Illicit Opioid Users Research Articles

Predictors of transition to opioid dependence among illicit pharmaceutical opioid users

that it increased well-being/life satisfaction (94, 94%) than those in the CE group (31% for spiritually significant; 76% for well-being). Conclusions: The phenomenology of psilocybin experiences in the LS group was more similar to that in the ME group than the CE group, suggesting that laboratory procedures are effective at minimizing negative experiences andmaximizing positive experiences. Financial support: NIH grants T32DA007209 and R01DA003889, the Heffter Research Institute and the Council on Spiritual Practices.

Contraceptive use and pregnancy outcomes among opioid drug-using women: a retrospective cohort study.

ObjectiveThe contraceptive needs of illicit opioid users differ from non-drug users but are poorly understood. The aim of this study was to describe contraceptive use and pregnancy outcomes in opioid-using women, and to examine their association with a range of risk factors.MethodThis retrospective cohort study used UK general practice records, Treatment Outcomes Profile and National Drug Treatment Monitoring System data, and a nested data validation exercise. A cohort of 376 women aged 20–61 years were in active treatment for opioid addiction in October 2010 at two specialised primary care practices in North-East England. Outcomes were age-adjusted prevalence estimates for contraceptive use and pregnancy outcomes in users of illicit opioids. The association between lifestyle-related risk factors and contraception was explored.ResultsDrug-using women made lower use of planned (non-condom) contraception (24% vs 50%, p<0.001), had more frequent pregnancy terminations (0.46 vs. 0.025, p = 0.004) and higher annual incidence of chlamydia (1.1% vs. 0.33%, p<0.001), when compared with age-matched population data. Specifically, there was low use of oral contraceptives (4% vs. 25%, p<0.001), IUCD (1% vs. 6%, p<0.001), and sterilisation (7% vs. 6%, p = 0.053), but higher rates of injectable contraceptives (6% vs. 3%, p = 0.003). A total of 64% of children aged <16 years born to this group did not live with their mother. No individual risk factor (such as sex-working) significantly explained the lower use or type of non-condom contraception.ConclusionsThis is the first study to describe planned contraceptive use among drug-users, as well as the association with a range of risk factors and pregnancy outcomes. The low uptake of planned contraception, set against high rates of terminations and sexually transmitted disease demonstrates the urgent clinical need to improve contraceptive services, informed by qualitative work to explore the values and beliefs influencing low contraceptive uptake.

Personality as a risk factor for illicit opioid use and a protective factor for illicit opioid dependence

BackgroundMost studies investigating the role of personality as a risk factor for the development of opioid dependence compare dependent opioid users with healthy controls who never used heroin. In order to understand the potential protective role of personality, it is crucial to compare illicit opioid users who never became dependent with dependent opioid users. AimsThis study aims to examine the role of personality as a risk factor for opioid use and as a protective factor for the development of opioid dependence. MethodsComparing personality factors between three groups: (1) 161 never-dependent illicit opioid users who have been using illicit opioids but never became opioid dependent; (2) 402 dependent opioid users in methadone maintenance treatment or heroin-assisted treatment; and (3) 135 healthy controls who never used heroin. Personality was assessed with a short version of Cloninger's Temperament and Character Inventory. ResultsNever-dependent opioid users reported more Novelty Seeking and Harm Avoidance and less Self-Directedness and Cooperativeness than healthy controls and more Reward Dependence and Self-Directedness, and less Harm Avoidance than dependent opioid users. Furthermore, never-dependent opioid users reported more Self-Transcendence than both dependent opioid users and healthy controls. ConclusionsNever-dependent opioid users may have started to use opioids partly due to their tendency to seek novel and/or spiritual experiences (high Novelty Seeking, high Self-Transcendence) and their tendency to avoid aversive stimuli (high Harm Avoidance), whereas they may have been protected against the development of dependence by their need for social approval (high Reward Dependence) and their self-efficacy (high Self-Directedness).

Preventing Prescription Opioid Overdose Deaths

Preventing Prescription Opioid Overdose Deaths

“I just wanted to tell you that loperamide WILL WORK”: A web-based study of extra-medical use of loperamide

AimsMany websites provide a means for individuals to share their experiences and knowledge about different drugs. Such User-Generated Content (UGC) can be a rich data source to study emerging drug use practices and trends. This study examined UGC on extra-medical use of loperamide among illicit opioid users. MethodsA website that allows for the free discussion of illicit drugs and is accessible for public viewing was selected for analysis. Web-forum posts were retrieved using web crawlers and retained in a local text database. The database was queried to extract posts with a mention of loperamide and relevant brand/slang terms. Over 1290 posts were identified. A random sample of 258 posts was coded using NVivo to identify intent, dosage, and side-effects of loperamide use. ResultsThere has been an increase in discussions related to loperamide's use by non-medical opioid users, especially in 2010–2011 Loperamide was primarily discussed as a remedy to alleviate a broad range of opioid withdrawal symptoms, and was sometimes referred to as “poor man's” methadone. Typical doses ranged 70–100mg per day, much higher than an indicated daily dose of 16mg. ConclusionsThis study suggests that loperamide is being used extra-medically to self-treat opioid withdrawal symptoms. There is a growing demand among people who are opioid dependent for drugs to control withdrawal symptoms, and loperamide appears to fit that role. The study also highlights the potential of the Web as a “leading edge” data source in identifying emerging drug use practices.

Prescription Opioid Misuse

Prescription opioid use is highly prevalent and a major physician concern. However, little is known about how individuals initiate into use of these medications or how they use them later in life. Hydromorphone is a medication of particular interest given its subjective similarities to heroin and tendency to be misused by illicit opioid users. The purpose of this study was to evaluate the characteristics of initial, and more recent, hydromorphone use occasions as remembered by a population of individuals in treatment for their opioid use. Seventy-eight clients enrolled in low-threshold methadone maintenance treatment were interviewed regarding their earliest and most recent uses of hydromorphone. Hydromorphone was first used after trying many different substances (eg, tobacco, alcohol, hallucinogens, powder cocaine). Two-thirds of the sample reported initially using hydromorphone without a prescription. Participants who initially used hydromorphone without a prescription reported using for different reasons (ie, to get high, curiosity vs manage pain), via different routes of administration (ie, injection vs orally), and were more likely to co-use other substances, than those whose earliest hydromorphone use was prescribed. However, these 2 subgroups did not differ greatly during their most recent use occasion (ie, the majority reported using to avoid withdrawal, via injection; almost 50% reported co-use with other substances). There was considerable variability in characteristics of hydromorphone use initiation among individuals enrolled in low-threshold methadone maintenance treatment. However, later use of hydromorphone was remarkably consistent across individuals and shares many characteristics previously documented for heroin use. Additional investigations into hydromorphone are warranted, particularly given previous findings regarding the prevalence of nonmedical use of this drug and its similarities to heroin.

Current and potential pharmacological treatment options for maintenance therapy in opioid-dependent individuals.

Opioid dependence, manifesting as addiction to heroin and pharmaceutical opioids is increasing. Internationally, there are an estimated 15.6 million illicit opioid users. The global economic burden of opioid dependence is profound both in terms of HIV and hepatitis C virus transmission, direct healthcare costs, and indirectly through criminal activity, absenteeism and lost productivity. Opioid agonist medications, such as methadone and buprenorphine, that stabilize neuronal systems and provide narcotic blockade are the most effective treatments. Prolonged provision of these medications, defined as maintenance treatment, typically produces improved outcomes when compared with short-duration tapers and withdrawal. The benefits of opioid agonist maintenance include decreased illicit drug use, improved retention in treatment, decreased HIV risk behaviours and decreased criminal behaviour. While regulations vary by country, these medications are becoming increasingly available internationally, especially in regions experiencing rapid transmission of HIV due to injection drug use. In this review, we describe the rationale for maintenance treatment of opioid dependence, discuss emerging uses of opioid antagonists such as naltrexone and sustained-release formulations of naltrexone and buprenorphine, and provide a description of the experimental therapies.

Buprenorphine as a safe alternative to methadone in a patient with acquired long QT syndrome: a case report

A 52-year-old man with a medical history of intravenous drug abuse was admitted to our hospital with syncope due to torsades de pointes (TdP). Two days earlier, he had used methadone. The electrocardiogram showed a prolonged corrected QT interval (QTc) of 600 ms. Continuous telemetry observation showed multiple episodes of TdP. The patient was diagnosed with bradyarrhythmia-induced TdP with acquired long QT syndrome resulting from methadone use. The QTc normalised within 2 weeks after discontinuation of the methadone. In this case of a patient with opioid dependency, there is a reasonable risk of repeated methadone use. Therefore, implantable cardioverter defibrillator or pacemaker implantation is justified but risky because of possible infections when using intravenous drugs. Given the high mortality rates seen in untreated illicit opioid users, this patient needs an alternative pharmacological treatment. Buprenorphine is an opiate-receptor agonist associated with less QTc prolongation. The patient was referred to a rehab clinic and treated with an oral combination of buprenorphine and naloxone (Suboxone). During this therapy, his QTc remained normal.

Effectiveness of chronic hepatitis C treatment in drug users in routine clinical practice: results of a prospective cohort study

Injection drug users are often excluded from hepatitis C virus (HCV) treatment. This study compares sustained virological response, adherence, and quality of life in patients with or without a history of illicit drug use in routine clinical practice. This is a post-hoc analysis of a prospective, observational study conducted in 1860 patients who received peginterferon alpha-2b/ribavirin combination therapy. Nondrug users (NDUs) were defined as patients without a history of drug addiction; former drug users (FDUs) as patients who had stopped using illicit drugs or opioid maintenance therapy and active drug users (ADUs) as patients using illicit drugs or on opioid maintenance therapy. Virological response, adherence, and the health-related quality of life were assessed by the measure of HCV RNA in the serum, self-report and 36-item short-form health survey Questionnaire, respectively. The analyzed population included 1038 (56%) NDUs, 578 (31%) FDUs, and 244 (13%) ADUs. About 85% of ADUs were on opioid maintenance therapy and 25% used illicit drugs. Although ADUs had a more chaotic lifestyle and more psychiatric disorders, sustained virological response of ADUs (58%) did not differ from that of NDUs (49%) and FDUs (51%) (P=0.133). Adherence rates were 39% in NDUs and FDUs, and 37% in ADUs (P=0.883). Health-related quality of life was improved in the three groups after the end of treatment. Our study suggests that HCV therapy in ADUs on opioid maintenance therapy is as effective as in other HCV patients. The effectiveness of HCV therapy in illicit drug users needs to be evaluated in further studies.

Methadone-associated Q-T interval prolongation and torsades de pointes

The association of methadone with Q-T interval prolongation and torsades de pointes (TdP) is reviewed, and recommendations for preventing Q-T interval prolongation in methadone users are provided. Abnormalities in voltage-gated potassium channels have been shown to lead to prolonged action potentials that are expressed as long Q-T intervals, and methadone has been found to interact with the voltage-gated potassium channels of the myocardium. While cardiac arrhythmias in methadone users have been reported for several decades, specific reports of methadone-associated Q-T interval prolongation and TdP did not appear in the literature until the early part of the 21st century. Because not every patient experiences Q-T interval prolongation with methadone, recent research has elucidated risk factors that predispose patients to this adverse effect, including female sex, hypokalemia, high-dose methadone, drug interactions, underlying cardiac conditions, unrecognized congenital long Q-T interval syndrome, and predisposing DNA polymorphisms. Given the high mortality rates seen in untreated illicit opioid users and the clear efficacy of methadone in treating opioid addiction, the risk of using methadone, even in a patient with other risk factors for Q-T interval prolongation, may outweigh the alternative of no pharmacologic treatment. A baseline electrocardiogram (ECG), personal and family history of syncope, and a complete medication history should be obtained before a patient begins treatment with methadone. Given the apparent synergistic effects of parenteral methadone and chlorobutanol, oral methadone should be used whenever possible. Q-T interval prolongation and TdP associated with the use of methadone are potentially fatal adverse effects. A thorough patient history and ECG monitoring are essential for patients treated with this agent, and alterations in treatment options may be necessary.

A Blueprint for Reforming Access to Opioid Medications: Entry Points for International Action to Remove the Policy Barriers to Care and Treatment

Opioids medicines are the standard of care for treating severe pain. Drugs like methadone and buprenorphine have proven effective in treating dependency on heroin and other opiods. Access to therapeutic opioids is not only medically appropriate - it is the law. The world's drug control treaties recognize that opioid medicines are indispensable to proper medical care, and require signatories to take measures to adequately provide for their effective medical use.In spite of all the reasons that access to therapeutic opioids should be routine everywhere, there remains a huge unmet need and a striking global inequality in access. The WHO has estimated that 80% of the world's cancer patients and half of all people with AIDS suffer untreated severe pain. Millions of injection drug users and illicit opioid users are forced to go without methadone treatment because the opioids needed for care are either overly regulated or under-provided. The purpose of this report, funded by the U.K. Department for International Development, is to capture what can be learned from past reform efforts, and to set out practical interventions that can help nations at any stage of readiness. Its primary audience is those who fund, advocate for or facilitate policy reform through technical assistance and training. The Blueprint begins with a discussion of the guiding principles of balance and sustainability. It then sets out a strategy for investment in opiod access reform built around an understanding of the cycle of policy learning and identifies tactics for advancing reform that were effective in the countries whose experience we examined.

The Global Diversion of Pharmaceutical Drugs series

In recent issues of Addiction, a number of papers have described an apparent increase in the use of diverted pharmaceutical drugs [1–3]. In multiple high-income countries the use of some illicit drugs, particularly heroin, has plateaued or dropped [4,5]. However, data sources also suggest that use of diverted pharmaceutical opioids is increasing [3,5], particularly morphine, oxycodone, codeine and hydromorphone. Studies in the United States have reported dramatic increases in extra-medical prescription opioid use, e.g. fentanyl, morphine and oxycodone [6]; the number of opioid analgesic poisoning deaths in the United States almost doubled between 1999 and 2002, and by 2002 was identified in more deaths than either heroin or cocaine [1,7]. Australian epidemiological monitoring data suggest that the use of codeine, morphine and, to a lesser extent, oxycodone, has increased among people who inject drugs regularly, driven possibly by sustained decreases in the availability and quality of heroin in the country [5]. A longitudinal survey of illicit opioid users in the Canadian OPICAN study documented higher levels of pharmaceutical opioid use among its cohort members in 2005 compared to 2001 [8]. The causes and mechanisms of this phenomenon remain poorly understood, particularly outside the United States [1]. It is likely that lower availability of heroin explains the increase in some contexts; increased marketing and availability of the pharmaceutical products accounts for it in others. In other countries still, an increase in the production of pharmaceutical opioids, accompanied by a poor capacity to police supply chains and minimize large-scale diversion, accounts for it in others. Whatever the causes may be, the observed epidemiological developments described in high-income countries have major implications for interventions, policy and research. The processes of diversion are fundamentally different from those seen with traditional illicit drugs such as heroin and cocaine. Illicit drugs production and manufacture have inspired border protection and military-style intervention, with arguably little positive effect and significant identifiable negative consequences. Pharmaceutical drugs are developed for their medical benefits; they are produced by pharmaceutical companies; and extra-medical use can occur through the drugs being over-marketed, over-prescribed, misprescribed or stolen at either wholesale or patient levels [9]. This situation presents new and complex challenges and demands new evidence to inform responses at all levels. This issue of Addiction sees the first in a new series exploring the diversion of pharmaceutical drugs for extra-medical use; it will explore the processes and drivers of diversion of pharmaceutical drugs, rather than people misusing their own prescriptions. We are currently inviting colleagues from around the world to provide manuscripts and research reports describing different national experiences of diversion of pharmaceuticals (e.g. oxycodone in the United States or benzodiazepines in Australia); different experiences of diversion of treatment drugs (e.g. methadone across the United Kingdom); the effects of different policies and which (if any) policy changes have impacted on the issue; and what external factors have acted to increase, diminish or change the nature of the diversion of some drugs. We hope to report on very different experiences in the next few years, providing an opportunity for comparing and contrasting different types of research, different drugs, different policies and, of course, different locations. We begin the series with a paper by Paoli et al.[10] which explores India's role in the world illicit opioid market, particularly its role as a producer. This piece highlights how India, a major illicit opioid consumer, is also the sole licensed exporter of raw opium, and that this unique status may be enabling substantial and diversion to the illicit market. This paper serves as an excellent description of how the many factors involved with the production and distribution of pharmaceuticals interact to allow diversion into the illicit market. This is an emerging issue that will be covered in multiple papers. We invite you to submit letters commenting on articles in the series and, indeed, to submit appropriate ideas for future papers for this series.

Profiling poly-substance use typologies in a multi-site cohort of illicit opioid and other drug users in Canada–a latent class analysis

‘Poly-substance use’ is increasingly prevalent among street drug user populations. The objective was to employ latent class analysis (LCA) to empirically categorize and extract potential typologies of poly-substance users within a multi-site cohort of illicit opioid and other drug users (OPICAN) in Canada, and examine potential associations with social and health indicators. Drug use patterns of 582 participants from the most recent follow-up (2005) of the cohort study–focusing on drug use prevalence indicators in the past 30 days–were empirically analyzed via LCA. These classes were further examined for associations with social and health variables using chi-square, ANOVA. Binomial logistic regression models were used to predict class membership. LCA analysis resulted in eight distinct user typologies, characterized both by the distinct relative prevalence of different substances (e.g., including: heroin, prescription opioids, benzodiazepines, cocaine, crack, alcohol, cannabis, and others) used and administration routes (e.g., injection or noninjection), the majority of which were described by the predominant use of two or more distinct substance groups (e.g., opioids and stimulants). At least two of the active poly-substance user classes were described by predominant noninjection as the primary route of administration. ‘Poor or fair’ health status was reported at the highest prevalence level by the class of intensive poly-substance injectors, while HCV-positive status was disproportionately low in the classes of current noninjectors. Analytical examination of poly-substance use patterns is a distinct challenge for meaningful drug use monitoring, also providing important evidence for targeted prevention and treatment interventions.

Comparing heroin users and prescription opioid users in a Canadian multi‐site population of illicit opioid users

Recent data suggest increasing prescription opioid and decreasing heroin use among street drug users, yet little is known on possible differential use characteristics and outcomes associated with these drugs. [While we recognise that, correctly, these populations would need to be labelled as opioid 'abusers' or 'non-medical users', we rely on the simpler terms 'use' and 'users' for the population under study within the wider context of them being engaged overall in illicit opioid use activities.] This study compared drug use, health, and socio-economic characteristics between heroin (H)-only, prescription opioid (PO)-only and mixed heroin and prescription (PO & H) users in a Canadian multi-site cohort of illicit opioid and other drug users (OPICAN). Data from the most recent (2005) multi-component assessment of the H-only (n = 94), PO-only (n = 304) and PO & H (n = 86) cohort sub-samples were analysed. Based on bivariate analyses of variables of interest, a multinomial logistic regression analysis (MLRA) model was computed, comparing PO-only and PO & H groups to the H-only reference group, respectively. H-only users were found in two of the seven study sites. Based on the MLRA, PO-only and PO & H users, compared to H-only users, were more likely to: be older, use benzodiazepines and cocaine, use drop-in shelters and less likely to use walk-in clinics. PO-only users were also more likely to: be white; receive legal income; use drugs by non-injection; have physical health problems; and use private physician services. Our study underscores the increasing prevalence of PO compared to heroin use in the study population. Differences between PO-only and H-only users were more pronounced than differences between PO-only and PO & H users. PO-only use may be associated with lowered health risks and social burdens, yet concerns regarding polysubstance use and drug sourcing arise. Challenges for targeted interventions are discussed.

Regulating opioid prescribing to provide access to effective treatment while minimizing diversion: an overdue topic for research

Regulating opioid prescribing to provide access to effective treatment while minimizing diversion: an overdue topic for research

Clinical update: codeine maintenance in opioid dependence

In Australia, the USA, and Europe, 0·4%–0·8% of adults develop a dependence on illicit opioids. These people typically use opioids daily, despite being arrested, imprisoned, infected with blood-borne viruses, and having non-fatal drug overdoses. 1 Degenhardt L Hall WD Warner-Smith M Lynskey M Illicit drug use. in: Ezzati M Lopez A Rodgers A Murray CJL Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. World Health Organization, Geneva2004: 1109-1175 Google Scholar Users of illicit opioids have generally been those who inject heroin, but, during the 1990s, many in Europe, North America, and parts of Asia reverted to older methods of use, including smoking and chasing of heroin—inhalation of the fumes released when heroin is heated. 1 Degenhardt L Hall WD Warner-Smith M Lynskey M Illicit drug use. in: Ezzati M Lopez A Rodgers A Murray CJL Comparative quantification of health risks: global and regional burden of disease attributable to selected major risk factors. World Health Organization, Geneva2004: 1109-1175 Google Scholar Because of a substantial reduction in heroin supply in the early 21st century, users in Australia, Canada, and the USA have increasingly used pharmaceutical opioids. 2 Fischer B Rehm J Patra J Cruz MF Changes in illicit opioid use across Canada. CMAJ. 2006; 175: 1385-1387 Crossref PubMed Scopus (93) Google Scholar

Predictors of methadone maintenance treatment utilization in a multisite cohort of illicit opioid users (OPICAN)

Although methadone maintenance treatment (MMT) has been a primary treatment response to illicit opioid use in Canada for decades, analytical treatment data are scarce. Using data from the multisite OPICAN cohort of illicit opioid and other drug users repeatedly assessed between 2002 (baseline) and 2005 (last follow-up [FU]), we (1) longitudinally examined characteristics associated with MMT uptake between baseline and FU and (2) cross-sectionally compared drug use patterns between cohort participants in MMT ( n = 133) and those not in MMT ( n = 400) at the last FU through bivariate and multivariate analyses (stepwise logistic regression). Significant baseline predictors of MMT uptake emerging in the logistic regression model included injection drug, heroin, as well as alcohol use, housing status, and Quebec City as a site. Furthermore, lower prevalence levels of opioid (e.g., morphine and OxyContin) and nonopioid (e.g., cocaine and crack) drug use as well as lower frequency of heroin use days were observed among MMT users. This study highlights potential factors relevant for improved MMT uptake and illustrates possible reductions of drug use related to MMT.

Local Drug–Crime Dynamics in a Canadian Multi-Site Sample of Untreated Opioid Users

This multi-site study analysed self-reported involvement in property crime, drug dealing, and sex work, across five Canadian cities, among a sample of 677 illicit opioid and other drug users outside of treatment. First, we assessed drug-use patterns and the extent of illegal income-generating behaviour for each city. We then analysed factors and city interactions contributing to engagement in the respective criminal activities, including drug-use patterns, socio-economic characteristics, and other illegal activities. With this approach we explored city-specific patterns of crime prediction; thus we identified local drug–crime associations. The study sample was recruited by outreach and snowball methods and was assessed by standardized study protocols. Findings revealed substantial differences among the cities regarding both the extent and frequency of illegal activities. In regard to local differences, multiple logistic regression models revealed that crack use was strongly associated with property crime in Toronto, while cocaine use was strongly related with sex work in Montreal and Quebec City. This evidence points to local dynamics of drug cultures that are related to specific criminal activities. Implications for further research and intervention efforts are discussed.

Heroin-assisted Treatment (HAT) a Decade Later: A Brief Update on Science and Politics

Since the initial Swiss heroin-assisted treatment (HAT) study conducted in the mid-1990s, several other jurisdictions in Europe and North America have implemented HAT trials. All of these studies embrace the same goal-investigating the utility of medical heroin prescribing for problematic opioid users-yet are distinct in various key details. This paper briefly reviews (initiated or completed) studies and their main parameters, including primary research objectives, design, target populations, outcome measures, current status and-where available-key results. We conclude this overview with some final observations on a decade of intensive HAT research in the jurisdictions examined, including the suggestion that there is a mounting onus on the realm of politics to translate the-largely positive-data from completed HAT science into corresponding policy and programming in order to expand effective treatment options for the high-risk population of illicit opioid users.

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

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. …