Country report Finland AIRI PARTANEN JUKKA MÄKI Buprenorphine more common as a problem drug According to information obtained from the Finnish Drug Treatment Information System (Partanen & Virtanen 2001; 2002; 2003) 1, abuse of buprenorphine has become more common among drug users seeking treatment. There was a clear change within the opiate group, although the relative proportions of the main intoxicant groups have remained at the same level in 2000 2002 (Figure 1). In 2000, heroin was clearly more common than buprenorphine as the primary opiate leading to the seeking of treatment, but in 2002 the situation had reversed. Mixed substance abuse is common, and also among those who use opiates. Those who sought treatment primarily due to heroin used as secondary drugs (2. or 3. substance) in 2002 especially amphetamine (52%), cannabis (43%), and buprenorphine (34%). However, those who sought treatment due to buprenorphine mentioned as their second or third problem substance most frequently benzodiazepines (41%), cannabis (41%) or amphetamine (39%), but more rarely heroin (21%). Of those who sought treatment due to buprenorphine, 82 85% had experience of injecting within the preceding month, while the proportion among the heroin users ranged from 49 74%. Those who sought drug treatments primarily due to heroin were older (mean age 29.4 years) than those who sought drug treatment due to buprenorphine (mean age 25.4 years). The mean age of all the drug clients in the substance treatment services was 26.2 years. 156 NORDISK ALKOHOL- & NARKOTIKATIDSKRIFT VOL. 21. 2004. ENGLISH SUPPLEMENT
Opiates Heroin Buprenorphine Other opiates Stimulants Sedatives and tranquillizers Cannabis Alcohol and drugs 2000 2001 2002 No intoxicants mentioned 0 5 10 15 20 25 30 35 % Source: Partanen A. (2003) The National Drug Information System 2000 2002: Buprenorphine more common as a problem substance. Tiimi 6/2003, p. 7 10. Figure 1. Primary problem substance of those entering treatment in 2000 2002 (%) The proportion of those who have received opiate substitution treatment has risen during the last three years. One in four of those who sought treatment for heroin and one in ten of those who sought treatment for buprenorphine received opiate treatment. Problem use of buprenorphine already in the 80s Buprenorphine is not a new substance that only emerged among drug users in the 2000s. Signs of its problem use have been observed earlier. In a survey carried out among the clients of the detoxification unit at the Helsinki University Hospital in 1987 1991 (Meretniemi, no date), it was shown that the main substance of abuse was amphetamine at 31% of the clients, the mixed use of alcohol and drugs at 19%, buprenorphine at 11%, cannabis at 10 per cent and heroin at 9%. In the material now under scrutiny, the experiments of the 1980s are evident in the background for those seeking substance treatment primarily due to buprenorphine, although the experiments only became more widespread after the latter half of the 1990s (Figure 2). The decrease of heroin use and the increase of buprenorphine in the 2000s have also become evident in the statistics on drug offences. The clear drop in heroin use started in 2001, when the supply stopped almost completely due to the reduction of heroin production in Afghanistan. Meanwhile, buprenorphine has already surfaced among seized narcotics since the latter half of the 1990s, but has according to the National Bureau of Investigation (Keskus- NORDISK ALKOHOL- & NARKOTIKATIDSKRIFT VOL. 21. 2004. ENGLISH SUPPLEMENT 157
% 30 25 20 15 15 19 yrs (N =1,210) 20 24 yrs (N =1,845) 25 29 yrs (N =1, 075) 30 34 yrs (N =657) 10 5 0 1985 1990 1995 2000 2002 Source: Partanen A. (2003) The National Drug Information System 2000-2002: Buprenorphine more common as a problem substance. Tiimi 6/2003, p. 7 10. Figure 2. The relative share of those who began the use of buprenorphine and entered treatment due to drug abuse in 2002 in the age groups 15 19 years, 20 24 years, 25 29 years and 30 34 years according to the primary substance that led to the seeking of treatment. rikospoliisin tiedote 2003) become more common in street trading due to the reduced availability of heroin. The medicinal treatment of opiate dependents Great hopes have been placed on the use of buprenorphine in the treatment of heroin users. The medical treatment results have been encouraging and hardly any risk of dependency or deaths due to overdoses are expected with its use. Buprenorphine has nonetheless falteringly become part of the medical treatment of opiate dependents. Due to a certain doctor who gained publicity by prescribing buprenorphine to a large number of patients, buprenorphine was labelled a nonmanageable, self-medicating substance or even intoxicant. Buprenorphine has also become problematic since it is to a significant degree injected in Finnish drug culture, and therefore subject to the risk of communicable diseases. The current medical treatment of opiate dependents has been seen to represent a strict and restrictive substitution treatment model (Virtanen 2004) in which admittance to treatment has been subject to strict criteria and the realisation of medical treatment is carefully monitored (Decree 289/2002 issued by the Ministry of Social Affairs and Health). Both methadone and buprenorphine are used in substitution treatment. Criteria for treatment are among others a proven opioid dependence and previously failed detoxification attempts involving other treatments. Those receiving treatment for opioid dependence usually collect their doses daily from the treatment unit. Medical care and psychosocial rehabilitation are also an integral part of the treatment. There have been positive experiences of buprenorphine in opiate treatment (Baas & Seppänen-Leiman 2002). Special state subsidies were granted to municipalities in 2002 and 2003 to increase among other things opiate substitution treatment and the development of treatment services for drug addicts with severe problems. In 2001, approximately 200 158 NORDISK ALKOHOL- & NARKOTIKATIDSKRIFT VOL. 21. 2004. ENGLISH SUPPLEMENT
persons received medical treatment for opiate dependency; in August 2002, the number of persons in care was 400 and at an equivalent period in 2003, the number of persons in opiate substitution treatment was estimated to be 500 (Virtanen 2004; Villikka 2003). According to Schering Plough (2004) there were about 600 persons in opiate substitution treatment in Finland in the end of 2003 of whom 428 were in buprenorphine substitution treatment. However, the need for opiate treatment has still been estimated to be considerably higher than the supply, something that has resulted in the formation of treatment queues in some localities. One may have to wait to gain admittance to buprenorphine treatment especially in the metropolitan area (Villikka 2003). Discussion The use of buprenorphine as part of the problem use of substances has emerged as a topic in public debate after 2000 when the street use of buprenorphine has increased. The ascendance of buprenorphine into public consciousness has also been sped up by the development of the medical treatment of opiate dependents. The negative tinge attached to buprenorphine in the media has been caused by the medical care practices of the abovementioned physician, which the supervising authorities have been forced to deal with accordingly. From a medical point of view, buprenorphine is a effective drug in the treatment of opiate dependents, but has simultaneously proven to be a deepening problem among abusers and especially so among young ones. This has also been observed in treatment services, where there has been criticism directed towards opiate treatment, as it has been demonstrated that those who seek treatment may continue its use on the street. The importance of non-medical treatment for persons hooked on drugs has also been brought to attention. From the perspective of the treatment of problem users it is however important that the availability of medical treatment for opiate dependents is increased further in Finland despite the increasingly common street use of buprenorphine. The demand for opiate substitution treatment is greater than the current supply of this form of treatment. In Finland, opiate substitution treatment is very supervised, which in itself binds resources. This also restricts the supply of treatment. There is lively discussion about criteria for treatment and how treatment should be carried out. Alongside the development of the treatment of opiate dependents, attempts have also been made to prevent the supply and spread of buprenorphine in the illegal street market. Finnish opiate abusers used to go on trips especially to France to get buprenorphine, which has had a liberal prescription practice. The Decree on the personal import of pharmaceuticals to Finland (1088/2002), which came into force at the beginning of 2003 and was based on the Schengen Agreement, stopped import from France (Hermanson 2003). However, the import of buprenorphine has also continued after this, although the source country has changed to Estonia. Comparison of material from the National Drug Treatment Information System for 2000 2002 gives some indication that the use of buprenorphine may be starting at a younger age than previously. This NORDISK ALKOHOL- & NARKOTIKATIDSKRIFT VOL. 21. 2004. ENGLISH SUPPLEMENT 159
might reflect that buprenorphine has particularly aroused the interest of younger users and that it might become the first opiate used for some. Typical in the substance abuse of buprenorphine is injection and its use as part of a mixture of various substances. A clear risk of overdosing is associated with the mixed use of buprenorphine, benzodiazepines and alcohol (Kintz 2001). Findings associated with buprenorphine cases involving deaths have also been observed, while overdoses associated with heroin have conversely decreased as the availability of heroin has dropped (Vuori 2003). It is important that the extent of buprenorphine abuse and its various patterns of use and related user culture are monitored closely. Although the use of buprenorphine has presumably partly replaced heroin use among opiate users, this situation might change as the supply of heroin changes. There are also some indications that buprenorphine may have become the first opiate used among young problem drug users. This may be creating a new type of substance abuse group, whose treatment will set new challenges for treatment service professionals. It would be especially important now to clarify to what extent buprenorphine has become an established product in the range of the drug trade, and to what extent those waiting in treatment queues use street buprenorphine as an alternative to legitimate medical treatment. It would also be valuable to establish how well medicinal buprenorphine treatment alongside improvements in the life situation of users reduces the side use and injection of buprenorphine and benzodiazepines. Translation Jason O Neil Airi Partanen, Special planning officer, STAKES The National Research and Development Centre for Welfare and Health, POB 220, FIN-00531 Helsinki e-mail: airi.partanen@stakes.fi Jukka Mäki, Managing director, Probation Foundation Finland, Kinaporinkatu 2 E 39, FIN-00500 Helsinki e-mail: jukka.maki@krits.fi NOTE 1 Anonymous statistical information on clients who have sought treatment for substance abuse at treatment services, as well as their use of services, social background, substance use and risk behaviour is collected in the National Drug Information System. REFERENCES Baas, A. & Seppänen-Leiman, T. (2002): Kadulta korvaushoitoon. Buprenorfiinihoidon kehittämisprojektin (1.-30.6. 2000) loppuraportti (From the Street to Substitution Treatment. The final report of the buprenorphine treatment development project (1-30 June 2000) ). A- klinikkasäätiön raporttisarja nro 38 Hermanson, T. & Järvinen P. (2003): Schengen-sopimus lopetti buprenorfiinin hankkimisen Ranskasta ( The Schengen Agreement stopped the import of buprenorphine from France). 160 NORDISK ALKOHOL- & NARKOTIKATIDSKRIFT VOL. 21. 2004. ENGLISH SUPPLEMENT
Suomen Lääkärilehti 58 (5): 549-551 Keskusrikospoliisin tiedote 14.02.2003 (National Bureau of Investigation bulletin on 14 February, 2003): Huumerikoksia kirjattiin edellisvuotta vähemmän, mutta huumeet edelleen vakava ongelma (Less drug-related crime was recorded last year, but drugs still a serious problem) Kintz, P. (2001): Deaths involving buprenorphine: a compendium of French cases. Forensic Science International 121 (1-2): 65-69 Meretniemi, K.: Huumeenkäyttäjät Suomessa. Tutkimus Helsingin yliopistollisen keskussairaalan Huumevieroitusyksikössä vuosina 1987-1991 hoidetuista asiakkaista. Moniste (Drug Users. A study among the clients treated at the detoxification unit at Helsinki University Hospital during 1987-1991. Hand-out) Partanen, A. & Virtanen, A. (2001): Päihdehuollon huumeasiakkaat 2000 (The drug clients of the treatment services). Stakes, tiedonantajapalaute 9/ 2001 Partanen, A, & Virtanen, A. (2002): Päihdehuollon huumeasiakkaat 2001 (The drug clients of the treatment services). Stakes, tiedonantajapalaute 9/ 2002 Partanen, A. & Virtanen, A. (2003): Päihdehuollon huumeasiakkaat 2002 (The drug clients of the treatment services). Stakes, tilastotiedote 14/2003 Schering-Plough (2004): Buprenorfiini lääkehoito tänään 1 (Buprenorphine treatment today 1) Villikka, H. (2003): Kartoitus opioidiriippuvaisten lääkekorvaushoidon hoitojonoista (A survey of the waiting lists for substitution treatment of opioid dependents). Sosiaali- ja terveysministeriö, monisteita 2003:16 Virtanen, A. (2004): Huumausainetilanne Suomessa 2003 (Drug Situation in Finland, 2003). Stakes, tilastoraportti 1/ 2004 (Stakes, statistical report 1/2004). Vuori, E. (2003): Alkoholi- ja huumekuolemat (Alcohol and drugrelated deaths). In: Heinonen J. (ed.): Alkoholi- ja huumetutkimuksen vuosikirja Tommi 2003 (The Year Book of Alcohol and Drug Research- Tommi 2003)). Keuruu: Otavan kirjapaino 2003. NORDISK ALKOHOL- & NARKOTIKATIDSKRIFT VOL. 21. 2004. ENGLISH SUPPLEMENT 161