Discussion

• Author: European Monitoring Centre for Drugs and Drug Addiction (EU body or agency)
• Pages: 36-38

TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications

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or distributing smaller quantities of medications that generally they have themselves been

prescribed (Fountain et al., 2000; Fountain and Strang, 2003; Cicero and Inciardi, 2005; Mravcik

et al., 2018). These are comparatively closed systems of current opioid users and patients

undergoing OST (Spunt et al., 1986; Johnson and Richert, 2015). Small quantities of OST

medications are re-sold or handed over for free between family members, friends and

acquaintances with similar drug experiences (Johnson and Richert, 2015). Among some groups

of high-risk opioid users, it may be considered morally right to share one’s medication with those

who do not have access to OST programmes and are at risk of experiencing withdrawal

symptoms (Havnes et al., 2013). Effective anti-diversion policies will necessarily require an

understanding of these morally driven transactions at the local level.

5. Discussion

European countries have experienced unprecedented health and social consequences of

increasing heroin use and drug injecting that emerged in the 1980s, in particular rising HIV/AIDS

and overdose deaths, as well as crime and open drug scenes. Today, remarkable

improvements have been documented in many countries, where comprehensive drug policies

incorporating scaled-up OST programmes with methadone and buprenorphine have been

implemented (Hedrich and Pirona, 2017). Substantial progress has been made towards the

elimination of new HIV infections among people who inject drugs, and high availability of OST

has been instrumental in this achievement. Across the European Union, which in 2017 had over

500 million citizens, just 1 046 newly reported HIV cases were attributed to drug injecting. In

many cities, crime and public order problems related to drug use have also diminished

substantially. OST has been a contributing factor in reducing the social cost of heroin use and

improving the life expectancy of heroin users, and we are now observing ageing cohorts in their

40s and 50s while, at the same time , the number of younger heroin-naive users is at an all-time

low. These data provide some reassurance that Europe is currently not facing a similar opioid

crisis as that recently observed in the United States.

At the same time, the use of and harms associated with opioids other than heroin, primarily

among experienced and older high-risk opioid users, are providing cause for concern. Signals

from law enfo rcement agencies and health data indicate growing issues with tramadol and

fentanyl and fentanyl derivatives, while data presented here reveal that the scale of domestic

diversion and misuse of prescription OST medications is not negligible in several countries.

5.1. Addressing harms

Currently, methadone remains the predominant medication prescribed for OST in two thirds of

the EU Member States. It is therefore also the one most commonly mentioned among opioid-

related deaths involving OST medications. WHO guidance recommends that different opioid

substitution medications be made available for treatment. Increasing the range of available

buprenorphine-based OST medications, including the abuse-deterrent combination

buprenorphine-naloxone, could reduce the risk of mortality associated with non-prescribed

methadone. As a partial agonist, buprenorphine-based medications present a safer toxicological

profile than methadone, which is a full agonist and increases the risk of overdose when used

outside therapeutic guidance. A recent study in the United Kingdom examined the population-

wide overdose risk emerging from the prescription of methadone and buprenorphine for OST in

England and Wales (Marteau et al., 2015). This analysis of the relative safety of buprenorphine

and methadone for OST revealed that buprenorphine was six times safer than methadone with

regard to the overdose risk among the general population.