Buprenorphine Overseas


“The history of the treatment of narcotic withdrawal is a long and dishonorable one. The trail is strewn with cures enthusiastically received and then quietly discarded when they turned out to be relatively ineffective or even worse, productive of greater morbidity and mortality… Any claim for a new method should be put forward modestly and viewed with skepticism until amply documented by careful experimental procedures.” Herbert Kleber (1982)

A couple of interesting articles about buprenorphine overseas hit my inbox recently.

First, from Finland [emphasis mine]:

Young women are at particular risk of death from illicit drug use, according to preliminary results from a major ongoing study by the University of Eastern Finland’s public health department.

The study confirms that drug users have a higher mortality rate than others of the same age, and that this is higher among male users in general. However it finds that women under the age of 25 form an exception. Their risk of death may be as much as 20 times higher than that of non-drug using women in their age group.

The findings are part of a epidemiologic project being carried out in partnership with Helsinki’s Deaconess Institute, Stockholm’s Karolinska Institutet, the Finnish National Institute for Health and Welfare and others. It is a follow-up study of about 5,000 illegal drug users in the Helsinki region who sought treatment at the Deaconess Institute between 1998 and 2008.

10% mortality rate

By the end of 2010, about 500 drug users, or roughly one in 10, had died.

. . .

Relatively few violent ends

Among men, drug-related deaths are more evenly distributed among various age groups. The most common causes are heart attacks and infection. Researchers were surprised that violence seemed to play a marginal role in drug users’ deaths.

Of the approximately 500 deaths, only 14 were attributed to violence – far fewer than from traffic accidents, for instance.

. . .

Subutex and amphetamines most common

Among those seeking help at the Deaconess Institute, buprenorphine has become the most abused drug in the past decade. Marketed for use in heroin treatment, this powerful painkiller is also sold as a street drug. It’s better known under the brand name Subutex.

Next, in the Czech Republic, buprenorphine addiction has become enough of a problem that they are doing research on using methadone and buprenorphine-naloxone to treat buprenorphine addiction. (Yes, you read that right.)

Is this what we want for our family, neighbors, friends, co-workers and country?

Drug Overdose Deaths Are Increasing Pretty Much Everywhere

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These images speak for themselves. Here are a couple of important sentences:

Between 1999 and 2009, drug poisoning deaths grew by 394 percent in rural areas and 279 percent for large metropolitan areas, according to the CDC’s county-level look at the data.

According to the CDC, roughly 60 percent of all OD deaths in 2010 were caused by prescription drugs, with three-fourths of those cases involving painkillers.

The work of advocates like these is growing more important.

Blue indicates a lower overdose rate and red indicates a higher rate (13+ per 100,000)
Blue indicates a lower overdose death rate and red indicates a higher overdose death rate (13+ per 100,000)


Quality of life and death

English: Graveyard in Barnes
English: Graveyard in Barnes (Photo credit: Wikipedia)

A study out of Australia looks at death rates among opioid addicts receiving opioid substitution treatment (OST, for short. It’s methadone.) in New South Wales between 1985-2005. It’s a HUGE sample–43,789 people. If fact, the paper says:

This cohort is likely to represent the majority of opioid dependent people in that State during this period, perhaps as high as 80%.

To my mind, the strongest argument for methadone and buprenorphine has been overdose prevention–that dead addicts can’t recover and drug-free treatment isn’t going to work for everyone at every point in time. If I’m the parent of a heroin addict and they’ve refused drug-free treatment or relapsed after high quality drug free treatment of the adequate dose and duration, maintenance might look like the least bad option. At least they’ll be alive, right? (Of course, my concern is that these drugs have become the first line treatment and access to better options is diminishing.)

So, what did they find in this cohort?

Well,  8.8% of the cohort died. (9.4% of men.)

There were 3,685 deaths in the cohort between 1985 and 2005 for a crude mortality rate of  894 per 100,000py (95% CI: 865, 923) (Table 1).

How did they die?

The majority of deaths were drug-related  (n=1932; 52%), with most of these (n=1574; 82% of all drug-related deaths) coded as accidental opioid deaths. The bulk of remaining deaths were due to unintentional injuries (n=975; 26% of all deaths) and suicide (n=484; 13% of all deaths).

Did they at least live long lives?

Using the Australian life tables approach, there was an estimated 160,055 Years of Potential Life Lost (YPLL) in this cohort, an average of 44 YPLL per person who died, and 29 years of YPLL before age 65 (Table 4). Just under half (45%) of the YPLL were due to accidental opioid-related deaths (an average loss of 46 years of potential life, or 31 years prior to age 65). Motor vehicle accidents accounted for the highest average YPLL, 47 years, or 33 years before age 65.

How does this compare with the rest of the population?

The overall age-, sex- and year-standardised mortality ratio was 6.5 (95% CI: 6.3-6.7) indicating that our cohort had 6.5 times the rate of mortality than that expected in the population.

Is this unique to Australia?

The average of 44 years of potential life lost for each fatality in the cohort highlights the fact that deaths in opioid users often occur at a young age. This was particularly the case for avoidable causes of death such as drug overdose and injuries. The pattern of YPLL was broadly similar to previous analyses of a Californian male cohort (n=581) in the US, followed from 1962 to 1997 (10). Both studies found that opioid overdoses were the largest contributor to YPLL but suicides made a larger contribution to YPLL in our cohort, and homicide a larger contribution in the Californian cohort.

Now, this doesn’t mean that methadone doesn’t reduce death rates. It means that the death rate is still very high.

It also means that quality of life questions shouldn’t be dismissed with snarky quips like, “What kind of QOL do dead people have?“, because methadone patients die in large numbers too.

If you’re thinking that those were the bad old days, before we had buprenorphine, think again. Retention rates for methadone and buprenorphine are not great. When put head to head, methadone has higher retention rates.

I’ll also throw in a reminder from a previous post about were I stand on ORT:

Just to be sure that my position is understood. I’m not advocating the abolition of methadone.

Here’s something I wrote in a previous post: “All I want is a day when addicts are offered recovery oriented treatment of an adequate duration and intensity. I have no problem with drug-assisted treatment being offered. Give the client accurate information and let them choose.”

Another: “Once again, I’d welcome a day when addicts are offered recovery oriented treatment of an adequate duration and intensity and have the opportunity to choose for themselves.”

It’s also worth noting that there is a link between AA and methadone.


The surgery was a success, but…

1368951062alarabalaanPublic health workers are declaring their harm reduction approach a success:

Harm reduction — not a war on drugs — has reduced illicit drug use and improved public safety in what was once Ground Zero for an HIV and overdose epidemic that cost many lives, says a 15-year study of drug use in Vancouver’s impoverished Downtown Eastside.

The report by the B.C. Centre for Excellence in HIV/AIDS found that from 1996 to 2011, fewer people were using drugs and, of those who were, fewer were injecting drugs, said Dr. Thomas Kerr, co-author of the report and co-director of the centre’s Urban Health Research Initiative.

“A public health emergency was declared here because we saw the highest rates of HIV infection ever seen outside of sub-Saharan Africa — in this community. At the same time, the community was being levelled by an overdose epidemic,” Kerr said after presenting his findings to members of the group affected at a community centre in the heart of the neighbourhood.

Vancouver took a public health approach to the crisis, opening the country’s first supervised injection site in 2003, and Kerr said the statistics show that approach was successful.

Kerr goes on to pull the scientific evidence card, casting critics as stupid, unethical and indifferent to death:

“We have a federal government that ignores science in favour of ideology, and people are sick and dying as a result,” Kerr said.

“When we’re dealing with matters such as life and death, I think we’re obligated to base our decisions on the best available scientific evidence. I think it’s unethical to do otherwise.”


There was some disappointing news for health officials in the study.

There has been only a slight drop in mortality rates among the city’s illicit drug users, who have a death rate eight times higher than the general population.

What’s that saying? The surgery was a success, but the patient died.

Now, I’m not saying that law enforcement is a better approach and I’m not saying that reduced disease and crime are unimportant, they are important. However, one of my concerns about public health approaches is that they are often designed to serve the public rather than the individual. When the death rate is only slightly affected, and addicts are still using and homeless, who’s best served by these outcomes of reduced disease and crime?

Harm reduction is not enough. In and of itself, it is not bad.

It’s just bad when the public and professionals declare victory while addicts continue to suffer terrible quality of life.

How much money was spent to achieve these outcomes? How else might that money have been spent?

Why not recovery?

Dead addicts don’t recover, but…

Naloxone (1)
Naloxone (Photo credit: intropin)

This has gotten a lot of press. There’s naloxone distribution doubt this will reduce overdose deaths. However, some pretty important questions remain:

  • What happens after the overdose?
  • What services/interventions might have prevented the overdose in the first place?

The article references placing defibrillators in public places. What happens after someone is saved by one of those defibrillators? An ambulance comes and takes them to receive treatment. (Often treatment that costs tens of thousands of dollars.)

0 = Number of times the word “treatment/treat/treatable” appears in the article

0 = Number of times the word “recovery/recover” appears in the article

So … dead addict don’t recover, but why do we seem to care so little about treating what nearly killed the patient?

Failure to rescue

Atul Gawande found that hospitals have high rates of variance in post surgical complications but the reason is not what he expected.

But there continue to be huge differences between hospitals in the outcomes of their care. Some places still have far higher death rates than others. And an interesting line of research has opened up asking why.

Researchers at the University of Michigan discovered the answer recently, and it has a twist I didn’t expect. I thought that the best places simply did a better job at controlling and minimizing risks—that they did a better job of preventing things from going wrong. But, to my surprise, they didn’t. Their complication rates after surgery were almost the same as others. Instead, what they proved to be really great at was rescuing people when they had a complication, preventing failures from becoming a catastrophe.

Scientists have given a new name to the deaths that occur in surgery after something goes wrong—whether it is an infection or some bizarre twist of the stomach. They call them a “failure to rescue.” More than anything, this is what distinguished the great from the mediocre. They didn’t fail less. They rescued more.

This is something that Dawn Farm has invested a lot of energy into. I wonder if this is also what separates the best treatment centers from the rest?

[via Andrew Sullivan]