AuthorEuropean Monitoring Centre for Drugs and Drug Addiction (EU body or agency)
TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications
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 ones 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.

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