Injection of medications used in opioid substitution treatment in Australia after the introduction of a mixed partial agonist–antagonist formulation

Louisa Degenhardt, Briony K Larance, James R Bell, Adam R Winstock, Nicholas Lintzeris, Robert L Ali, Nicolas Scheuer and Richard P Mattick
Med J Aust 2009; 191 (3): 161-165.


Objectives: To examine the levels and predictors of injection of buprenorphine–naloxone (BNX) — a combination of a partial opioid agonist and an opioid antagonist for treating opioid dependence — which was specifically developed to limit injecting. Comparison was made with injecting of two other opioid substitution treatment medications, methadone and buprenorphine (BPN); severe harms have been documented after injection of the latter.

Design and participants: Injecting was studied in regular injecting drug users (“IDUs”) and current opioid substitution treatment clients (“clients”). Regular IDUs are interviewed annually in each Australian capital city (about 900 per year) and data for 2003–2007 were used; 399 clients were interviewed in 2007. Data on injection of opioid substitution treatment medications between 2003 and 2007 were adjusted for availability of medications (from national sales data for methadone, BPN and BNX). Predictors of injecting were analysed by multiple regression analyses.

Setting: Capital cities of all Australian states and territories.

Main outcome measure: Injection of opioid substitution treatment medications among individuals both in and out of treatment.

Results: In the year after its introduction in Australia, BNX was injected less frequently and by fewer regular IDUs and clients compared with BPN, particularly when differences in the availability of medications were taken into account. Some individuals did nonetheless regularly inject BNX. Injection of methadone, BPN and BNX was more likely to occur among those injecting other pharmaceutical opioids.

Conclusions: A partial opioid agonist–antagonist combination appears to be less commonly and less frequently injected by clients in treatment and IDUs who are not. Further studies are needed to evaluate longer-term trends in use and harms.

  • Louisa Degenhardt1
  • Briony K Larance1
  • James R Bell2
  • Adam R Winstock3
  • Nicholas Lintzeris3
  • Robert L Ali4
  • Nicolas Scheuer1
  • Richard P Mattick1

  • 1 National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW.
  • 2 The Langton Centre, South Eastern Sydney and Illawarra Area Health Service, Sydney, NSW.
  • 3 Drug Health Services, Sydney South West Area Health Service, Sydney, NSW.
  • 4 WHO Collaborating Centre for the Treatment of Drug and Alcohol Problems, University of Adelaide, Adelaide, SA.



We thank the many people receiving opioid substitution treatment, or who regularly inject drugs, who agreed to be interviewed; and Susannah O’Brien for her assistance with coordination of this project.

Competing interests:

Louisa Degenhardt, Briony Larance and Richard Mattick were provided with an untied educational grant by Reckitt Benckiser to monitor the extent of injection of BNX, and to compare it with injection of established opioid substitution treatment medications; they and Adam Winstock have received support for speaking at workshops held by Reckitt Benckiser. Reckitt Benckiser had no role in the design, conduct, reporting, or analysis of the study, or in interpretation of the study results or preparation of the manuscript. James Bell and Robert Ali have previously received support for speaking at workshops held by Reckitt Benckiser and Schering Plough.

  • 1. World Health Organization/United Nations Office of Drugs and Crime/Joint United Nations Programme on HIV/AIDS. WHO/UNODC/UNAIDS position paper: substitution maintenance therapy in the management of opioid dependence and HIV/AIDS prevention. Geneva: WHO, 2004.
  • 2. Mattick RP, Kimber J, Breen C, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev 2008; (2): CD002207.
  • 3. Mattick RP, Kimber J, Breen C, Davoli M. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database Syst Rev 2003; (2): CD002209.
  • 4. NHS National Institute for Health and Clinical Excellence. Methadone and buprenorphine for managing opioid dependence. NICE Technology Appraisal Guidance 114. London: NICE, 2007.
  • 5. Inciardi JA, Surratt H, Kurtz SP, Burke JJ. The diversion of prescription drugs by health care workers in Cincinnati, Ohio. Subst Use Misuse 2006; 41: 255-264.
  • 6. Inciardi JA, Surratt HL, Kurtz SP, Cicero TJ. Mechanisms of prescription drug diversion among drug-involved club- and street-based populations. Pain Med 2007; 8: 171-183.
  • 7. Rajagopal MR, Joranson DE, Gilson AM. Medical use, misuse, and diversion of opioids in India. Lancet 2001; 358: 139-143.
  • 8. Parfitt T. Designer drug Subutex takes its toll in Tbilisi. Lancet 2006; 368: 273-274.
  • 9. Jenkinson R, Clark NC, Fry CL, Dobbin M. Buprenorphine diversion and injection in Melbourne, Australia: an emerging issue? Addiction 2005; 100: 197-205.
  • 10. Lintzeris N, Lenne M, Ritter A. Methadone injecting in Australia: a tale of two cities. Addiction 1999; 94: 1175-1178.
  • 11. O’Brien S, Black E, Roxburgh A, et al. Australian drug trends 2006: findings from the Illicit Drug Reporting System (IDRS). NDARC Monograph 60. Sydney: National Drug and Alcohol Research Centre, University of New South Wales, 2007.
  • 12. Degenhardt L, Larance B, Mathers B, et al. Benefits and risks of pharmaceutical opioids: essential treatment and diverted medication. A global review of availability, extra-medical use, injection and the association with HIV. Sydney: National Drug and Alcohol Research Centre, University of New South Wales, 2008.
  • 13. Aboltins CA, Daffy JR, Allen P. Fungal endophthalmitis in intravenous drug users injecting buprenorphine contaminated with oral Candida species [letter]. Med J Aust 2005; 182: 427. <MJA full text>
  • 14. Winstock AR, Lea T, Sheridan J. Prevalence of diversion and injection of methadone and buprenorphine among clients receiving opioid treatment at community pharmacies in New South Wales, Australia. Int J Drug Policy 2008; 19: 450-458.
  • 15. Ritter A, Di Natale R. The relationship between take-away methadone policies and methadone diversion. Drug Alcohol Rev 2005; 24: 347-352.
  • 16. Humeniuk R, Ali R, McGregor C, Darke S. Prevalence and correlates of intravenous methadone syrup administration in Adelaide, Australia. Addiction 2003; 98: 413-418.
  • 17. Bell J, Byron G, Gibson A, Morris A. A pilot study of buprenorphine-naloxone combination tablet (SuboxoneTM) in the treatment of opioid dependence. Drug Alcohol Rev 2004; 23: 311-317.
  • 18. McAleer SD, Mills RJ, Polack T, et al. Pharmacokinetics of high-dose buprenorphine following single administration of sublingual tablet formulations in opioid naive healthy male volunteers under a naltrexone block. Drug Alcohol Depend 2003; 72: 75-83.
  • 19. Ling W, Smith D. Buprenorphine: blending practice with research. J Subst Abuse Treat 2002; 23: 87-92.
  • 20. Harris D, Jones RT, Welm S, et al. Buprenorphine and naloxone co-administration in opiate-dependent patients stabilized on sublingual buprenorphine. Drug Alcohol Depend 2000; 61: 85-94.
  • 21. Topp L, McKetin R. Supporting evidence-based policy-making: a case study of the IDRS. Bulletin on Narcotics 2003; LV, Nos 1 and 2: 23-30.
  • 22. Winstock AR, Lea T, Madden A, Bath N. Know-+ledge about buprenorphine and methadone among those receiving treatment for opioid dependence. Drugs Educ Prev Policy 2008; 15: 395-409.
  • 23. Lintzeris N, Pritchard E, Sciacchitano L. Investigation of methadone dosing in Victoria: factors influencing dosing levels. Melbourne: Turning Point Alcohol and Drug Centre, 2007.
  • 24. Stoller KB, Bigelow GE, Walsh S, Strain EC. Effects of buprenorphine/naloxone in opioid-dependent humans. Psychopharmacology 2001; 154: 230-242.
  • 25. Bell J, Shanahan M, Mutch C, et al. A randomized trial of effectiveness and cost-effectiveness of observed versus unobserved administration of buprenorphine-naloxone for heroin dependence. Addiction 2007; 102: 1899-1907.
  • 26. Royal Australasian College of Physicians Australasian Chapter of Addiction Medicine. Clinical guidelines: assessing suitability for unsupervised medication doses in the treatment of opioid dependency. (accessed Apr 2009).
  • 27. Vidal-Trecan G, Varescon I, Nabet N, Boissonnas A. Intravenous use of prescribed sublingual buprenorphine tablets by drug users receiving maintenance therapy in France. Drug Alcohol Depend 2003; 69: 175-181.
  • 28. Guichard A, Lert F, Calderon C, et al. Illicit drug use and injection practices among drug users on methadone and buprenorphine maintenance treatment in France. Addiction 2003; 98: 1585-1597.
  • 29. Haasen C, Verthein U, Degkwitz P, et al. Heroin-assisted treatment for opioid dependence: randomised controlled trial. Br J Psychiatry 2007; 191: 55-62.
  • 30. Lintzeris N, Strang J, Metrebian N, et al; RIOTT Group. Methodology for the Randomised Injecting Opioid Treatment Trial (RIOTT): evaluating injectable methadone and injectable heroin treatment versus optimised oral methadone treatment in the UK. Harm Reduct J 2006; 3: 28.


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