TECHNICAL REPORT | Balancing access to opioid substitution treatment with preventing diversion of medications
Dependence Update 2017 Independent Expert Working Group, 2017). The main difficulty for
patients who are using non-prescribed OST medications is that it is not possible for doctors to
accurately predict equivalent therapeutic doses in most cases at the start of treatment. This is
especially true for street methadone or buprenorphine, as the purity is variable, or when past
dosages are unknown. It is also problematic to convert the dosage from one medication to
another when the half-lives are not equivalent (e.g. between methadone and buprenorphine).
Clinicians must therefore apply careful clinical judgement and monitor the progress of treatment
carefully, especially during the early stages of treatment. The initial OST dose should aim to
achieve an effective level of comfort, both physical and psychological, while minimising the
likelihood of overdose.
4. Prevention of diversion of opioid substitution treatment
OST medications such as methadone and buprenorphine are controlled drugs for medical (and
scientific uses) and can be obtained only by prescription from a doctor. Depending on the
country, specialised doctors (e.g. psychiatrists or accredited medical doctors) or non-specialised
doctors (e.g. general practitioners) can prescribe these medications (for an overview, see
EMCDDA, 2019b). These controlled medications are subject to strict record keeping and
storage in pharmacies, either at community pharmacies or at OST treatment centres. Despite
these precautions, the diversion of prescription OST medications for non-medical use remains a
common problem in Europe.
European countries have implemented a number of strategies at the national level to control
and prevent the diversion of OST medications (EMCDDA, 2016). These include providing
training for clinicians and patients, implementing strategies to assure therapeutic compliance by
appropriate prescription of dosing, the use of electronic medicine dispensers and employing
control measures such as patient toxicology tests, pill counts and unannounced monitoring.
Monitoring of prescribing practices can take place through registers of patients and/or pharmacy
transactions and the enforcement of appropriate prescribing through disciplinary measures or
administrative sanctions. Other control measures include legal restrictions on the medical
professions and clinical settings and dispensaries of pharmaceuticals that are allowed to
prescribe and/or dispense OST medications, pre-authorisation procedures, the use of special
prescribing forms and regulations stipulating that administration of doses must be under direct
supervision in specialised treatment centres or pharmacies.
One strategy to prevent the diversion of OST medications is to register patients receiving OST
and, in some countries, one central register records all patients at the national level. This has a
number of advantages, as it prevents patients from receiving methadone, buprenorphine or
other OST medications from more than one source. It can be used to limit access to other
controlled medicines requiring central approval, such as other opioids, and it can provide more
accurate data on treatment numbers than would be available in situations in which central
registration is not used. A potential disadvantage, however, of the central registration of patients
is that it can risk breaches of privacy, and this may deter some patients from entering treatment.
According to WHO guidelines, safe and effective treatment of opioid dependence can be
achieved without central registration. Because such registration could cause harm if privacy is
breached, it should be used only if government agencies have effective systems for maintaining
privacy and personal data security. In addition, in most Member States, especially in eastern
European countries, medical doctors have to use special prescription forms, often in multiple
copies, to inform the central registration system. These forms are not always free of charge, and