Diversion of Methadone and Buprenorphine from Opioid Substitution Treatment: Patients who Regularly Sell or Share Their Medication

Abstract

Diversion—the practice of patients selling or sharing their medication—is a much debated problem of opioid substitution treatment. Regular diversion by patients was studied at 11 opioid substitution treatment programs in the south of Sweden. Using quantitative and qualitative data, it was investigated whether those patients differ from other patients, their motives for and means of diversion, and who the recipients are. Regular diverters are a small, yet heterogeneous group. Continued illicit drug use, however, stands out as a common risk factor. Pecuniary need and a desire to help friends are other important motives. The client base mainly consists of people from the regular diverters’ own drug milieus.

KEYWORDS:

• Methadone
• buprenorphine
• opioid substitution treatment
• diversion
• illicit use

Notes

a. In the quantitative interview study, regular diverters—a population which, according to the author's definition, constituted 8.5% of the total number of patients interviewed—were responsible for more than 80% of the self-reported days with diversion.

b. In Sweden, OST is only offered to people with a documented opiate addiction (heroin, morphine, or opium) of at least one year's standing. Such documentation may be issued by addiction treatment services, social services, the penal system, needle exchange programs, etc.

c. Methadone-based OST has been strictly regulated in Sweden ever since its inception in 1966, and may only be ordered by psychiatrists. However, when buprenorphine was added to OST framework in 2000, all physicians had the authority to prescribe this substance. A public debate on diversion led to buprenorphine being subject to the same regulations as methadone from 2005 onward.

d. The reason why these users require illicit methadone or buprenorphine may vary, but it is often a case of trying to avoid withdrawal symptoms (for instance if they have failed to get hold of heroin) or wanting to perform self-detoxification or manage OST on their own. Such “self-treaters” may be users who are on the waiting list for a program, have been involuntarily discharged, or have an ambivalent attitude toward OST, or for other reasons have chosen not to apply for a place in treatment. The motives for and experiences with self-treatment will be studied in a separate article, based on some 30 qualitative interviews.

e. Out of all the 411 patients that were interviewed, only one admitted that he had sought treatment in order to get access to medication that he could sell. This user had been prescribed buprenorphine by a GP in the early 2000s, without having to provide documentation of opiate or opioid addiction (see also endnote b).