Buprenorphine supply by community pharmacists in Victoria, Australia: perceptions, experiences and key issues identified.

Buprenorphine is dispensed primarily in community pharmacies in Victoria, with buprenorphine prescribing expanding nationally. The aim of this paper was to examine issues that affect the delivery of buprenorphine in the community setting. A cross-sectional survey was conducted of 282 pharmacies participating in the methadone and buprenorphine programme across Victoria. Dispensing pharmacists completed the survey, designed to canvass issues around buprenorphine diversion and other issues related to the programme. Themes from the results indicated that there was concern from the majority of pharmacies with the issue of the supervision of buprenorphine and diversion of dispensed doses. The rate of suspected diversion was 1.5 times per 100 doses per month or 33 times per 100 clients per month. Seventy-four per cent of pharmacists indicated that this was a negative aspect of buprenorphine treatment. Frequency of suspected and confirmed diversion was associated with the number of pharmacy clients. Pharmacists' perceptions of issues related to buprenorphine appeared to affect opinions of buprenorphine clients and the buprenorphine programme more generally. Pharmacists believe that a significant level of diversion is occurring. This finding warrants serious attention, particularly in light of the increasing use of buprenorphine nationally and internationally.

Treating codeine dependence with buprenorphine: Dose requirements and induction outcomes from a retrospective case series in New South Wales, Australia.

INTRODUCTION AND AIMS: Codeine dependence is an emerging public health concern, yet no studies have specifically examined the treatment of codeine dependence. Given the lower potency of codeine it cannot be assumed that buprenorphine dose requirements for heroin dependence will generalise to codeine. This is the first study to examine buprenorphine treatment for codeine dependence. DESIGN AND METHODS: Retrospective case series of 19 codeine-dependent treatment entrants who received sublingual buprenorphine maintenance treatment through six specialist inpatient and outpatient treatment centres. Baseline codeine doses and buprenorphine dose at days 7 and 28 were collected, in addition to details on general demographics, pain and mental health, substance use and outcomes after 28 days of buprenorphine treatment. RESULTS: A significant linear relationship was found between initial codeine dose and dose of buprenorphine given at days 7 and 28 for the codeine dose range of 50-960 mg day-1 (mean: 564 mg; 95% confidence interval 431-696 mg). Median buprenorphine dose was 12.0 mg (interquartile range 9.5 mg, range 4-32 mg) at day 7 and 16.0 mg (interquartile range 13.5 mg, range 4-32 mg) at day 28. Buprenorphine doses received were markedly higher than estimated codeine doses based on standard dose conversion tables. DISCUSSION AND CONCLUSIONS: With increasing presentations relating to codeine dependence, these findings provide important guidance to clinicians. Buprenorphine doses were consistently higher than doses estimated based on the dose of codeine consumed, and were comparable with doses used in the treatment of dependence with heroin and more potent prescription opioids. [Nielsen S, Bruno R, Murnion B, Dunlop A, Degenhardt L, Demirkol A, Muhleisen P, Lintzeris N. Treating codeine dependence with buprenorphine: Dose requirements and induction outcomes from a retrospective case series in New South Wales, Australia. Drug Alcohol Rev 2015].

Comparing treatment-seeking codeine users and strong opioid users: Findings from a novel case series.

INTRODUCTION AND AIMS: Few studies have described those seeking treatment for codeine dependence. This study aimed to compare patients presenting for treatment where either codeine or a strong pharmaceutical opioid (oxycodone or morphine) was the principal drug of concern to understand if codeine users may have unique treatment needs. DESIGN AND METHODS: Retrospective case review of 135 patients from three geographical areas in New South Wales, Australia. Cases where the principal drug of concern was codeine (n = 53) or a strong pharmaceutical opioid (oxycodone or morphine, n = 82) were compared. Differences in demographic characteristics, pain history, mental health, substance use history and, subsequently, the treatment that was received were examined. RESULTS: People whose principal drug of concern was codeine were more likely to be female (66% vs. 37%, P < 0.001), employed (43% vs. 22%, P < 0.01) and use only one pharmaceutical opioid (91% vs. 49%, P < 0.001). There was no difference in age between the codeine group (mean 38.6 years) and the strong opioid group (39.3 years). Opioid substitution therapy was the most common treatment received by both groups although codeine patients were more likely to be treated with buprenorphine than methadone (odds ratio = 7.7, 95% confidence interval 2.2-27.2, P < 0.001) and more likely to attempt withdrawal (odds ratio = 2.6, 95% confidence interval 1.2-5.3, P = 0.010). DISCUSSION AND CONCLUSIONS: There are important differences between codeine-dependent patients and strong prescription opioid-dependent patients. Further work should explore the outcomes of withdrawal versus maintenance treatment for codeine users.

Nabiximols as an agonist replacement therapy during cannabis withdrawal: a randomized clinical trial.

IMPORTANCE: There are no medications approved for treating cannabis dependence or withdrawal. The cannabis extract nabiximols (Sativex), developed as a multiple sclerosis treatment, offers a potential agonist medication for cannabis withdrawal. OBJECTIVE: To evaluate the safety and efficacy of nabiximols in treating cannabis withdrawal. DESIGN, SETTING, AND PARTICIPANTS: A 2-site, double-blind randomized clinical inpatient trial with a 28-day follow-up was conducted in New South Wales, Australia. Participants included 51 DSM-IV-TR cannabis-dependent treatment seekers. INTERVENTIONS: A 6-day regimen of nabiximols (maximum daily dose, 86.4 mg of Δ9-tetrahydrocannabinol and 80 mg of cannabidiol) or placebo with standardized psychosocial interventions during a 9-day admission. MAIN OUTCOMES AND MEASURES: Severity of cannabis withdrawal and cravings (Cannabis Withdrawal Scale), retention in withdrawal treatment, and adverse events. Secondary outcomes include postwithdrawal cannabis use, health outcomes, and psychosocial outcomes. RESULTS: Nabiximols treatment significantly reduced the overall severity of cannabis withdrawal relative to placebo (F8,377.97 = 2.39; P = .01), including effects on withdrawal-related irritability, depression, and cannabis cravings. Nabiximols had a more limited, but still positive, therapeutic benefit on sleep disturbance, anxiety, appetite loss, physical symptoms, and restlessness. Nabiximols patients remained in treatment longer during medication use (unadjusted hazard ratio, 3.66 [95% CI, 1.18-11.37]; P = .02), with 2.84 the number needed to treat to achieve successful retention in treatment. Participants could not reliably differentiate between nabiximols and placebo treatment (χ21 = 0.79; P = .67), and those receiving nabiximols did not report greater intoxication (F1,6 = 0.22; P = .97). The number (F1,50 = 0.3; P = .59) and severity (F1,50 = 2.69; P = .10) of adverse events did not differ significantly between groups. Both groups showed reduced cannabis use at follow-up, with no advantage of nabiximols over placebo for self-reported cannabis use (F1,48 = 0.29; P = .75), cannabis-related problems (F1,49 = 2.33; P = .14), or cannabis dependence (F1,50 < 0.01; P = .89). CONCLUSIONS AND RELEVANCE: In a treatment-seeking cohort, nabiximols attenuated cannabis withdrawal symptoms and improved patient retention in treatment. However, placebo was as effective as nabiximols in promoting long-term reductions in cannabis use following medication cessation. The data support further evaluation of nabiximols for management of cannabis dependence and withdrawal in treatment-seeking populations. TRIAL REGISTRATION: anzctr.org.au Identifier: ACTRN12611000398909.

Severe opiate withdrawal in a heroin user precipitated by a massive buprenorphine dose.

By diverting his dispensed medication, our patient collected 11 buprenorphine tablets (8 mg each), which he took in one day. The result was not respiratory depression, but instead severe opiate withdrawal lasting four days--this scenario has not previously been reported. This case highlights features of the unique pharmacology of buprenorphine and some key issues for its use in the management of heroin dependence.

Training primary health care professionals to provide buprenorphine and LAAM treatment.

This paper describes the development and implementation of training programs for primary care medical practitioners and pharmacists in the delivery of buprenorphine and LAAM treatment in the management of opiate dependence. Separate training programs were developed for each medication. Each training package included learning objectives, training materials, and assessment instruments. Findings of the evaluation of these initiatives and the subsequent Australian postregistration training program for buprenorphine are described.