Re: Illicit Opioid Use and its Key Characteristics: A Select Overview and Evidence from a Canadian Multisite Cohort of Illicit Opioid Users

Abstract

Dear Editor: I found the articles on opioid treatment1,2 in the September 2006 edition of your journal informative and interesting. I was particularly interested in the paper by Fischer, Rehm, and Firestone.1 The 2 comments that struck me the most were, first, that methadone maintenance therapy (MMT) offered few, if any, benefits for nonopioid use and, second, that buprenorphine maintenance had little additional value when compared with MMT. I believe that one of the main differences that may account for their assertions, when compared with the experiences in the United States, is the fact that both MMT and buprenorphine programs are office-based treatments in Canada, whereas MMT programs are federally and state-regulated in the United States. Because of the strict regulation of MMT programs in the United States, they are generally highly structured and comprehensive. Hence, even though they are directed at opiates, the psychosocial programs are quite comprehensive, and skills learned in these programs can be used to address other, nonopioid, illicit drugs. Second, the programs are able to guide patients with appropriate referrals to programs that address other nonopioid illicit drugs. I do not agree with Fischer and colleagues' comment that buprenorphine maintenance may offer little additional value to the current MMT program. Several recent studies have highlighted possible advantages of buprenorphine maintenance treatment. A study by Montoya et al,3 which evaluated buprenorphine treatment for concomitant cocaine and opiate dependence, was quite revealing. In it, 200 outpatients dependent on both substances were randomly assigned to double-blind groups receiving buprenorphine plus weekly individual drug abuse counselling. The study concluded that sublingual buprenorphine at 16 mg daily is well tolerated and effective in reducing concomitant opiate and cocaine use, and more important, the therapeutic effect on cocaine use appeared independent of that on opiate use.3 An injectable depot formulation of buprenorphine that uses biodegradable polymer microcapsule technology has been developed. It is believed that this formulation would minimize the risks of patient nonadherence or illicit diversion of the medication. A study by Sigmon et al4 looked at the effectiveness of this formulation. This was a double-blind, placebo-controlled study, and data collected from 2 studies involving a single injection of 58 mg of buprenorphine concluded that the depot formulation provided effective buprenorphine delivery over several weeks.4 An earlier, open-label study by Sobel et al5 had indicated that this depot formulation produced substantial opioid blockage that persisted for 6 weeks. Thus studies show that buprenorphine would offer significant additional value in the course of time. References 1 . Fischer B, Firestone Cruz M, Rehm J. Illicit opiod use and its key characteristics: a select overview and evidence from a Canadian multisite cohort of illicit opiod users (OPICAN). Can J Psychiatry. 2006;51(10):624-634. 2. van den Brink W, Haasen C. Evidence-based treatment of opioid-dependent patients. Can J Psychiatry. 2006;51(10):635-646. 3. Montoya ID, Gorelick DA, Preston KL, et al. Randomized trial of buprenorphine for treatment of concurrent opiate and cocaine dependence. Clin Pharmacol Ther. 2004;75(1):34-48. 4. Sigmon SC, Moody DE, Nuwayser ES, et al. An injection depot formulation of buprenorphine: extended bio-delivery and effects. Addiction. 2006;101(3):420-432. 5. Sobel BF, Sigmon SC, Walsh SL, et al. Open-label trial of an injection depot formulation of buprenorphine in opioid detoxification. Drug Alcohol Depend. 2004;73(1):11-22. Adegboyega Oyemade, MD New Haven, Connecticut REPLY: Illicit Opioid Use and Its Key Characteristics: A Select Overview and Evidence From a Canadian Multisite Cohort of Illicit Opioid Users Dear Editor: We are pleased to respond to Dr. …