BUPRENORPHINE
and agonist properties began to really accelerate . Methadone maintenance was largely looked upon as a solution to treating opioid-dependent veterans and crime in the USA . Despite its support , its limitations were recognised fully .
By the late 1970s it was assumed that buprenorphine could effectively replace methadone as a treatment in opioid dependence because of its low misuse potential – essentially it was thought to have the benefits of both methadone and naltrexone but fewer drawbacks .
TREATMENT Although sublingual buprenorphine was launched from 1982 for analgesia , it wasn ’ t until 1998 that it was licensed for the treatment of opioid dependence in the UK as an alternative to methadone .
Despite the support buprenorphine gained as having the potential to be the next major medicine for treating opioid dependence , it took three decades to be fully approved and utilised in drug treatment services . The development of buprenorphine met with political and social challenges and as an additional option for opioid substitution treatment it has had mixed responses from patients . The dismantling of the barriers that can exist for opioid substitution treatment , as seen with the widespread use of buprenorphine in France , have led to innovative ways of tackling overdose , treatment and retention rates .
In the next article we will look at the introduction of different buprenorphine preparations , its use during the COVID-19 pandemic , and its safety and cost in comparison to methadone .
Dr Georges Petitjean is the substance misuse medical lead for Inclusion , part of Midlands Partnership NHS Foundation Trust . Deanne Burch is the hepatitis C elimination coordinator for the NHS Addictions Providers Alliance ( NHS APA ).
BUPRENORPHINE PIONEERS
We owe the ability to use buprenorphine as an opioid substitution treatment today to some scientists with endless determination and perseverance . Among them , William Martin , Kenneth Bentley , Donald Jasinski and John Lewis ( pictured ).
John Lewis was born in Gloucester in 1932 and studied chemistry at Oxford . He was instrumental in the development of buprenorphine .
Inclusion : www . inclusion . org The NHS Addictions Provider Alliance : www . nhsapa . org
The authors have not received any financial or other support from pharmaceutical companies and the articles are their own opinion . See the February 2022 issue for part two .
WHAT DID CLINICIANS THINK ABOUT BUPRENORPHINE ?
We asked Dr Emily Finch , vice chair of NHS APA , vice chair of the Addictions Faculty at the Royal College of Psychiatrists and clinical director at South London and Maudsley NHS Foundation ’ s Southwark Central Acute and Addictions Directorate .
When buprenorphine first came to the market as an addiction treatment option in the UK , what were the fears and expectations in drug and alcohol services ?
Discussions were dominated by cost when it first came in . It was initially much more expensive . So there were many thoughts about who was most suitable for it – essentially we were rationing it . The first person I gave it to [ in 2004 ] went into precipitated withdrawal . It probably made me very cautious . Over time prescribers and service users gradually understood the need to be in withdrawal when given the first dose .
There were concerns about the difficulties supervising it . It took longer . It was a time when methadone maintenance was not very old in England and most methadone was supervised . At that time we also had lofexidine which we were using for detox . Service users did not like it at all initially .
We were sceptical about the evidence from France , where methadone was not an option , and the US literature where it was introduced because they couldn ’ t use methadone in ‘ office based ’ settings – effectively primary care . We knew about its reduced overdose potential but we weren ’ t that convinced .
In your opinion , has buprenorphine reached its initial expectations of being a safer and preferred alternative to methadone ?
I don ’ t think that was the initial expectation – perhaps by the drug companies , but not by most UK prescribers . It has revolutionised opioid
detox and has been successful where drug use may be less chaotic . That is its biggest impact – it is safer but only if the service user will take it . All of my prescribing and the policies I have written have emphasised offering buprenorphine as an option equal to methadone – maximal patient information and influenced by the NICE technology appraisal . Often this means prescribing buprenorphine first , then if that is not successful they ’ re prescribed methadone .
How do you explain that buprenorphine prescribing has not become the ‘ gold standard ’ in opioid substitution therapy , as it was originally predicted to be ?
I don ’ t think it was predicted to be the ‘ gold standard ’. Perhaps it is because it doesn ’ t make service users intoxicated . So , they stop taking it . The fact that they need to be in withdrawal for induction is a barrier . Other barriers can be the perception that you cannot ‘ use on top ’ and the fear of not being able to use .
Additionally there has been diversion of buprenorphine in prisons because of the inability to supervise it and the difficulty in induction for many . This can reduce retention rates . The reality is that many people who use drugs in the UK carry on ‘ using on top ’ of their opioid medication . Does that say something about the adequacy of the rest of the treatment system ?
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