The misuses of Subutex, indicated in heroin withdrawal, are too numerous. The Academy of Medicine enacts a series of very controversial rules to put an end to it.
- 150,000 patients are under treatment with Subutex (high-dose buprenorphine).
- About 15% of them misuse it, for example by injecting it.
- According to the Academy of Medicine, misuse costs paying agencies 250 million euros.
- The generalist branch of the Addiction Federation denounces a series of errors in the press release from the Academy.
The National Academy of Medicine is worried and lets it know. In a brief press release, Jean Costentin, Jean-Pierre Goullé and Gérard Dubois warn about the misuse of Subutex (high-dose buprenorphine) and its generics in heroin and opioid withdrawal. They propose three solutions to improve good compliance: prescribe methadone as first-line, favor generics “more difficult to inject” than Subutex and generalize the use of Suboxone (naloxone / buprenorphine).
Subutex is prescribed as a substitute for opiates in people who are addicted to it. In France, 150,000 patients receive buprenorphine. But in the eyes of the Academy of Medicine, those who do not observe the rules of the prescription are too numerous. “The product is eagerly sought after by heroin addicts, easily accessible by simple prescription: it gives rise to trafficking for which the paying agencies bear the brunt”, denounce the signatories of this press release. This formulation causes an uproar on the side of addictologists. In addition, several errors were noted.
Easier access to substitutes
Buprenorphine should be initiated after failure of methadone, according to the Academy of Medicine. “Offering first-line methadone is not possible,” objected Dr. Xavier Aknine, general practitioner of the MG Addiction pole at the Addiction Federation. The reason is twofold: Subutex and its generics are easier to access and can be prescribed by any doctor. Methadone, on the other hand, can only be prescribed in certain specialized centers, and always in hospitals, which limits its scope. This hierarchy is not even mentioned in recommendations issued in 2004 after the consensus conference.
“The French substitution model is based on wide and easy access to high-dose buprenorphine (HDB) which has greatly contributed to the reduction of morbidity, mortality and social damage over the past 20 years”, recalls Anne-Claire Brisacier, researcher at the French Observatory for Drugs and Drug Addiction (OFDT).
An increased cost
With the increased access to Subutex, a common phenomenon appeared: that of misuse. It concerns about 15% of patients under treatment. This phenomenon is well known to addictologists. It has several causes, including the profile of patients, who are often heroin addicts.
Dr Xavier Aknine, general practitioner (MG Addiction): ” A certain proportion of patients inject Subutex because they injected heroin before and have not mourned this mode of consumption. “
Misuse is precisely what motivates this point of the Academy of Medicine. But MG Addiction, pole of the Addiction Federation, denounces “a malicious presentation. The rapporteurs estimate the cost of misuse in France at 250 million euros. A figure that is in no way supported and difficult to justify in view of the 110,000 patients under treatment. Not to mention that, according to the latest figures from Health Insurance, only 52 million euros have been reimbursed to policyholders.
A phenomenon difficult to identify
To fight against misuse, Social Security has strengthened control measures, supposed to limit unjustified access to the drug. In particular, pharmacists must write their name on each prescription that they issue. But according to a specialist in the file, the “misusers” escape this by exchanging vital cards. Result: according to the OPPIDUM 2009 survey, 10% of patients taking Subutex have never received a prescription.
The other problem linked to misuse is the method of consumption. Subutex is sold as a tablet to dissolve under the tongue. But according to the data from the national pharmacovigilance monitoring, injection of Subutex is the main form of use. The solution is simple for the Academy of Medicine: highlight generics, supposed to be less easily injectable. But the list of excipients has recently been amended, and products causing skin necrosis have been withdrawn.
Xavier Aknine : ” Generics are also injected since they are consumed sublingually. What is recommended with Suboxone is not a panacea either because it is also injected. “
Finally, it is difficult to define the patients who “misuse”. “These are mainly nomadic patients, who move from one practice to another,” explains Jacques Battistoni, general practitioner in Caen (Calvados). The patients I know are obviously not those. The key to good practice, he said, is dialogue with confidence.
Dr Jacques Battistoni, general practitioner: ” Things go well if we manage to build a relationship over time. These are relationships that take place over time. “
But the Academy of Medicine, contrary to its habits, did not consult general practitioners or addictologists, for whom these considerations seem obvious.
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