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
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.
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.
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.
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.
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.
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).
