Our Sponsors are an important foundation of our online community. Please visit their websites.
Our Associate Sponsors provide valuable support to our community and help build 'The Wall'.
Our partners help move the Wired In agenda forward.
Join our community, create your own profile page, and communicate about what matters to you.
I am doing a little research. Any input would be gratefully received. I recently attended a lecture by Marc Auriacombe, M. Fatseas MD, PhD in which he discussed his paper ‘Why Buprenorphine is so successful in treating opiate addiction in France?’ What comes across is this;
Drugs deaths in France circa 80 per annum? Drugs deaths in Scotland circa 600 per annum? France has a population 10 times the size! Why, on the face of it, does France seem to have more success with preventing drugs deaths?
It is suggested by M. Auriacombe that the success is down to treating opiate addiction primarily with buprenorphine as opposed to throwing methadone at the problem as we have done in the U.K.
I am not smart enough to work out if the the apparent success (and the figures appear astonishing) is down to buprenorphine and the manner in which patients are treated or given access to it, or do the figures look so great as a result in differing data collection methods?
Can any one help, because the conclusion I am coming to at the moment, irrefutably, is methadone is on the whole hated by those who have used it. And is implicated in a huge amount of drugs deaths ( more than heroin was in Edinburgh last year). Am I right?
If so should we move away from methadone to buprenorphine as our primary substitute to street sold opiates? (This may start a RIOTT, excuse the pun, but I do not wish to get into prescribing heroin as a substitute, not in this conversation. However, I doff my cap to it as a part of the recovery system on the whole.
Methadone definitely has a crucial role to play in treating opiate addiction today, however are we so entrenched in methadone prescription historically, regardless to the feelings of users and ex users that we are failing to make other substitutes (your suggestions welcome) more widely and prominently available?
What happens if we stop prescribing methadone as a matter of course (not entirely of course)? Would drugs death go down in the UK? Up? Stay the same?
Would you please give me your views, I am really interested in service users and practitioners opinions. Can bupronorphine hold an opiate addict from his or her drug of choice?
At the moment I am of the view that an increased prescribing/GP accessibility to buprenorphine, coupled with a reduction in new methadone prescriptions in the majority of circumstances, really may lower drugs deaths in the long run.
Thank you so much for taking the time to read this, your feed back will be valued. Lets hear the voice for change. Viva recovery.
Patrick
An extremely interesting question – I am as interested in the answers as you are!
And great to have a blog from you on the site!
Ditto!
This is a very pertinent question Patrick, and one that could be raised at the next National Drug Related Deaths Forum. Some analysis of the data would be useful too as apparant ‘leakage’ of buprenorphine has reduced deaths elsewhere too. I will try and find out more.
Nice theme, which really got me thinking.
I’m posing more questions than answers here I’m afraid.
In terms of measuring success of the buprenorphine programme in France, is the mortality rate from drug deaths the only gauge? How does buprenorphine do in terms of recovery outcomes?
Are the French good at drug death surveillance? Do they measure the same way that we do?
Is buprenorphine in fact the cause of any difference?
Are we comparing like with like? Is the French opiate dependent population the same as the Scottish population? Are the injecting rates the same? Are the polydrug rates the same?
Is access to treatment faster and is the penetration of treatment better in France than it is in Scotland? Do addicts move out of addiction, finishing addiction careers at an earlier age than in Scotland? Do addicts have less co-morbidity in France than in Scotland?
Are families and addicts more likely to perform resuscitation and call emergency services in France?
Do social context, community, affluence and less stigma have protective effects in France because these things are more robust there?
I guess what I’m saying is that it is complex and while there may well be protective effects from using buprenorphine (it makes sense on paper at least), there might be other factors at play.
Pucker blog, I can only give you my limited knowledge and experience, detox from herion is usually 3 weeks in a supervised enviroment, down my way in London buprenorphine is not used in general.
As it can be abused by users, crushed up and injected. I myself use Temgesic 200 microgram Buprenorphine Sublinual tablets for my back pain. Dissolved under the tongue.
I have not heard of anyone being presribed it as an alternative, Subotex is the norm this way for subsetute.
In general detoxing is safe, although unpleasant yet far safer than alcoholics detoxing.
I hope others will try and not challange this or be judgemental on my comment, it is only what I have seen, been and witnessed.
Hope this is of use?
Buprenorphine is effective to a degree when an addict is trying to achieve stabilisation, it is only effective when the recovering addict has lowered their opiate use, subutex is usually an option given when an addict reduces to a dose of 30 ml of methadone and the transition can still be uncomfortable, buprenorphine does not bond well with other opiates i.e heroin so there are limits on how one could use on top of this medication, though subutex contains no opiate antagonistic unlike suboxone, subutex as Martain rightly says can be abused by injecting or snorting (snorting happened a lot in jails i’ve frequented) they can also be mixed with cyclizene to give you a poor mans diconal, probably loosing you now sorry, my point is you’ll take what your given when your being prescribed and it’s down to the addicts choice if they progress or regress with their medication, any form of treatment can be positive or negative for the addict and this depends on the addicts mindset which can be ever changable, as for the statistics, they tend to paint the required government picture, i would’nt take much heed by them and who can trust the french (joke)
I think this may be of use to those interested
From parlimentry questions at Scottish GOV
S3W-23936 – Richard Simpson (Mid Scotland and Fife) (Lab) (Date Lodged Wednesday, May 13, 2009): To ask the Scottish Executive what guidance it has issued on the use of burprenorphine or suboxine in the treatment of heroin addiction as part of choice in management and recovery for addicts.
Answered by Fergus Ewing (Tuesday, May 26, 2009): The Drug Misuse and Dependence: UK Guidelines on Clinical Management (sometimes known as the Orange Book) provide guidelines for clinicians on the treatment of drug misuse. This includes information on pharmacological interventions including buprenorphine and Suboxone®.
The Scottish Government strongly supports these guidelines as stated in the drug strategy – The Road to Recovery.
A copy of the guidelines can be found at:
http://www.scotland.gov.uk/Publications/2007/09/drug-clinical-guidelines.
S3W-23937 – Richard Simpson (Mid Scotland and Fife) (Lab) (Date Lodged Wednesday, May 13, 2009): To ask the Scottish Executive whether the variation in prescribing burprenorphine or suboxine across NHS boards reflects patient choice or NHS board choice.
Answered by Fergus Ewing (Thursday, May 28, 2009):
The decision on what drugs to prescribe for opiate addiction is taken by clinicians in consultation with their patient.
I am not sure the numbers who are using suboxone in each health board area…. but i think if i remember correctly across Scotland its about 2% .
I am also not sure if it is available to users if they do indeed Know that they can request it as an alternative to methadone in each health board area either?
great and timely blog Patrick!
whoops fergus respose above ends with the line “The decision on what drugs to prescribe for opiate addiction is taken by clinicians in consultation with their patient.”
questions after that mine!
Dear Patrick,
My French connections say you should take Marc Fatseas and buprenorphine (alias Subutex) with a very large pinch of salt.
At roughly the same time and for the same reasons that the UK government were persuaded by psycho-pharm advisers to introduce methadone here, the same international vested interests persuaded the French to use buprenorhine.
The miserable “success” of both these addictive “substitutes for heroin” has been very similar (i.e. less than 3% recovery over three years – see Professor Neil McKeganey’s Glasgow University investigation which has been confirmed by the NTA).
As a result, in the same way as methadone is falling out of favour here, buprenorphine is falling out of favour in France, and I am reliably informed that their psycho-pharm advisers are now therefore recommending methadone as having proved successful in the UK, and thus a good alternative to buprenorphine !
The other side of that coin is Monsieur Fatseas now peddling in the U.K. the idea that buprenorphine has been successful in France, and so should be used here !
Psycho-pharms from many countries are notorious for using international “scientific lecturers” to scratch each other’s backs in order to protect their various national turnovers and profits. (Try and get hold of reports from the former editor of the British Medical Journal).
Trust this helps.
Kenneth Eckersley,
C.E.O. Addiction Rcovery training Services.
Thank you all so much please don’t stop here as we seem to be getting somewhere..I really am so grateful, I do not know the answers.. you people do.. So I will purposefully try to agitate more reaction in saying the below. Please remember this is not out of disrespect to any one. I would love a timulated debate here.
One question raised by Martin is very valid ( he asked the most too, thanks Martin, you just gave me a lot more food for thought !).. in asking…‘Is access to treatment faster and is the penetration of treatment better in France than it is in Scotland? ‘
The short answer I believe is yes, as Buprenorhine is prescribed by GP’s directly on a much wider scale in France than in the UK and Methadone has [historically] more restrictions on it’s availability in France. This not only increases the likelihood of a user being offered Buprenorphine ( at first point of contact) but it also increases the likelihood of a continued level of engagement with services, as the patient has to delve deeper into tiers of treatment to recieve a methadone substitute than he or she does for Buprenorphine. This could be evidenced by the fact that we know opiate addicts lives are more than often unmanageable so they fail to make appointments on referral to 2nd tier drug specialists so may be more likely to turn back to the street without even trying Buprenorphine.
As an accidental consequence I am of the view that this ( overall) reduced level of prescribed Methadone will also result in less diversion.
Now, keeping a user engaged in services is a key, and first tier prescription of methadone without drug referral is unrealistic. As we are aware a more consistent and continued level of engagement is a key to recovery, even if the first course of treatment does not lead to abstinence or recovery it is evidenced as having an accumalitive affect. So to answer it is more accesable and I believe as a result methadone is diverted less. Buprenorphine is not the killer that methadone is and thus its diversion is less lethal.
Tony A also raises a valid point in stating ‘it is only effective when the recovering addict has lowered their opiate use, subutex is usually an option given when an addict reduces to a dose of 30 ml of methadone and the transition can still be uncomfortable’….
this is generally the view and I did state it [bpn] may not hold the opiate addict.. but come on.. still uncomfortable.!!. of course it is uncomfortable, breaking any addiction is uncomfortable.. One thing I hear on a wekly basis is coming off Methadone is harder than coming off Heroin..and both can be done ( relatively) safely cold turkey.. a wonder drug that makes it comfortable is not forthcoming, if it was easy or more comortable we would not be having this discussion.
In any event. How about this for a controversial thought? And I intend to be so to stimulate a response.. ‘I am not of the view it would be entirley helpful to make it ‘ nice and comfortable’ to recover from addiction. It could become be all to easy to rely on the remedy time and again and all to easy to forget the hard work put in to come off the drug in the first place ( which is a deterrent to relapse) as those clean may say “hey it was easy…” so what if I relapse. I will take wonder drug 123 again “.
If one argues people will not use Buprenorphine because it is uncomfortable shall we just keep them comfortable and dying in droves on methadone or be more patient specific and limit methadone prescriptions to those it will help INTO RECOVERY.. ie lets not throw Methadone at the problem, people are different and this should be reflected by the range of availability, accessability and education given to the medical frontline..
Its the engagement that is the key.. if a GP can ( be aware of ) and is tested to prescribe the less diverted and less dangerous Bupronorphine are we not making head way..people do not OD on buprenorphine as much, injecting is a problem but no where near as large a cause of drugs deaths as those caused by Methadone.. lets get real.. Methadone works but its hard to support an argument that it should be any more than a last ditch life saver.
We are all very (and quite rightly) repectful of one anothers opinions in this debate.. but I do get the feeling some of you are not really letting go with what you really think.. come on this could be great.. can any one change my mind from Marc Auriacombes conclusions… I am quite humble show me why we should maintain the status quo? what is the answer.. the comfortable argument does’nt cut it and certainly won’t touch the non using population who vote in our decision makers.. To deny politics plays a role would be folly.. does that mean we just keep doing this to 600 people a year? I think not. We need to present a cogent palatable argument for an alternative to this widely ( but not universally) disliked situation.
May be its just me that thinks Methadone kills, is hated by most of those maintained on it. This is what I hear? Are those abstinent around me giving me the wrong end of the stick.. one thing I will stand by is this.. when a supposed alleged cure ( methadone) lasts longer than the originally addiction ( opiates)..it is usually not really a cure at all………..its an excuse for ambivelance..
Patrick
and thank you Michaela, Peapod, Dougie and especially Annemarie..You have hit the nail on the head… I am currently formulating a body of seperate research with a team of service users targeting the question ….what do patients want at first point of contact.. We are questioning patients directly
We hope to have many structured,valid and monitored detailed responses with the help of the NHS body involved…
I have little doubt at all ( as I ask my peers regularly ) that most will not even know what suboxone really is…how are we supposed to involve patient choice when the choice of available treatments are not put at eyeline on the ( metaphorical ) supermarket shelf! Thank you for your exteremly interesting report above..I agree with your sentiment entirely…
The discomfort is in the fact of BPN’s limited effect to stave off withdrawal from opiates, this discomfort only lasts whilst you adjust to BPN, i personally don’t see being prescribed as attaining recovery, just another drug in the mix, the majority of addicts see methadone as breakfast then they go in search of their substance of choice, the value in BPN is that for some reason it interferes with the effectiveness of opiates, so the addict is more prone to only use the BPN for that problem (opiates), the addict usually adds something else in to the mix for better suppression i.e alcohol, benzo’s, not much recovery going on there then is there?
So i wonder what the figures are like for alcohol and other problems related to BPN, the fact is that if an addict is motivated to recover then it is of no importance what medication you prescribe for they will reduce and come off substances because they’ve chose to change no matter the discomfort, also in the irrationality of addiction and sometimes in the irrationality of recovery withdrawal is the least motivating event to stay clean for it’s horror is soon forgotten and the memories of the good old days come flooding back, most people in active addiction are poly substance abusers so BPN has a limited effect for one drug, an addict requires an individual plan to facilitate their needs for recovery, BPN could be in this plan at an appropriate point, i believe substance of choice being prescribed is the way forward to recovery and ongoing choices about reduction/detoxification to be agreed with the recovering addict, this would remove the need for illicit drug use and all concerned would know what cards they are playing with, but that’s another discussion, a good thought provoking blog.
As peapod said above, comparing mortality rates across countries is fraught with difficulties. There is always a tendency to look for simple answers, e.g. its all about methadone/buprenorphine but these are very complex issues and there is rarely a simple answer. There are studies comparing outcomes, including mortality, for methadone and buprenorphine which show one or other drug to be superior and others that show no statistically significant difference. It is also the case that, on the face of it, buprenorphine is more expensive than methadone, though costs benefit analyses show they are roughly the same. The NICE guidance, which summarises studies can be found here http://guidance.nice.org.uk/TA114/Guidance/Evidence
In our area, people are prescribed both drugs according to need/preference. Often a person will be on methadone and switch to buprenorphine as they reduce their dose, others are prescribed buprenorphine straight off the bat. In terms of why prescribing practice is so variable across England, in my experience clinicians (who are, after all, only human!) are pretty cautious with ‘new’ things, custom and practice exerts just as great a ‘pull’ on them as it does on the rest of us and treatment ‘norms’ can become deeply embedded and difficult to shift.
I would close by repeating what we all know deep down, which is that if the problem is complex then the solution will be too.
Nice blog! I have a few ideas that may or may not be helpful/interesting…
First, as far as seeing how practitioners decide on what, out of meth or subutex, to give people, have a look at the DoH guidelines – the ‘orange book’. It’s at http://www.nta.nhs.uk/publications/documents/clinical_guidelines_2007.pdf and outlines how all practitioners should be working.
See section 5.3.5 – explaining how to decide between meth and subs. This includes safety – risk of diversion or OD – and patient preference, among other things. I wouldn’t recommend subutex to someone who didn’t want to stop using as what I find tends to happen is they miss days when they want to use, life doesn’t stabilise out, they’re more likely to feel they’re failing and therefore drop out of treatment, remaining at more risk of OD. But if someone says they’re ready to stop then it’s great.
Also, methadone can be made a lot safer from diversion by ensuring it’s supervised enough. Obviously some people may still induce sickness and sell the results but this is pretty rare as far as I’m aware.. Where I work we have an extremely low death rate because we make sure methadone is adequately supervised in the chemist.
I think someone mentioned painful withdrawals making people less likely to start using again – I’m pretty sure some research has been done on this showing it doesn’t make a blind bit of difference, but can’t think where I saw it. It’s a logical argument but since when are people’s brains logical things? That takes quite a bit of conscious forward planning when you’re about to use a drug.
Having worked with Methadone etc for many, many yrs and Subutex since 1999. Both at various CDT, detox/stabilisation units and Rehabs, I can honesly say from experience, that Methadone has a place for those not yet ready to give up using and still need to search for that “buzz” by using “on top”. That’s their choice and journey. However, I was consistantly convinced that when someone wanted to move towards, abstainance (however slow that may be), Subutex was the best method because it enabled users to have a clear head and become accustomed to “reality”, giving them time to adjust and as for many, it was quite frighening. They could get back to work, look after their children better etc. The detox could be as slow as necessary and we (both staff and user) felt we were working more together. In the 4 yrs at the CDT, it was almost unheard of to have a death from Methadone (other than someone obtaining it illicitly). In the whole of the area I was the manager, we had a handful of users on Methadone. Those who were, was by mutual agreement that they did not want or were ready to change. We had an enlightend consultant who saw the benefit of subutex for the client and society. He had used it in other countries. No need to “top up” and safer. Most was supervised consumption until stability was attained. Especially if the client was working. However, things changed when a new consultant came along, he had read some research that by “flooding the recipters in the brain with Methadone and the client won’t want to use heroin”. Well what a load of “old cods walop”. But this was research from the Netherlands and suddenly dispite my best efforts, the policy changed and clients were encouraged to have “as much Methadone as they wanted for as long as they wanted”. Result, as most addicts will – up went the Methadone and down went the Subutex. More on the streets, cheaper the cost and the rest is history. This change was not only some research (which you can always find some conflicting reseach) but Methadone is so much cheaper than Subutex and I firmly believe that is the bottom line. In detox and Rehab, we ALWAYS use Subutex (occationally Lofexidine) because it causes less pain, the client is able to participate in groups much sooner and they are much healthier overall. I hope some of this is useful for your reasearch. If you need any more info, please contact and I will do my best. Maureen
Thanks KIllick, Bayberry clinic and Jenny N, again oce more thankyou Tony ( you are passionate and I appreciatte the effort you put into responding) Tony I do take your point. But do not quite see where your argument is heading.. are you saying we maintain the status quo and keep prescribing meth as we do. If so, I am inclined to challenge that view, something needs to change. The question is what? Of course users will prefer methadone at first.. infact more than that, they would prefer consumption rooms with couches and ambient trance music, but it is not going to happen.. and you are dead right there is not much recovery going on there.
Recovery is a different issue. I am paid up member of the recovery movement and a member of the most expense club in the world ‘ the fellowship’..but if we want to reduce drug deaths per annum.. ,the topic here is, prescribing methadone is failing. You seem to be saying lets prescribe the drug of choice.. ok.. if you are where do we draw the line, do we do the same for solvent abusers, coke addicts and GBL users? What we have in BPN is a politically viable alternative today, I say it is being under used. I would love to see prescribed heroin but that debate is different and further from reality today. BPN is an OST that is less likely to kill. Right now, this year. People dont OD on it (very rarely anyway).
Poly drug use is an inevitability but if you are doubting that methadone is the most prevelant and most implicated substance found at post mortem in poly drug cns caused deaths the GROS figures will contradict that. I dont believe you are saying lets maintain the status quo, you are to learned for that..
Maureen great addition to the comments thank you…and very helpful I may contact you in the near future. Patrick
Killick do you have a reference or any supporting evidence for your comment ….”‘There are studies comparing outcomes, including mortality, for methadone and buprenorphine which show one or other drug to be superior and others that show no statistically significant difference. It is also the case that, on the face of it, buprenorphine is more expensive than methadone, though costs benefit analyses show they are roughly the same.’”……….
Where sis you get that from? I would like to read it it would really help. Secondly BPN per dose is more expensive I agree however in the long run BPN is cheaper due to the fact it can be made cheaper to access as access is less controlled, the prescriptive route being direct from GP, not drug workers who are more difficult to engage
with and will just throw wethadone at the problem any way..
Patrick.
Hi Patrick
some studies
Doran, shanahan et al 2003 BPN vs MMT; a cost effectiveness analysis
Harris, Gospodarevskaya and Ritter 2005: ‘A Randomised Trial of the Cost Effectiveness of Buprenorphine as an Alternative to Methadone Maintenance Treatment for Heroin Dependence in a Primary Care Setting’
Connock, jaurez-garcia et al 2007 Health Technol Assess. 2007 Methadone and buprenorphine for the management of opioid dependence: a systematic review and economic evaluation
The link in my first post to NICE also leads to their summary of lots of key evidence.
Hope that’s helpful
Magic Killick thank you.. definately going to check that out..
And I forgot to thank Kenneth above for his contribution. Thanks Kenneth. I take what you say on board as a very valid contribution.
So..I am still confused..? What to do?
Would people agree with the following (very vague )conclusions.
Methadone Positives:
..is more effective at holding Opiate addicts in many cases ( due to the buzz/effect/comfort it affords the patient).
Negatives:
However, it is, as prescribed/used/diverted at present, implicated in (even proportinately) vastly more deaths than BPN.
Thus, it’s strength seems to me, to be the opportunity [service providers] have to capaitalise on the potential for engagement with the patient. But this would have to be coupled with an [ expensive] tightening up of the prescription method to eliminate as much diversion as possible.
Notwithstanding the above,, there is no guarantee that the methadone patient will not top up with opiates or other CNS’s. So I would still view it as a very high risk OST, and not, therefore likely to reduce drugs deaths by a huge amount, unless the mind set of the patient is treated effectively at the same time, as the majority of deaths are caused by polydrug use, which in turn are caused by a need/desire to get ‘out of ones head’.
So Methadone could be used to better effect if prescribed/monitored more effectively to reduce diversion. However, to simply tighten up the manner in which it is prescriped/monitored – without complimenting its prescription with actual bio-psyco-social therapy would be fruitless as poly drug use would still be highly likely.
BPN: Positives;
Certainly, less likely to be a cause of O/D or implicated in a death.
Easier to prescribe/access from a GP;
Negatives: May not hold the hardened user due to discomfort, leading to disengagement with services and a possibility of the addict going back out on the street and the problem drug use continuing/and or topping up with polydrug use;
Dangerous if injected( although rare);
Likely to be diverted if prescribed as widely as it is in France.
It is clear at present both modalities have a part to play in OST. However, I am inclined to conclude that at first point of engagement with services, Methadone should not be the default prescription as it is today.
The whole problem seems ( quite rightly ) to be a fear of disengagement with services and I agree engagement is the key to recovery.
So make it known really very clearly to a patient that If an OST does not hold him or her, he/she can return and consider an alternative modality, (without penalising them in any way for displaying the continuing symptoms of addiction [ using ] ), and let the service user know that other options are available, (including abstinence) and that there is nothing wrong if the first course of treatment fails. One could argue that early doors a physician should almost expect a relapse of sorts due to the time it takes to put in place bio-pyscho-social changes.
So why not take the starting point as BPN as a default first treatment, unless the service provider is absolutely sure this will not even ‘touch the sides’? Even then, why not make available effective and safe Heroin prescription centres rather than launch Methadone at every opiate addict that walks through the door.
I respectfully and gratefully accept all I have read above from those who have kindly contributed and I must acknowledge Methadone has a role to play, but not as a treatment of first resort as it is today. It is implicated in far to many deaths.
The landscape has changed since the 80’s, I believe retention of and attention paid to the service user is more important today than the immediate/default requirement of methadone based harm reduction that was instilled in us 30 yrs ago.
With proper, caring, non-punitive attention paid to the patient and BPN as a starting point ( it wont work all the time, but neither does methadone) is it not bound to be the case that it would be reduce the amount of patients dependant on methadone. Even one less? If BPN does not work and one retains patient contact ( crucial as mentioned above) an alternative can be made quickly available. One of which could be
Prescribed heroin in a controlled environment .. Less will die for sure……. and thats what I want to see… discuss…………
I missed this post back in February and came across it while searching on a related topic. In the early 90’s The French involvement with bupe was significantly greater than in the UK but mainly because there was extremely limited methadone prescribing from specialist clinics at the time. (I think there was only one street clinic in Paris then ).
As in the UK, the french equivalent of a GP could prescribe bupe without the same degree of stigma as Methadone and did so with relatively few controls. The small numbers of drug deaths were an artifact of the poor DRD data collection system, essentially a drug death is usually only recorded as such if the casualty is dealt with by the emergency fire and rescue service “sapeurs – pompiers” which usually occurs when someone is found in a public place.
I would not wish to make any confident statement about the superiority of one form of substitute prescribing over another, my experience tells me that each has advantages and disadvantages each requires different controls for different risks, trial and error is often the pragmatic route to stability and all of them involve a level of restriction of freedom with the transfer of responsibility for some aspects of living from the individual to the prescriber.
