Twelve-year trend in treatment seeking for buprenorphine abuse in Finland.
Uosukainen H, Kauhanen J, Voutilainen S, Föhr J, Paasolainen M, Tiihonen J, Laitinen K, Onyeka IN, Bell JS.
PMID: 22835477
This is a descriptive study of people seeking treatment in Helsinki from 1997 to 2008. There were 4817 total clients including 780 patients who reported that buprenorphine was their primary drug of abuse. They were compared to the 598 who's primary drug of abuse was heroin and the 1249 who's primary drug was amphetamine. (That add's up to 2627 it is unstated what the primary drug for the remaining 2190 patients was).
Buprenorphine abuse appears to gradually supplant heroin. The annual proportion of buprenorphine clients increased from 3% in 1998 to 38% in 2008. Since 2002, buprenorphine clients were half of all opioid users. Treatment seeking for heroin abuse almost ceased after 2000–2002. This may be explained by the authors comment "The availability of heroin in the Finnish drug markets has been exiguous [very small] since 2001".
It is unclear how these buprenorphine users began their careers. Were they heroin users who switched due to market forces, or has buprenorphine become a "gateway drug"? The authors cite another study stating "some buprenorphine users started their IV drug abuse with buprenorphine" but I could not find the original citation.
Concurrent alcohol abuse in these buprenorphine abuses doubled from 25.5% in 1997–2000
to 54.9% in 2007–2008.
The authors describe the fascinating recent history of opiates in Finland.
The availability and abuse of illicit drugs increased in Finland from the early 1990s. 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 to 14,500–19,000 in 2005. Seventy to 80% of problem drug users abused illicitly manufactured amphetamine and the remainder abused opioids.
Reports of high-dose buprenorphine abuse in Finland date back to the late 1990s and coincide with the initiation of opioid substitution treatment. 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. 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 Helsink. Buprenorphine abuse was the main reason for treatment seeking in 33%of all clients with substance use disorders in Finland in 2009. Buprenorphine findings in forensic post-mortem investigations have increased from less than 10 cases in 2000 to 104 cases in 2008.
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.
The authors note: "buprenorphine clients in Finland differed from prescription opioid users in other countries since they resembled “street users.” In other countries, prescription opioid users were more likely to receive a legal or higher income, use non-injection routes of administration, have physical health problems (e.g., pain) as a reason for initial opioid use" and this certainly reflects our own experience here in Seattle.
The authors do not comment as to whether Finland's switch from pure buprenorphine to buprenorphine/naloxone in 2007 has lead to any change. The combination product is intended to reduce IV use. It does appear that countries where pure buprenorphine was introduced that misuse and diversion has been a bigger problem. On the other hand, prescribing practices may play a larger role. Overall this story from Finland may be a helpful cautionary tale and encourage holding our buprenorphine patients as accountable as we are able.
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