French Field Experience with Buprenorphine

Abstract

In most European countries, methadone treatment is provided to only 20-30% of opiate abusers who need treatment due to regulations and concerns about safety. To address this need in France, all registered medical doctors since 1995 have been allowed to prescribe buprenorphine (BUP) without any special education or licensing. This led to treating approximately 65,000 patients per year with BUP, about ten times more than with more restrictive methadone policies. French physician compensation mechanisms, pharmacy services, and medical insurance funding all minimized barriers to BUP treatment. About 20% of all physicians in France are using BUP to treat about half of the estimated 150,000 problem heroin users. Daily supervised dosing by a pharmacist for the first six months resulted in significantly better treatment retention (80% vs 46%) and lower heroin use. Intravenous diversion of BUP may occur in up to 20% of BUP patients and has led to various infections and relatively rare overdoses in combination with sedatives. Opiate overdose deaths have declined substantially (by 79%) since BUP was introduced in 1995. Newborn opiate withdrawal in mothers treated with buprenorphine compared to methadone was reported to be less frequent, less severe, and of shorter duration. Although some of the public health benefits seen during the time of buprenorphine expansion in France might be contingent upon characteristics of the French health and social services system, the French model raises questions about the value of tight regulations on prescribing BUP imposed by many countries throughout the world.

Neonatal Abstinence Syndrome

“…12 Buprenorphine was approved as an alternative to methadone for opioid addiction in both Europe (1996) and the United States (2002). 13,14 The use of buprenorphine during pregnancy has also resulted in NAS. 15,16 Neonatal withdrawal secondary to the maternal use of prescription pain medications is the latest additional etiology in the history of neonatal withdrawal (Fig 1).…”

Routes of abuse of prescription opioid analgesics: a review and assessment of the potential impact of abuse-deterrent formulations

“…[52] Patches may also be boiled to make a "tea", which can be ingested or injected. [53][54][55] Available data suggest that injection is the most common route of abuse for buprenorphine, [56][57][58][59][60][61] although abuse via inhalation has also been reported. [60,[62][63][64] However, differences in routes of abuse have been reported between different buprenorphine formulations.…”

Uses of Diverted Methadone and Buprenorphine by Opioid‐Addicted Individuals in Baltimore, Maryland

“…(13,14) Once heroin supply rebounded, researchers found that diverted methadone was most often used for self-medication for withdrawal or self-detoxification rather than for its euphoric effects. (15,16) In recent years, the widespread availability of buprenorphine treatment through primary care physicians in France was found to be associated with a significant decrease in heroin-overdose deaths, crime, and HIV transmission, (17) yet its availability as a source of treatment has also led to some buprenorphine diversion and misuse by injection, and to some overdose deaths when injected with benzodiazepines. (17,18,19) Other recent reports indicate that buprenorphine from France and other western European countries is being diverted to Georgia, a country in which buprenorphine is not legally available, where it has contributed to rising levels of injection drug abuse.…”

“…(15,16) In recent years, the widespread availability of buprenorphine treatment through primary care physicians in France was found to be associated with a significant decrease in heroin-overdose deaths, crime, and HIV transmission, (17) yet its availability as a source of treatment has also led to some buprenorphine diversion and misuse by injection, and to some overdose deaths when injected with benzodiazepines. (17,18,19) Other recent reports indicate that buprenorphine from France and other western European countries is being diverted to Georgia, a country in which buprenorphine is not legally available, where it has contributed to rising levels of injection drug abuse. (20) Buprenorphine has also been identified as a drug of abuse for polydrug injectors in Finland, (21) Australia, (22) Singapore and Malaysia, (23) and India.…”