Twelve-year trend in treatment seeking for buprenorphine abuse in Finland
Introduction
Prescription opioid abuse has become a major international public health problem (Degenhardt et al., 2008). In the United States (U.S.) prescription opioid abuse increased markedly during the last decade (Compton and Volkow, 2006, Office of Applied Studies, 2010), with 14% of the U.S. population self-reporting illicit use of prescription opioids during their lifetime (Substance Abuse and Mental Health Services Administration, 2009). The epidemic of overdose deaths and hospitalizations in the U.S. has mirrored the rapid increase in the use of opioids since the 1990s (Coben et al., 2010, Bohnert et al., 2011). Urgent action is needed to better understand and address the prescription opioid abuse problem (Yokell et al., 2011, Office of National Drug Control Policy, 2011).
The U.S. research has highlighted frequent abuse of oxycodone and hydrocodone (Cicero et al., 2005, Cicero et al., 2007). However, abuse of other prescription opioids including buprenorphine is also common, particularly in Europe and Asia (Yokell et al., 2011). Abuse of high-dose buprenorphine products (i.e., those for opioid substitution treatment) is also increasing in the U.S. (Johanson et al., 2012). Buprenorphine is a partial agonist of μ opiate receptor with a ceiling effect in humans (Martin et al., 1976, Walsh et al., 1994). While the abuse potential was initially presumed to be low (Jasinski et al., 1978), abuse of low-dose buprenorphine products (i.e., those marketed for pain) has been reported since the 1980s (O’Connor et al., 1988, Chowdhury and Chowdhury, 1990). Low-dose buprenorphine was the most frequently abused drug among intravenous (IV) drug users in Glasgow, Scotland, between 1989 and 1990 (Lavelle et al., 1991). In New Zealand, low-dose buprenorphine was withdrawn due to misuse in 1991 (Robinson et al., 1993). More recently, high-dose buprenorphine abuse has been reported in Australia (Larance et al., 2011b), Malaysia (Bruce et al., 2009), Sweden (Hakansson et al., 2007), Georgia (Otiashvili et al., 2010) and France (Vidal-Trecan et al., 2003). Low-dose buprenorphine abuse has been reported in some South Asian countries (Larance et al., 2011a). Studies have shown that buprenorphine abuse is especially common among clients receiving opioid substitution treatment (Vidal-Trecan et al., 2003, Moratti et al., 2010), but it is not restricted to these clients (Hakansson et al., 2007, Vicknasingam et al., 2010).
The availability and abuse of illicit drugs increased in Finland from the early 1990s (Hakkarainen and Tigerstedt, 2005). As a countermeasure, official opioid substitution treatment programs commenced with buprenorphine (Subutex) and methadone in 1997. Low-dose buprenorphine for pain was marketed prior to this time. The estimated number of problem drug users in Finland increased from 11,500–16,400 in 1998 (Partanen et al., 2000) to 14,500–19,000 in 2005 (Partanen et al., 2007). Seventy to 80% of problem drug users abused illicitly manufactured amphetamine and the remainder abused opioids (Partanen et al., 2007).
Reports of high-dose buprenorphine abuse in Finland date back to the late 1990s and coincide with the initiation of opioid substitution treatment (Partanen et al., 2004). Among 500 clients of needle exchange services in Finland's three largest cities between 2000 and 2002, 59% of clients had used buprenorphine intravenously in the previous month (Partanen et al., 2004). One third used buprenorphine on a daily basis. Buprenorphine was the most frequently used IV drug among IV drug users attending a needle exchange program in Helsinki (Alho et al., 2007). Buprenorphine abuse was the main reason for treatment seeking in 33% of all clients with substance use disorders in Finland in 2009 (Forsell et al., 2010). Buprenorphine findings in forensic post-mortem investigations have increased from less than 10 cases in 2000 to 104 cases in 2008 (Forsell et al., 2010). The buprenorphine/naloxone combination product (Suboxone) was first marketed in Finland in 2006. Since December 2007 it has been the only high-dose formulation of buprenorphine with marketing approval. Single ingredient buprenorphine (Subutex) was withdrawn in 2007 due to concerns about misuse.
Previous studies on the characteristics of buprenorphine users have had small sample sizes, been cross-sectional or had short follow-up periods (Basu et al., 2000, Winslow et al., 2006, Otiashvili et al., 2010, Vicknasingam et al., 2010, Aich et al., 2010, Schuman-Olivier et al., 2010, Bazazi et al., 2011), or concentrated on opioid substitution treatment clients (Vidal-Trecan et al., 2003, Roux et al., 2008, Moratti et al., 2010). The characteristics of prescription opioid users compared to heroin users have been studied (Sigmon, 2006, Fischer et al., 2008, Nielsen et al., 2011, Subramaniam and Stitzer, 2009, Wu et al., 2011). However, studies on the characteristics of buprenorphine users, changes in these characteristics over time, and in comparison to other drug users are lacking. These unanswered questions are important for both clinicians and policy makers.
The objective of this study was to examine the trend in characteristics of clients seeking treatment for buprenorphine abuse and compare them to those seeking treatment for heroin and amphetamine abuse.
Section snippets
Study context and sample
Data were collected at the Helsinki Deaconess Institute (HDI), a large public utility foundation that provides inpatient and outpatient treatment services for persons with alcohol and other substance abuse disorders. The HDI provides services to clients from the greater Helsinki metropolitan area, including Espoo, Vantaa and eight other nearby municipalities (overall population 1.3 million people). The majority of Finnish illicit drug users live in this area (Partanen et al., 2007). Clients of
Trends in treatment-seeking between 1997 and 2008
A total of 780 clients sought treatment for buprenorphine abuse from 1997 to 2008. The annual proportion of buprenorphine clients increased sharply in 2000, peaked in 2004 and again in 2008 (31.6% and 37.6% of all initial client visits; Fig. 1). Since 2002, buprenorphine clients have constituted half of all opioid users (range: 49.3% in 2006, 60.3% in 2008). A total of 598 clients who sought treatment from the HDI from 1997–2008 used heroin as their primary drug. Heroin was the most commonly
Discussion
To our knowledge, this is the first large-scale long-term study to examine the characteristics of clients seeking treatment for buprenorphine abuse compared to those seeking treatment for heroin and amphetamine abuse. The proportion of clients abusing buprenorphine increased from 1997 to 2008. It was also found out that concurrent substance abuse increased during the study period. Buprenorphine clients had more risky abuse patterns in terms of IV administration, daily abuse and concurrent
Conclusion
Treatment seeking for buprenorphine abuse has increased in Finland to the extent it has almost replaced treatment seeking for heroin abuse. Daily abuse and intravenous administration were common among buprenorphine clients from 1997 to 2008. Concurrent substance abuse increased among buprenorphine clients during the study period. Buprenorphine clients were more likely to be daily users, administer drugs of abuse intravenously and report concurrent prescription medication abuse than heroin and
Role of funding source
Funding for this study was provided by the Academy of Finland Grant 118584 and the Graduate School in Pharmaceutical Research in Finland, who had no involvement in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.
Contributors
HU, JK and JSB were involved in study design and protocol development. JF and MP were involved in data collection. HU managed the literature searches, conducted the statistical analyses and wrote the first draft of manuscript. JSB provided detailed feedback on the manuscript. All authors contributed to and have approved the final manuscript.
Conflict of interest
HU has received unrelated grant funding from Lundbeck Ltd. All other authors declare that they have no conflicts of interest relevant to the contents of the manuscript.
Acknowledgements
The authors would like to thank Kimmo Ronkainen, MSc, for assistance with data management and Jenni Ilomäki, PhD, and Ulrich Tacke, docent, for their contribution to the study. The study was supported by grants from the Academy of Finland and the Graduate School in Pharmaceutical Research in Finland. We are thankful to all the HDI staff members for their participation.
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