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Buprenorphine Abuse Among Opiate Addicts

British Journal of Addiction (1988) 83, 1085-1087

JOHN J. O'CONNOR, M.B., M.R.C.Psych., EAMONN MOLONEY, M.B.,RAYMOND TRAVERS, M.B. & AISLING CAMPBELL, M.B.

National Drug Advisory & Treatment Centre, The Charitable Infirmary, Jervis Street, Dublin 1, Ireland

Summary

Buprenorphine has been described as a potent analgesic with low abuse potential. Sporadic reports in the world literature would seem to contradict this view. A retrospective study of all opiate addicts first presenting over a 12-month period showed an increasing level of buprenorphine abuse. The implications of these findings are discussed.

Introduction

The search for an effective analgesic without dependence-producing properties has continued for many years. Morphine and other opiates have proven to be potent analgesics; however their abuse by the addict population, and the occasional development of 'therapeutic addiction' has limited long term use and widespread prescribing of these drugs.

Buprenorphine (Temgesic), introduced to Ireland in 1980, seemed to satisfy the criteria for a potent non-addictive analgesic, being 25-40 times as potent as morphine on a dose-for-dose basis1, having a milder euphoriant effect and minimal withdrawal symptoms. Jasinski et al. (1978)2 stated that buprenorphine had "obvious therapeutic applications as an analgesic of low abuse potential"

The following analysis of opiate addicts attending the National Drug Advisory & Treatment Centre (NDTAC) challenges this view, and confirms suspicions previously raised in the world literature, that buprenorphine is indeed a drug of abuse.

Few reports of buprenorphine abuse have appeared in the world literature over the last 4 years. The first indication of its abuse came from New Zealand in 19833 where both general practitioners and pharmacists highlighted an increasing demand for the drug.

Figure 1

Temgesic abusers as % of all opiate addicts first presenting to the National Drugs Advisory & Treatment Centre 1st September 1986-31st August 1987.

Their suspicions were confirmed in 19864, by reports from drug dependence treatment centers, that 50% of 'hardcore' drug addicts were using buprenorphine. A detailed case report from Australia in 19845 showed that buprenorphine ampoules "can induce a state of physical dependence which leads to drug seeking behaviour even though the withdrawal syndrome is mild". Concern with the misuse of the injectable form of buprenorphine led to its being restricted to hospital pharmacies in 19846.

In Germany7 three cases of buprenorphine dependence were reported among patients being treated for moderate to severe pain. These patients had on previous history of opiate addiction. Widespread abuse of buprenorphine has been reported in Scotland8. Indeed, in Edinburgh it has been described as the 'drug of choice'9. Intravenous use of the crushed tablet form has also been reported in Manchester in 198610 and more recently in Edinburgh11.

Method

A retrospective survey was carried out of all opiate addicts first presenting at the National Drug Advisory & Treatment Centre between 1st September 1986 and 31st August 1987. General demographic details and drug history were reviewed.

Discussion

Buprenorphine (Temgesic) was first introduced to Ireland in 1980 and the first case of its abuse presented to the National Drug Advisory & Treatment Centre in February 1986. It is clear from the results of this study that buprenorphine is now established as a major drug of abuse among Dublin's opiate addicts and that its abuse is becoming increasingly common. This contradicts earlier claims that buprenorphine has a low abuse potential.

The main object of this study was to establish the extent of buprenorphine abuse among opiate addicts. The study relied on self-reporting by addicts of drugs abused-this method of data collection has been shown to be reliable12. It is clear that buprenorphine is only one of a number of powerful analgesic drugs abused, mainly intravenously. Because of its relatively recent introduction, it is not surprising that the average length of abuse is only 11 months.

In Dublin, buprenorphine tablets are sold on the illicit drug market for between IR£3 and IR£5 each. They are crushed and either taken sublingually, snorted or more frequently dissolved and injected intravenously. Buprenorphine is rarely the preferred drug but is used to prevent withdrawal symptoms when heroin is unavailable. The decreased street availability of heroin may be a reason for the dramatic increase in buprenorphine abuse13.

Up to July 1st, 1987, buprenorphine could be obtained without a prescription in Ireland14. This, in addition to complacency regarding its abuse potential, led to increased prescribing by General Practitioners and hospitals. Being aware of its abuse, most pharmacists refused to dispense the drug without a prescription; only a small proportion actually did so. This ensured a steady source of supply which rapidly became known to Dublin's addict population.

Over the past 6 months, there are increasing reports from General Practitioners of young patients presenting to their surgeries seeking buprenorphine as the only effective analgesic for dubious physical complaints. Forged prescriptions and pharmacy break-ins are another source of supply.

On the black market, a heroin habit of 0.5g per day (purity 10-15%) is satisfied by 8-10 buprenorphine 0.2mg tablets. The former casts IR£80 and the latter IR£24 to IR£50 per day one obvious reason for the increased popularity of buprenorphine, particularly among the younger, unemployment addict.

Addicts report a less intense euphoriant effect with buprenorphine as compared with heroin but this can be accentuated by the concurrent use of cyclizine. However, its cheaper price and easier availability would probably explain its widespread abuse.

The findings of this study have major implications for the prescribing of buprenorphine and this drug has been recently become a prescription-only medicine in Ireland (Misuse of Drugs (Amendment) Regulations-Schedule 2) 15. It is important that clinicians recognize its abuse potential.

It is remarkable that more widespread buprenorphine abuse has not been reported in other countries. There is obviously a need for further research into the extent of buprenorphine abuse in other addict populations. Pharmacological studies of the drug should be reviewed in the light of these statistics. It is clear that regardless of its 'unique pharmacological properties', this is a drug high abuse potential.

References


1.COWAN, A, LEWIS, J.W. & MAC FARLANE, I. R. (1977) Agonist and antagonist properties of buprenorphine, a new antinocioceptive agent, British Journal of Pharmacology, 60, pp. 573-575
2.JASINSKI, D. R., PEVNICK, J. S. & GRIFFITH, J. D. (1978) Human pharmacology and abuse potential of the analgesic byprenorphine, Archives of General Phsychiatry, 35, pp.501-516.
3.HARPER, I. (1983) Temgesic abuse, New Zeland Medical Journal, 96, p. 777.
4.RAINEY, H.B. (1986) Abuse of buprenorphine, New Zeland Medical Journal, 99, p. 72.
5.QUIGLEY, A. J., BREDEMEYER, D. E. & SEOW, S. S. (1984) A case of buprenorphine abuse, Medical Journal of Australia, 140, pp. 425-426.
6.CURRAN, A. C. W. (1984) Temgesic restricted to hospitals, The Medical Journal of Australia, 140, p.246.
7.RICHERT, S., STRAUSS, A., VON ARNIM, T.,VOGEL, P., ZECH, A. (1983) Medikamentenabhangigkeit von Buprenorphine, Munchener Medizinische Wochenschrift, 125, pp. 1195-1198.
8.ROBERTSON, J.R. (1987) Heroin, AIDS and Society (London, Hodder & Stoughton).
9.ROBERTSON, J.R. & BUCKNALL, A. B. V. (1986) Buprenorphine: Dangerous drug or overlooked therapy, British Medical Journal, 292, p. 1465.
10.STRANG, J. (1985) Abuse of buprenorphine, Lancet, 2, p. 725.
11.ROBERTSON, J.R.,ROBERTS, J. J. K.., et al. (1987) Management of Drug Abuse, Lancet, 2, p. 284.
12.BENSON, G. & Holmberg, M.B. (1985) Validity of questionnaires in population studies on drug use, Acta Psychiatrica Scandinivica, 71, pp. 9-18.
13.GARDA SIOCHANA DRUG SQUAD, Dubline (1987) Personal Communication.
15.MISUSE OF DRUGS (AMENDMENT) REGULATIONS (1987) S.I. no. 263 of 1987, p1. 4229 (Dublin, Government Stationery Office).
9.ROBERTSON, J.R. & BUCKNALL, A. B. V. (1986) Buprenorphine: Dangerous drug or overlooked therapy, British Medical Journal, 292, p. 1465.
10.STRANG, J. (1985) Abuse of buprenorphine, Lancet, 2, p. 725.
11.ROBERTSON, J.R.,ROBERTS, J. J. K.., et al. (1987) Management of Drug Abuse, Lancet, 2, p. 284.
12.BENSON, G. & Holmberg, M.B. (1985) Validity of questionnaires in population studies on drug use, Acta Psychiatrica Scandinivica, 71, pp. 9-18.
13.GARDA SIOCHANA DRUG SQUAD, Dubline (1987) Personal Communication.
15.MISUSE OF DRUGS (AMENDMENT) REGULATIONS (1987) S.I. no. 263 of 1987, p1. 4229 (Dublin, Government Stationery Office).

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