Lack of Reduction in Buprenorphine Injection After Introduction of Co-Formulated Buprenorphine/Naloxone to the Malaysian Market

Abstract

Background Diversion of buprenorphine (BPN) has been described in settings where it is legally prescribed and has resulted in increasing concern. To address this concern, co-formulation of buprenorphine/naloxone (BPN/NLX) replaced buprenorphine alone in Malaysia in December 2006. Methods To assess the significance of BPN/NLX introduction, 41 BPN/NLX injectors in Kuala Lumpur, Malaysia were recruited using a modified snowball recruitment technique. Results In January 2007, all subjects had previously injected BPN alone. During the transition from injecting BPN alone to co-formulated BPN/NLX, the mean daily BPN injection dose increased from 1.88 mg (range 1.0–4.0 mg) to 2.49 mg/day (p < .001). Overall, 18 (44%) subjects increased their daily amount of injection while 22 (54%) had no change in dose; only one subject reduced the amount of injection. Development of opioid withdrawal symptoms was the primary outcome, however the only symptom that was significantly associated with BPN/NLX dosage was the report of “stomach pains” (p = .01). In logistic regression analysis, the development of opioid withdrawal symptoms was associated with increased benzodiazepine injection and increased syringe sharing. Conclusion and Scientific Significance These data suggests that the introduction of BPN/NLX did not reduce injection related risk behaviors such as syringe sharing and was associated with increased benzodiazepine use. Evidence-based approaches to treat BPN injection are urgently needed.

Opiate withdrawal syndrome in buprenorphine abusers admitted to a rehabilitation center in Tunisia

“…By the end of the treatment period, results were in favor of methadone 33 . However, these results need more investigation before they can be generalized 32 .…”

“…The approach involves using µ-opioid agonists with long half-lives, such as buprenorphine and methadone that will reduce withdrawal symptoms and produce less drug-like effects. Up to the present time, there has been no evidence-based guidelines for the management of buprenorphine injection 32 . In a trial led in Iran by Ahmadi and Ahmadi K, 204 buprenorphine injectors were randomized to receive methadone(orally), buprenorphine (sublingually) or naltrexone, an opioid antagonist, (orally) along with counselling sessions.…”

“…Some countries like the United-States 2 , France 34 or Malaysia 32 , use Suboxone®, an association of buprenorphine and naloxone, as part of their dependence management plan. On terms of effectiveness, this combination can be compared to Subutex® in the treatment of opioid dependence, as naloxone is not absorbed sublingually.…”

Abuse-Deterrent Formulations, an Evolving Technology Against the Abuse and Misuse of Opioid Analgesics

“…A study in Malaysia that evaluated the continued IV use of BUP-N after the discontinuation of BUP reported that 98 % either injected the same amount or more after the change with only 2 % decreasing their injection [51]. In Finland, 68 % of respondents in a survey at a needle exchange clinic reported that they had tried injecting BUP-N; 45 % used it more than once, and 8 % used it regularly.…”

Buprenorphine Use and Risk of Abuse and Diversion

“…Findings from a small sample (N=41) in Malaysia suggest that the introduction of the buprenorphine/naloxone combination did not decrease injection-related risk behaviors and was associated with increased benzodiazepine use [95]. A more systematic study in Malaysia, a two-wave survey of buprenorphine IDUs, found that both buprenorphine and buprenorphine/naloxone intravenous misuse occurred in heroin IDUs [60].…”