Buprenorphine substitution treatment in France: drug users' views of the doctor-user relationship

Intervention Stigma toward Medications for Opioid Use Disorder: A Systematic Review

Medications for opioid use disorder (MOUD) are evidence-based treatments, yet can be controversial among some populations. This study provides a systematic review of prejudice and discrimination toward MOUD, a form of "intervention stigma," or stigma associated with a particular medical treatment. A systematic search strategy was used in PsychInfo and PubMed to identify studies published between 1998 and 2018. Studies that empirically examined stigma toward MOUD were included if the manuscript was of moderate or high quality. Studies were analyzed using thematic synthesis. The search yielded 972 studies, of which 28 were included. Most studies utilized qualitative methods to examine intervention stigma toward methadone or buprenorphine, with one including naltrexone. Studies demonstrated that intervention stigma among healthcare providers was influenced by lack of training and abstinent treatment preferences. Providers equated MOUD with illicit substance use and at times refused to care for MOUD patients. Stigma among peer patients seeking treatment was also influenced by abstinent treatment preferences, and among the general public stigma was influenced by lack of MOUD knowledge. Intervention stigma was also driven at the policy level by high regulation of methadone, which fueled diversion and hindered social functioning among patients. Few studies indicated how to reduce intervention stigma toward MOUD. Intervention stigma affects both provision and perceptions of methadone and buprenorphine, decreasing access and utilization of MOUD. Future research should further develop and test MOUD stigma reduction interventions in a variety of social contexts to improve access to care and reduce patient barriers.

Perceptions and preferences for long-acting injectable and implantable medications in comparison to short-acting medications for opioid use disorders

Aim

Treatment for opioid use disorders has recently evolved to include long-acting injectable and implantable formulations of medications for opioid use disorder (MOUD). Incorporating patient preferences into treatment for substance use disorders is associated with increased motivation and treatment satisfaction. This study sought to assess treatment preferences for long-acting injectable and implantable MOUD as compared to short-acting formulations among individuals with OUD.

Methods

We conducted qualitative, semi-structured telephone interviews with forty adults recruited from across the United States through Craigslist advertisements and flyers posted in treatment programs. Eligible participants scored a two or greater on the heroin or opioid pain reliever sections of the Tobacco, Alcohol, Prescription Medications, and Other Substances (TAPS) Tool, indicative of a past-year OUD. Interviews were transcribed, coded, and thematically analyzed.

Results

Twenty-four participants (60%) currently or previously had been prescribed MOUD. Sixteen participants (40%) expressed general opposition to MOUD, citing concerns that MOUD is purely financial gain for pharmaceutical companies and/or a "band aid" solution replacing one drug with another, rather than a path to abstinence. Some participants expressed personal preference for long-acting injectable (n = 16/40: 40%) and implantable formulations (n = 12/40: 30%) over short-acting formulations. About half of the participants were not willing to use injectables (n = 19/40: 48%) or implantables (n = 22/40: 55%), preferring short-acting formulations. Mixed evaluations of long- and short-acting MOUD focused on considerations of medication-related beliefs (privacy, concern over an embedded foreign body), the medication-related burden (convenience, provision of structure and support, medication administration, potential side effects), and medication-taking practices (potential for non-prescribed use, control over dosage, and duration of treatment).

Conclusions

Though many participants personally prefer short-acting to long-acting MOUD, some were open to including long-acting formulations in the range of options for those with OUD. Participants felt long-acting formulations may reduce medication-related burden and the risk of diversion. Conversely, participants expressed concern about invasive administration and loss of control over their treatment. Results suggest support for expanded access to a variety of formulations of MOUD. The use of shared decision making may also help patients select the formulation best aligned with their experiences, values, and treatment goals.

Are patients' pejorative representations of buprenorphine associated with their level of addiction and of misuse?

BACKGROUND

In France, buprenorphine is at once the most widely prescribed and the most commonly misused opioid maintenance treatment (OMT). Unlike other medicines, it is seldom prescribed as a generic drug. Several studies have underlined the influence of the patient's representations when choosing brand-name rather than generic forms. We aim to prove a link between these pejorative representations and misuse, a higher degree of addiction and a preference for brand-name products.

METHODS

An observational study carried out at 11 sites in France using self-assessment questionnaires filled out in dispensing pharmacies by patients having come to them for buprenorphine delivery.

RESULTS

Analysis was based on 806 usable questionnaires. There indeed exists a significant correlation between pejorative representations of OMT by means of buprenorphine, and a higher degree of addiction and misuse (p < .0001 for each). Preference for the brand-name product is correlated with the representation of OMT as a "trap" (p = .020).

CONCLUSION

Our results underscore the existence of a link between patients' negative representations of their OMT and their drug-taking behavior. Prescribing physicians should consequently take these representations into account to more precisely identify the relevant behaviors and help their patients to evolve positively.

Preference for brand-name buprenorphine is related to severity of addiction among outpatients in opioid maintenance treatment

As a form of opioid maintenance treatment, high-dose buprenorphine is increasingly being used in the United States. On the French market since 1996, it is the most commonly prescribed and frequently employed opioid maintenance treatment. For unknown reasons, the brand-name form is used far more often than the generic form (76-24%). The objective was to show that the patients' levels of addiction were differentiated according to the form of buprenorphine currently being used and to their previous experience of a different form. An observational study in 9 sites throughout France used self-assessment questionnaires filled out in retail pharmacies by all patients to whom their prescribed buprenorphine treatment was being delivered. The 151 canvassed pharmacies solicited 879 patients, of whom 724 completed the questionnaires. Participants were statistically similar to non-participants. The patients using the brand-name form subsequent to experience with the generic form exhibited a more elevated addiction severity index and a higher dosage than brand-name form users with no experience of a different form. Compared to generic users, their doses were higher, their was addiction more severe, and their alcohol consumption was more excessive; they were also more likely to make daily use of psychotropic substances. However, the level of misuse or illicit consumption was similar between these groups. Preferring the brand-name buprenorphine form to the generic form is associated with a higher level of severe addiction, a more frequent need for daily psychotropics, and excessive drinking; but the study was unable to show a causal link.

The management of opiate use disorders in France: results of an observational survey of general practitioners

Background

When opioid-agonist treatments were approved in France in 1995, opiate use disorders began to be managed and treated by general practitioners (GPs), who have since then been encouraged to treat substance use disorders (SUDs) for heroin and other illegal substances. The objective of this study was to describe rates of: 1) SUDs in general practices in France; 2) characteristics of GPs treating SUDs; and 3) clinical practices surrounding SUDs. To place these data in the context of SUD treatment, we also gathered information from practicing SUD specialists.

Methods

Between December 2011 and January 2012, a nationally representative sample of GPs and SUD specialists were interviewed by phone, using a 12-item questionnaire that covered number of SUD patients, types of SUDs, and treatments. Data collected were confidential, and analysis was blinded with regard to physician identity.

Results

Forty-four percent of GPs and 68 % of specialists were included in the analysis. The mean number of patients estimated to have been seen at least once in the previous year was 3036 for GPs and 920 for specialists. Ninety-six percent of GPs reported having patients with SUDs. Tobacco, alcohol, and psychoactive drugs were the SUDs most frequently encountered by GPs, whereas tobacco, alcohol, heroin, and cannabis were most frequently encountered by specialists. Forty-three percent of GPs saw at least one patient with a heroin use disorder (HUD), and 82 % of GPs treating patients with HUDs had prescribed an opioid-agonist treatment during the previous 12 months.

Conclusions

The results of this study suggest that a large number of GPs now treat patients with opiate use disorders and that doctors appear to be convinced of the benefits of opioid-agonist therapy and have overcome their initial concerns. This represents a significant change in practice patterns since the introduction of opioid-agonist treatments in France.

Discontinuation of buprenorphine maintenance therapy: perspectives and outcomes

Buprenorphine maintenance therapy (BMT) is increasingly the preferred opioid maintenance agent due to its reduced toxicity and availability in an office-based setting in the United States. Although BMT has been shown to be highly efficacious, it is often discontinued soon after initiation. No current systematic review has yet investigated providers' or patients' reasons for BMT discontinuation or the outcomes that follow. Hence, provider and patient perspectives associated with BMT discontinuation after a period of stable buprenorphine maintenance and the resultant outcomes were systematically reviewed with specific emphasis on pre-buprenorphine-taper parameters predictive of relapse following BMT discontinuation. Few identified studies address provider or patient perspectives associated with buprenorphine discontinuation. Within the studies reviewed providers with residency training in BMT were more likely to favor long term BMT instead of detoxification, and providers were likely to consider BMT discontinuation in the face of medication misuse. Patients often desired to remain on BMT because of fear of relapse to illicit opioid use if they were to discontinue BMT. The majority of patients who discontinued BMT did so involuntarily, often due to failure to follow strict program requirements, and 1 month following discontinuation, rates of relapse to illicit opioid use exceeded 50% in every study reviewed. Only lower buprenorphine maintenance dose, which may be a marker for attenuated addiction severity, predicted better outcomes across studies. Relaxed BMT program requirements and frequent counsel on the high probability of relapse if BMT is discontinued may improve retention in treatment and prevent the relapse to illicit opioid use that is likely to follow BMT discontinuation.

A critical analysis of user satisfaction surveys in addiction services: opioid maintenance treatment as a representative case study

BACKGROUND

Satisfaction with services represents a key component of the user's perspective, and user satisfaction surveys are the most commonly used approach to evaluate the aforementioned perspective. The aim of this discursive paper is to provide a critical overview of user satisfaction surveys in addiction treatment and harm reduction services, with a particular focus on opioid maintenance treatment as a representative case.

METHODS

We carried out a selective critical review and analysis of the literature on user satisfaction surveys in addiction treatment and harm reduction services.

RESULTS

Most studies that have reported results of satisfaction surveys have found that the great majority of users (virtually all, in many cases) are highly satisfied with the services received. However, when these results are compared to the findings of studies that use different methodologies to explore the patient's perspective, the results are not as consistent as might be expected. It is not uncommon to find that "highly satisfied" patients report significant problems when mixed-methods studies are conducted. To understand this apparent contradiction, we explored two distinct (though not mutually exclusive) lines of reasoning, one of which concerns conceptual aspects and the other, methodological questions.

CONCLUSION

User satisfaction surveys, as currently designed and carried out in addiction treatment and harm reduction services, do not significantly help to improve service quality. Therefore, most of the enthusiasm and naiveté with which satisfaction surveys are currently performed and interpreted - and rarely acted on in the case of nonoptimal results - should be avoided. A truly participatory approach to program evaluation is urgently needed to reshape and transform patient satisfaction surveys.

Non-medical use of opioids among HIV-infected opioid dependent individuals on opioid maintenance treatment: the need for a more comprehensive approach

BACKGROUND

Opioid maintenance treatment (OMT) has a positive impact on substance use and health outcomes among HIV-infected opioid dependent patients. The present study investigates non-medical use of opioids by HIV-infected opioid-dependent individuals treated with buprenorphine or methadone.

METHODS

The MANIF 2000 study is a longitudinal study that enrolled a cohort of 476 HIV-infected opioid-dependent individuals. Data were collected in outpatient hospital services delivering HIV care in France. The sample comprised all patients receiving OMT (either methadone or buprenorphine) who attended at least one follow-up visit with data on adherence to OMT (N = 235 patients, 1056 visits). Non-medical use of opioids during OMT was defined as having reported use of opioids in a non-medical context, and/or the misuse of the prescribed oral OMT by an inappropriate route of administration (injection or sniffing). After adjusting for the non-random assignment of OMT type, a model based on GEE was then used to identify predictors of non-medical use of opioids.

RESULTS

Among the 235 patients, 144 (61.3%) and 91 (38.9%) patients were receiving buprenorphine and methadone, respectively, at baseline. Non-medical use of opioids was found in 41.6% of visits for 83% of individual patients. In the multivariate analysis, predictors of non-medical use of opioids were: cocaine, daily cannabis, and benzodiazepine use, experience of opioid withdrawal symptoms, and less time since OMT initiation.

CONCLUSIONS

Non-medical use of opioids was found to be comparable in OMT patients receiving methadone or buprenorphine. The presence of opioid withdrawal symptoms was a determinant of non-medical use of opioids and may serve as a clinical indicator of inadequate dosage, medication, or type of follow-up. Sustainability and continuity of care with adequate monitoring of withdrawal symptoms and polydrug use may contribute to reduced harms from ongoing non-medical use of opioids.

Pregnancy under subutex (buprenorphine): opinions expressed on French internet forums

Internet forums record the opinions and advice exchanged about pregnancy under Subutex. Two hundred and fourteen messages under 92 nicknames from four forums, especially dedicated to this subject in France, from August 2005 to July 2008 were collected and analyzed with QSR NIVIVO8. Most of the Internet users were women, pregnant, or with children, using Subutex. Very few professionals took part in them. The analysis of the opinions and representations of this substance, of medical practices, of exchanged advice, particularly on posology, was realized by the construction of a thematic tree.

[Opiate substitution: the users' point of view]

The needs of drug users for substitution therapy and drug-use-related care can vary greatly, a source of conflict between users and health care professionals and sometimes generating dysfunction of the health care system. For example, in France the lack of injection formulations for substitution therapy has led users to inject their substitution product (Subutex or Skenan) creating a bogus relationship with the pharmacist or physician who do not know how they should react. Beliefs held by health care professionals and the lack of drug abuse training in the pharmacy and medicine curricula can also lead to a dangerous situation for users: physicians may prescribe a dose too low for substitution with the risk of pushing the user into the black market to search for a complement. We detail here the way users would like to use substitution, focusing on the points where they are in agreement or disagreement with health care professionals. We explain why, in our opinion, it is fundamental to take into consideration the users' point of view.

Opiate dependents' experiences of the therapeutic relationship in methadone centers; a qualitative study

BACKGROUND

Methadone maintenance therapy is a treatment of choice for opiate addiction. Understanding opiate dependents' experiences of patients' treatment is a key to continue the treatment and can provide help to revise the standards of methadone centers and improve the quality of treatment. This study aimed to describe the essence and structure of opiate dependents' experiences with methadone maintenance therapy.

METHODS

It was a qualitative phenomenological study, in which participants were selected from opiate dependents referred to methadone centers in Kerman city in 2007. Sampling was purposive and continued until data saturation, which was achieved at 32 participants. Data were collected by in-depth interviews. Colaizzi's method was applied for data analysis. The rigor of the present study was assessed based on the criteria of confirmability and credibility.

FINDINGS

A total of 26 themes were extracted and categorized into three main themes including positive therapeutic alliance, negative therapeutic alliance and therapeutic alliance requests.

CONCLUSION

Client-centered therapy in methadone clinics creates a positive therapeutic alliance, and persuades patients to continue their treatment. Establishing a good relationship with patients during their treatment procedure is an effective way to meet the goals. Individual and group counseling sessions and advices on family and career related issues during the treatment should be considered as well.

[Multiple psychoactive substance use (alcohol, tobacco and cannabis) in the French general population in 2005]

OBJECTIVE

To quantify the different forms of polydrug use in the French population and the principal factors associated with it.

METHODS

Data came from the Baromètre Santé 2005, a general population study. Polydrug use was approached by 2 indicators: regular use of at least 2 products among alcohol, tobacco and cannabis, and the use during the year of at least 2 illegal drugs besides cannabis (not necessarily concomitantly).

RESULTS

Regular use of some combination of alcohol, tobacco and cannabis was reported by 8.3% of the population. Those aged 20-24 years combined tobacco and cannabis most frequently, with 11.6% reporting this joint use. Regular consumption of all 3 products was rare, reported by less than 1% of those aged 15-64 years. It was highest among those aged 20-29 years, but still less than 2% of the age group. The principal combination for those aged 35 years or older was alcohol and tobacco, and those in this group rarely combined cannabis with another substance. There was a strong association between cannabis use and use of other illicit psychoactive substances. Lifetime use of illicit psychoactive substances except for cannabis was reported by 10.0% of the 15-34 year-olds; for use during the previous year, it was 2.3%. The factors associated with these practices were unemployment, male gender, and youth. Postsecondary education appeared to distance young adults from the different forms of polydrug use.

DISCUSSION

Because use of multiple psychoactive substances is often associated with risk-taking or vulnerability, particular attention to these practices is justified. Surveys in the general population do not cover the most vulnerable or most "desocialized" populations and do not allow the most dangerous forms of polydrug use to be described. They supply useful information for assessing the extent of the most common combined uses in the population and their probable health and social repercussions.