors for selling or giving away of own OMT medication during treatment. As motivations behind IV use of own medication (‘non-adherence’) and selling or giving away of medications (‘diversion’) can be different, we propose assessment of predictors for these behaviours separately. Hence, in this paper, the focus is on prevalence of diversion of OMT medications and the predictors associated with it among Finnish OMT patients.
Section snippets
Study sample and data collection
The study was conducted by the University of Helsinki and the National Institute for Health and Welfare (THL) between May and July 2013. A questionnaire consisting of 18 multiple-choice and 4 free text questions (for supplementary material, please see Appendix S1) was distributed to all treatment units providing OMT in Finland, excluding prisons. A list of units and the number of their OMT patients was obtained from the THL registry.
A total of 2512 questionnaires were sent to treatment units,
Results
Completed surveys were received from 1508 patients, with a response rate of 60% calculated on the basis of the number of sent forms (2512). Of all the units included in the survey (206), 83% (170) participated in the study and a satisfactory regional coverage was reached. Of all the participating units, three units returned questionnaires with missing data (nine patients), two units did not have patients at that moment and one unit no longer existed. Compared to the total number of OMT patients
Discussion
This paper is the first published report on the prevalence of self-reported OMT medication diversion conducted with a target group of all OMT patients within one country, Finland. This is also one of the few studies to date to explore the predictors associated with selling and giving away of own OMT medication to others among clients attending OMT. We found that the rate of self-reported diversion was low, with only 7% of respondents reporting selling their OMT medication during the last six
Role of funding source
Funding for this study was provided through University of Helsinki and National Institute for Health and Welfare, Finland.
Contributors
The original idea and the first draft of the study design and the questionnaire came from author Kaarlo Simojoki. The study protocol, design and questionnaire were finalized in cooperation with authors Kaarlo Simojoki, Hannu Alho and Elina Kotovirta. Author Elina Kotovirta updated the registry of the treatment units and sent out the questionnaires to the clinics and operated as a contact person. Author Essiina Launonen received and registered the completed questionnaires, managed the literature
Acknowledgements
The authors would like to address special thanks to all the OMT patients who participated and all the staff members who were involved in this study. The authors also thank Jussi Ranta from the THL for assistance in sending the questionnaires.
Conflict of interest: Hannu Alho has received travel support from Reckit-Benckiser Pharmaceuticals and given expert lectures paid by Reckit-Benckiser pharmaceuticals.
Kaarlo Simojoki has provided medical expert services to Reckitt Benckiser Pharmaceuticals
References (47)
- et al.
Abuse liability of buprenorphine-naloxone tablets in untreated IV drug users
Drug and Alcohol Dependence
(2007) Self-report among injecting drug users: A review
Drug and Alcohol Dependence
(1998)- et al.
Parenteral buprenorphine-naloxone abuse is a major cause of fatal buprenorphine-related poisoning
Forensic Science International
(2013) - et al.
The prevalence and correlates of buprenorphine inhalation amongst opioid substitution treatment (OST) clients in Australia
International Journal of Drug Policy
(2011) - et al.
Diversion and abuse of buprenorphine: Findings from national surveys of treatment patients and physicians
Drug and Alcohol Dependence
(2012) - et al.
Post-marketing surveillance of buprenorphine-naloxone in Australia: Diversion, injection and adherence with supervised dosing
Drug and Alcohol Dependence
(2011) - et al.
The diversion and injection of a buprenorphine-naloxone soluble film formulation
Drug and Alcohol Dependence
(2014) - et al.
Inability to access buprenorphine treatment as a risk factor for using diverted buprenorphine
Drug and Alcohol Dependence
(2012) - et al.
Buprenorphine in primary care: Risk factors for treatment injection and implications for clinical management
Drug and Alcohol Dependence
(2008) - et al.
Buprenorphine sniffing as a response to inadequate care in substituted patients: Results from the Subazur survey in south-eastern France
Addictive Behaviors
(2008)
Self-treatment: Illicit buprenorphine use by opioid-dependent treatment seekers
Journal of Substance Abuse Treatment
Twelve-year trend in treatment seeking for buprenorphine abuse in Finland
Drug and Alcohol Dependence
Injection of buprenorphine and buprenorphine/naloxone tablets in Malaysia
Drug and Alcohol Dependence
Intravenous use of prescribed sublingual buprenorphine tablets by drug users receiving maintenance therapy in France
Drug and Alcohol Dependence
Prevalence of diversion and injection of methadone and buprenorphine among clients receiving opioid treatment at community pharmacies in New South Wales, Australia
International Journal of Drug Policy
Buprenorphine injection in Melbourne, Australia – An update
Drug and Alcohol Review
French field experience with buprenorphine
American Journal on Addictions
Illicit use of buprenorphine/naloxone among injecting and noninjecting opioid users
Journal of Addiction Medicine
The global diversion of pharmaceutical drugs: Opiate treatment and the diversion of pharmaceutical opiates: A clinician's perspective
Addiction
Illicit use of opioid substitution drugs: Prevalence, user characteristics, and the association with non-fatal overdoses
Drug and Alcohol Dependence
Case series of buprenorphine injectors in Kuala Lumpur, Malaysia
American Journal of Drug and Alcohol Abuse
Lack of reduction in buprenorphine injection after introduction of co-formulated buprenorphine/naloxone to the Malaysian market
American Journal of Drug and Alcohol Abuse
Use and misuse of buprenorphine in the management of opioid addiction
Journal of Opioid Management
Cited by (22)
Patterns, contexts, and motivations for polysubstance use among people who inject drugs in non-urban settings in the U.S. Northeast
2020, International Journal of Drug PolicyOpioid-related deaths and previous care for drug use and pain relief in Sweden
2019, Drug and Alcohol DependenceHigh buprenorphine-related mortality is persistent in Finland
2018, Forensic Science InternationalCitation Excerpt :Since the introduction of BNX it has become evident that both sublingual formulations, BPN and BNX, are abused intravenously, although the latter to a lesser extent [21–23]. In addition, BPN and BNX are also subject to considerable diversion and trafficking [24–26]. Until recently, it has not been possible to differentiate between BPN and BNX abuse by laboratory analysis.
Are patients’ pejorative representations of buprenorphine associated with their level of addiction and of misuse?
2018, Drug and Alcohol Dependence