Experiencia con buprenorfina en Francia / Buprenorphine: experience in France

Objetivo: En 1995 la Agencia del Medicamento Francesa aprobó buprenorfina (disponible en comprimidos sublinguales de 0,4, 2 y 8 mg) para el tratamiento de la dependencia a opiáceos, y la comercialización del producto comenzó en febrero de 1996. Rápidamente aumentó el uso de buprenorfina, prescrito principalmente por médicos generales. A finales de los noventa se estimó que los médicos generales estaban tratando aproximadamente a 65.000 pacientes al año con buprenorfina y a otros 4.000 pacientes con metadona. En marzo de 2001 se calculó que 74.300 pacientes eran tratados con buprenorfina (tomando una dosis sublingual de 8 mg/día), y otros 9.600 pacientes lo eran con metadona (tomando una dosis oral de 65 mg/día). Cualquier médico puede empezar prescribiendo buprenorfina y cualquier farmacia puede dispensar la medicación. No hay requerimientos de ninguna clase de entrenamiento especializado. La duración máxima de buprenorfina prescrita es de 28 días y el número máximo de dosis para llevar a casa es de siete días, aunque el médico puede hacer caso omiso a esta regla y especificar que sean suministrados más de siete días al paciente. Es posible para las farmacias suministrar diariamente, supervisando la dosis con buprenorfina, si está especificado por el médico. Los estudios han demostrado que esto aumenta el cumplimiento del paciente y reduce la desviación del fármaco. Material y métodos: Se analiza la experiencia clínica del uso de buprenorfina en Francia. Resultados: Los resultados obtenidos de la base de datos de los seguros médicos franceses nos dan información útil sobre los pacientes tratados con buprenorfina. En todos estos estudios, el 80 por ciento o más de los pacientes sólo visita a un médico de manera regular y va a por la medicación a una farmacia. Del 10 al 20 por ciento visita a varios médicos y/o obtiene la medicación en varias farmacias. Menos del 10 por ciento visita a muchos médicos, y posiblemente representan un grupo problemático. En comparación, esto es inferior a la proporción de pacientes problemáticos comunicados en centros de abuso de substancias en Francia, incluyendo los pacientes tratados con metadona. La generalización de estos datos significaría que 20.000 médicos generales (de unos 100.000) están actualmente prescribiendo buprenorfina a 70.000 pacientes (de unos 150.000 a 200.000 con problemas de heroína).Conclusiones: La existencia del abuso y mal uso de buprenorfina está documentada en informes de individuos que utilizan buprenorfina por vía intravenosa. Los usuarios de buprenorfina intravenosa pueden ser bien pacientes en tratamiento que desvían su tratamiento, o individuos que no están en tratamiento y ocasionalmente se inyectan buprenorfina pero prefieren heroína o cocaína. Entre los que no están en tratamiento y usan la vía intravenosa, la mayoría prefiere usar heroína o cocaína cuando es posible. Entre los pacientes en tratamiento hasta el 20 por ciento usa la vía intravenosa en algún u otro momento. Esto se ha constatado tanto para pacientes en tratamiento con buprenorfina o metadona. No obstante, los pacientes de buprenorfina tienen más probabilidades de inyectarse su propio tratamiento de buprenorfina que los pacientes de metadona, que son más proclives a inyectarse heroína o cocaína. Desde 1995 a 1999 el número de muertes por sobredosis disminuyó en un 79 por ciento mientras el número total de individuos bien en tratamiento con buprenorfina o metadona aumentó más del 95 por ciento (de menos de 2.000 a 60.000 al año). Varios autores han comunicado muertes en las cuales fue sugerida la buprenorfina como factor contributivo o causal. Desde 1996 a 2000 han sido comunicadas un total de 137 de dichas muertes. En todos los casos, excepto en uno, fueron identificadas benzodiacepinas y/u otros depresores respiratorios del sistema nervioso central además de buprenorfina (AU)

[Quantitative evaluation of sharing practices of materials at risk for infectious virus contamination by intravenous opiate users seeking treatment--application of the RAB(Risk for AIDS Behavior) self-administered questionnaire]. / Evaluation quantitative des pratiques de partage de matériel à risque de contamination infectieuse virale chez les usagers d'opiacés par voie intraveineuse faisant une demande de soins--utilisation de l'auto-questionnaire RAB.

The objective of this study was to quantify the occurrence of AIDS risk related sharing activities in i.v. opiate users seeking treatment using a self administered questionnaire. Subjects were recruited among first time consultants of an outpatient clinic and assessed using the Risk for AIDS Behavior questionnaire (RAB), a self administered questionnaire that assesses both needle-sharing and unprotected sexual activity; the Beck Depression Inventory (BDI) a self administered questionnaire that assesses depressive symptoms; and the Addiction Severity Index (ASI), a 45-min, structured interview that provides assessments of problem severity in seven functional areas commonly impaired among drug abusers. Among the 102 patients who came in for treatment, all 66 subjects reporting i.v. drug abuse agreed to participate. The study was based on the data collected from these 66 subjects of whom 49 were males (74%) and mean age +/- SD was 31 +/- 5. Fifty-eight-percent of theses subjects reported having shared needles or related paraphernalia over the past 6 months. Despite informational campaigns on the risks of sharing and despite the well spread knowledge of such a risk, most i.v. opiate users seeking treatment report having shared at least once over the previous 6 months.

[Evaluation of the use of psychotropic drugs from urine samples from subjects attending for the first time a clinic specializing in opium addiction]. / Evaluation de l'usage des psychotropes à partir d'échantillons urinaires chez des sujets s'adressant pour la première fois à une consultation spécialisée pour toxicomanie opiacée.

OBJECTIVES: Determine how well drug abusers requesting care accept urine sampling and the reliability of this method for evaluating drug use. METHODS: Subjects attending a specialized drug abuse clinic for the first time were requested to provide a urine sample for semiquantitative analysis using an immunological technique to identify the following substances: barbiturates, benzodiazepines, opiates, cocaine, amphetamines, cannabis, and dextropropoxyphen. RESULTS: All 98 subjects included in the study accepted the urine sample. More than 80% of the samples were positive for 1, 2 or 3 substances. The most frequent were, in decreasing order, opiates, cannabis, benzodiazepines and dextropropoxyphen. Among the opiate-positive subjects (70%), 80% were positive for 2 other substances, usually cannabis and benzodiazepines. Two-thirds of the cocaine-positive cases were observed among the most recently seen subjects. Among the 27 opiate-negative subjects, 16 stated they used buprenorphine. CONCLUSION: Within the setting of this study, urine sampling appeared to be well accepted by drug abusers. Urinalysis gave an objective evaluation of drug use and can be useful on an individual level providing complementary information to the overall examination. Urine sampling can also provide indicators for studying the evolution of drug use practices in different populations, both in a clinical and non-clinical setting.

[Effect of treatment with methadone on utilization of medical care by addicts seropositive for the AIDS virus. Results of a descriptive study, Bayonne, 1996]. / Influence des traitements par la méthadone dans la prise en charge médicale des toxicomanes séropositifs pour le virus du SIDA. Résultats d'une étude descriptive, Bayonne, 1996.

Since two years, 80 patients received methadone maintenance treatment in Bayonne Médecins du Monde Center. In this population, 48% are HIV positive... The aim of this study is to determine the impact of methadone maintenance treatment on the medical status of a group of HIV positive subjects. In addition to the Addiction Severity Index collected data and quality of life evaluation by the TEAQV, the following data are collected: compliance to appointments HIV clinic, CD4 status, evolution of weight, observance of HIV medicine. Preliminary results are presented, showing precisely and confirming the good influence of methadone maintenance treatment on medical care of patients with HIV and AIDS. This kind of study, before and during the maintenance treatment (base line, third month and every six months) appears as a very important stake: for this patients with HIV and AIDS, in term of personal and medical status, for us, in term of methadone treatment impact, and health public care.

[Descriptive studies of the use of the Addiction Severity Index in France]. / Données descriptives issues de l'utilisation de l'Addiction Severity Index en France.

The Addiction Severity Index (ASI) is an instrument that provides, in a 45-minutes semi-structured interview, a multidimensional assessment of substance abuse patients. It was designed in 1980 by A.T. McLellan et al., from Philadelphia PA, in North-America and introduced in France by our group in 1990. Over the past five years we have used it in different substance abuse populations including alcohol users. The goal of this paper is to review the adaptation procedure into French context and to present ASI data from different substance abuse sub-groups: opioïd dependent subjects seeking treatment and former heroïn addicted patients in maintenance treatment. After description of the ASI, presentation of the training procedure for its optimized use and methodological issues, we present for each opiate dependent group acceptability data, results of some of the ASI's 240 items and the severity scores. The Addiction Severity Index provides assessment of problem severity in seven functional areas in which substance abusers are commonly impaired and unable assessment of need for treatment. Objective and subjective patient data are collected in the following seven areas: medical, employment/ support, alcohol, drug use, legal, family/social relationship, and psychiatric. The ASI is both broad in the extent of its evaluation and yet easy to use for appropriately trained interviewers. Use of the ASI over the past five years allows us to underline the following characteristics: in the clinical setting the ASI unable a common descriptive analysis for need and adaptation for treatment of different patients populations; in the research setting the ASI is particularly suited for epidemiological studies of addiction and description, analysis or evaluation research.

A naturalistic follow-up study of French-speaking opiate-maintained heroin-addicted patients: effect on biopsychosocial status.

The purpose of this study was to evaluate the impact of opiate maintenance pharmacotherapy (OMP) on the biopsychosocial status of opiate-addicted patients in a cultural environment (France) that is not favorable to OMP and where methadone is not available. Buprenorphine and laudanum (opium tincture), which, to our knowledge, has not been reported previously in the scientific literature for OMP, were used in this study of a group of 18 opioid-dependent subjects. At time of initiation of OMP, mean age was 33 years, sex ratio male: female was 14:4, average duration of drug use was 11.2 years. Six patients received laudanum p.o., 15 g daily; 12 patients received buprenorphine sublingual 2 to 4 mg daily. This group of patients was selected because of persistent relapse and impairment after an average of 5.7 drug-free-oriented treatments over a period of 6.8 years. Initial evaluation and follow-up were made by way of a 150-min semi-structured interview using the Lifetime Retrospective Evaluation Score Table (LREST) and the Addiction Severity Index (ASI). Results showed that body weight and scores for physical and psychological health, socioprofessional status, and family relationships improved significantly after 14 months of OMP. These results show that highly impaired opiate-addicted patients doing poorly in drug-free treatment can respond to OMP even though methadone is not available and the idea of OMP is not favored.

Opiate withdrawal and electro-stimulation. Double blind experiments.

A rapid detoxification technique for heroin addicts is described. The technique uses an impulsional electric current developed by Limoge. The treatment is nonaggressive, very well tolerated by the addicts and leads to a good psychotherapeutic relationship with the medical staff. A successful physical detoxification is achieved in more than 80% of the cases (this figure is based on 400 patients treated by the method). The technique was subjected to two double-blind experiments. The first experiment tested the real efficacity of the electrical stimulation. The difference between the group of subjects stimulated and the unstimulated control group had a "p-value" which was significant at the 0,5% level. This leads us to believe that the electrical stimulation has a real positive effect. The second experiment reconfirmed the efficacity of the stimulation and showed that 24 hour continuous stimulation was not sufficient to produce a lasting effect. After about 50 hours stimulation a Naloxone test produced little or no reaction in the patients.