The prevalence of use of psychotropic drugs, buprenorphine and methadone on the streets, the polyuse of substances in Finland

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1 The prevalence of use of psychotropic drugs, buprenorphine and methadone on the streets, the polyuse of substances in Finland Hannu Alho, Professor Unit on Prevention and Treatment of Addictions, National Public Health Institute, Helsinki, Finland Drug Information Seminar, A-Clinic Foundation, Berlin, Drugs in Finland Most frequently misused drug: cannabis Less than 5% report to be frequent users Lifetime prevalence, adults, 1.9 %* Cocaine lifetime prevalence, adults, 1. %* Most frequently abused intravenous drugs: amphetamines and opioids Survey in 0*: ~16,000*,000 IV drug users prevalence of IV drug use is: %» in the capital Helsinki % < 50 % (6000*-10,000) are opioid users, mainly heroin *EMCDDA reports 1

2 The primary drug among patients entering treatment Primary drug % Opiate bupre heroin Amph Cann Sedat. & drugs Source: Drug treatment information system, Stakes. Drug harm reduction programs in Finland Opioid maintenance treatment programs (> 1997) Health counseling (>1998) large health care centers, special centers Needle exchange (>1998) Free needle exchange, anonymous, health counseling, now in all large cities

3 Incidence of new HIV infections among IDUs New HIV infections Whole country Helsinki 8 new in 07 Opioid Maintenance Treatment (OMT) in Finland In 199, private buprenorphine (Temgesig ) Clinic NO governance, NO framework In 1997, methadone treatment program started -MSAH decree regulated In 00, buprenorphine (Subutex ) registered for maintenance programmes: MSAH decree regulated In late 03, buprenorphine-naloxone combination product (Suboxone ) available under a pre-license: MSAH decree regulated In mid 07, Suboxone approved for OMT In 08, Subutex withdrawn from the market 3

4 OMT OMTs are regulated by MSAH decrees < 07 > 08 Initiation at specialized centers No prescription, no pharmacy distribution of buprenorphine or methadone Maintenance possible at registered clinics (A-Clinics) if trained personnel supervised dosing, with stabilised patients "take away" dosing allowed Medication not covered by PHCI However free for patients, city or municipal coverage , new decree Goal: better access to the treatment Pharmacy distribution of Suboxone allowed for stabilized patients The treatment can be initiated at PHC Regulation of the Ministry of Social Affairs and Health Regarding withdrawal and substitution treatment with specific drugs Issued in Helsinki on 17 January 08 Social- och hälsovårdsministeriets förordning om avgiftning och substitutionsbehandling av opioidberoende personer med vissa läkemedel Given i Helsingfors den 17 januari

5 Current OMT situation In 6/08, approximately 10 patients in OMT: 500 Suboxone, 145 Subutex and 53 methadone Estimation: approximately 13 % of opiate dependent persons in treatment programs 6-10 months waiting list for maintenance treatment of opioid-dependency Abuse liability of buprenorphine and methadone in untreated IV drug users Data from survey at needle exchange centres (6) in metropolitan Helsinki in 05*, 06, 07 Voluntary anonymous survey to all persons arriving to centre during two week period, return rate in 07 6 % Questions asked: What is the primary (mostly used) IV drug, what other drugs using, frequency, dosage of usage etc? Why am I using IV drugs? Experience of Suboxone IV usage? Street value of Subutex and Suboxone? * (Alho et al, Drug Alcohol Depend, 07) 5

6 Survey demographics, 07 Reply % ( n= 411) 61.9 Gender (male) 66 % Age (mean, years) 30.5 First experience wt. opiates (mean, years) Min/max (years) /44 Most frequently used primary IV drug (05) Percentage of Participants IV Drug Mainly Misused Buprenorphine Amph/Methamph Heroin/Morphine 07 Bup Amph OtO,Meth Heroin % 6

7 IV drugs used in addition to buprenorphine (05) 1% 1% 8% 4% 31% None Amp/MA Heroin/Mor Cocaine BD/Other Several Bup+amfe+benzo 44% 44% Heroin findings in the medico legal cause of death investigation in Finland Heroin findings Alho et al, Duodecim 07 7

8 Drugs findings in the medico legal cause of death investigation in Finland Total Female Opiates Heroin Buprenorphine Cannabis Amphetamines Cocaine Reasons for use of IV buprenorphine (05) 10% For pleasure/euphoria 1 % All other reasons 5% To treat drug withdrawal symptoms 73% To self treat addiction 8

9 Street price of 8 mg buprenorphine tablets Daily cost of other frequently misused drugs: amphetam , heroin 60 1 % suboxone 8mg subutex 8 mg 0 < Mean Subutex 35, Suboxone 19, highly significantly lower than that for Subutex: t(453)=19.33, p< Reasons for buprenorphine diversion Insufficient treatment opportunities - treatment restrictions Profit Self treatment/detoxification Employment restraints Hedonism/intoxication Availability - no heroin Safer/better than heroin 9

10 Future challenges in the opiate maintenance treatment IV misuse of buprenorphine (60-70%) Solution? Persons addicted to injection may continue buprenorphine-naloxone injection, however the street value of Suboxone is % less Benzodiazepines are commonly abused The most common reason for transfer to methadone is polydrug IV abuse Central Pharmacy Registry? The Finnish Experience, Conclusions I - control Tight control appear to have had little effect on the diversion of buprenorphine Does the new decree increase access and reduce diversion?? If tightly controlled - where does street buprenorphine originate? In 05 the Finnish custom confiscated 38,000 Subutex tablets, street buprenorphine originating from France, Estonia, Lithuania, Latvia and Germany Solution? 10

11 The Finnish Experience, Conclusions II - resources Limited access to treatment 13 % in treatment programs Most frequent reason for IV use of buprenorphine is self treatment of addiction More treatments should be available Does the new decree help the situation? Should buprenorphine be under public health care insurance? Public health care insurance reimburses patients for part of the cost of necessary medication prescribed by a doctor for the treatment of an illness. Reimbursement requires that the Pharmaceuticals Pricing Board has confirmed the reimbursability of the medicine and established a reasonable wholesale price Thank you for your attention 11

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