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Methadone’s dominance over
Suboxone in substitute prescribing may
have more to do with cost than
effectiveness. It could be time for a
reassessment, say
Neil McKeganey,
Christopher Russell
and
Lucy Cockayne
drug dependent. The drug users who had been prescribed methadone in this
general practice based study had a mean injecting career of some 20 years
compared to a mean of nearer five years for those who had not been prescribed
methadone. ‘Exposure to opiate substitution treatment was,’ the authors pointed
out, ‘inversely related to the chances of achieving long term cessation.’
Along with the worry that methadone may lengthen the duration of an
individual’s dependency, there has also been growing concern at the increasing
proportion of drug-related deaths that are in some way connected to methadone.
In Scotland, for example, some 47 per cent of drug user deaths were recently
shown to be connected with methadone (
DDN
, September, page 4), although it’s
not known what proportion of those deaths involved individuals who had sourced
their methadone on the streets rather than being prescribed the drug.
In the light of those concerns it’s understandable that attention has come to
focus on other substitute medications that may offer some of the benefits of
methadone without the additional risks. One such drug, the buprenorphine/
naloxone combination Suboxone, has been licensed for use in Europe since 2006.
*****
According to the National Institute for Health and Clinical Excellence (NICE)
there is very little difference between buprenorphine and methadone in terms
of their therapeutic effect and therefore, according to NICE, the decision as to
which drug to prescribe should be based upon an assessment of the individual
drug user’s circumstances.
On the basis of that advice one might have thought that Suboxone and
methadone would by now be prescribed at a broadly similar rate. This is certainly
the case in Norway, with methadone prescribed to 56 per cent of those receiving
opiate substitution treatment compared to 44 per cent who are on Suboxone. In
Sweden, 48 per cent of those on opiate substitution treatment are receiving
methadone, compared to 52 per cent who are being prescribed Suboxone.
W
ithin the drug treatment field there are few more
controversial subjects than the role of substitute
prescribing. For some people, drugs such as methadone
and Suboxone represent a lifesaver, enabling individuals to
reduce or cease their use of street drugs and stabilise their
lives as a prelude to their eventual recovery and rehabilitation. For others,
the prescription of these drugs on a maintenance basis is little more than a
form of state-sponsored addiction.
The importance given to recovery in the UK drug strategy has brought
renewed attention to the role of substitute prescribing, with the NTA recently
publishing revised guidance on how to maximise the beneficial impact of
opiate substitute treatment within a recovery-oriented treatment system.
In the period since the mid-1960s, when Vincent Dole and Marie Nyswander
undertook groundbreaking work, methadone has become the mainstay of
addictions treatment in countries across the globe. In the UK it is estimated that
something in the region of 166,000 drug users are receiving opiate substitution
treatment, the vast majority of whom are being prescribed methadone.
We know from research that methadone reduces drug users’ risk of
overdose, needle and syringe sharing, and of becoming HIV and HCV
positive. Research in Edinburgh has also shown that drug users who are
prescribed methadone have a significantly reduced risk of dying from drug-
related causes (Kimber
et al
, 2010). We also know that drug users prescribed
methadone commit fewer crimes, remain in contact with drug treatment
services for longer and have a more stabilised lifestyle. But what we do not
know is how good methadone is at enabling individuals to recover from
being psychologically or physically dependent on opiate drugs.
The Edinburgh based research undertaken by Kimber and colleagues gave
some cause for concern in this respect, with evidence showing that methadone
may lengthen, rather than shorten, the period over which individuals remain
16 |
drinkanddrugsnews
| November 2012
Substitute prescribing |
Suboxone
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