Can You Add Suboxone To Clean Urine
J Pharmacol Pharmacother. 2022 Jan-Mar; three(1): 15–19.
A urinalysis-based written report of buprenorphine and non-prescription opioid use amid patients on buprenorphine maintenance
Yatan Pal Singh Balhara
Department of Psychiatry and De-addiction, Lady Hardinge Medical Higher and SSK Infirmary, New Delhi, Republic of india
Raka Jain
i National Drug Dependence Handling Center, All India Found of Medical Sciences, New Delhi, India
Abstract
Objectives:
To understand the blueprint of use of opioid-substitution therapy (OST) and opioid corruption among patients on buprenorphine maintenance using urinalysis.
Materials and Methods:
The study was conducted at a tertiary care de-addiction heart. Nosotros reviewed the laboratory record of all consecutive urine samples sent for drug analysis over a period of one twelvemonth. In all, 179 consecutive urine samples were included in the analysis. The chi-square test was used to compare opioid abuse amongst those testing positive and negative for buprenorphine on urinalysis. Additionally, in lodge to assess the potential touch on of the prescribed induction and maximum dose of buprenorphine on the findings, we carried out the independent-samples t test. Level of statistical significance was kept at P<0.05 for all the tests.
Results:
Urinalysis failed to discover buprenorphine in 44.7% of the samples. Rate of detection of dextropropoxyphene was significantly higher amongst buprenorphine-negative samples (P<0.005). The prescribed consecration dose of buprenorphine was significantly lower among those testing positive for heroin. This was found for both buprenorphine-positive (P<0.005) equally well as buprenorphine-negative samples (P<0.005).
Conclusions:
These findings support the routine apply of urine drug screening among individuals on OST.
Keywords: Buprenorphine, opiate substitution therapy, urinalysis
INTRODUCTION
Opioid dependence adversely impacts personal wellness and economic productivity and is associated with many social and legal problems. At that place is high hazard of relapse after treatment for opioid addiction. Every bit part of harm minimization, opioid substitution therapy (OST) is started for such people. Buprenorphine has been established as a safe and cost-constructive long-term culling to methadone in substitution therapy for opioid dependence. It has shown benefits similar to those of methadone in retaining patients in handling and improving quality of life and overall health status.[ane] Withal, concerns have been expressed about the compliance with treatment and diversion of the prescription buprenorphine.[2–4] Besides, continued non-prescription opioid utilise has been documented among those on OST with buprenorphine.
The reliability of self-report nearly non-prescription drug apply and compliance with prescribed buprenorphine among opioid abusers remains debatable.[5] It has been recommended that the OST be corroborated and monitored using objective measures such as urine drug screening.[6] Utilise of urinalysis findings when combined with self-report could provide important insights into the pattern of OST employ and non-prescription opioid abuse among patients on buprenorphine therapy. Besides, it provides objective evidence of the compliance with the prescribed medication.
International guidelines on buprenorphine prescription recommend routine use of some objective method to validate self-report of drug employ design. Urine drug screening is the almost commonly used and the most cost-effective method for this purpose.[seven] The guidelines for use of buprenorphine in Bharat are in accord with the international recommendations. However, use of routine urine drug screening to ensure compliance is not recommended in these Indian guidelines.[8] Lack of resource and technical expertise are possible reasons for this.
The current study aims at understanding the blueprint of use of OST and non-prescription opioid utilize among patients on buprenorphine maintenance. We have used findings from urinalysis as an objective measure for this purpose.
MATERIALS AND METHODS
We reviewed the laboratory records of all urine samples sent for drug analysis over a period of 1 twelvemonth at a tertiary-intendance de-addiction center. All cases with buprenorphine prescription for OST during this flow were included in the written report. All the subjects were being treated equally outpatients and were being administered the medication from the treatment center on a biweekly basis.
At this center, urine samples sent for drug evaluation are screened for mutual drugs of abuse in the region as well as medications prescribed equally OST from the center, which include heroin (detected equally morphine), buprenorphine, dextropropoxyphene, and benzodiazepines. A supervised urine sample (fifty ml) is collected from patients coming for treatment at the de-addiction eye. It is then sent to laboratory for analysis. A standardized modified hydrolysis method followed by thin-layer chromatography (TLC) is used for detection of drugs in the urine.[9,10] The detection limit for urinalysis in the laboratory is 0.5 μg/ml for morphine (heroin) and dextropropoxyphene, 0.ii μg/ml for benzodiazepines, and ane.0 μg/ml for buprenorphine.
Data analysis was carried out using SPSS® version 17. The pattern of prescription buprenorphine employ and non-prescription opioid use was assessed using frequency distribution. We used the chi-square test to compare non-prescription opioid use amidst those testing positive and negative for buprenorphine on urinalysis. Additionally, in gild to assess the potential impact of the prescribed consecration and maximum dose of buprenorphine on the findings, we carried out the independent-samples t test.
Conditions of anonymity and confidentiality, as recommended in the establish'southward ethical guidelines, were strictly adhered to during the study.
RESULTS
A total of 179 consecutive urine samples received over a ane-year period were included in the study. The sociodemographic profile of the written report sample and the dose of buprenorphine during the consecration and maintenance phases is presented in Table ane.
Table one
Sociodemographic profile and buprenorphine prescription dose for the study sample (due north=179)
Buprenorphine was detected in 99 (55.three%) of the samples. Heroin and dextropropoxyphene were detected in 10 (5.6%) and 14 (7.8%) of the samples, respectively. Hence, the rate of non-prescription opioid use was thirteen.iv% [Table two; Figure 1]. The rate of detection of dextropropoxyphene was significantly higher amidst buprenorphine-negative samples (chi-square 14.25, df=1; P<0.005). The proportion of urine samples testing positive for heroin was similar in buprenorphine-positive samples and in buprenorphine-negative samples (chi-square 0.08, df= i; P=0.76).
Table two
Urinalysis findings for opioid employ for buprenorphine-prescribed opioid-dependent subjects
Findings of urinalysis for the full sample, buprenorphine-positive samples, and buprenorphine-negative samples
The induction dose of buprenorphine was significantly lower amongst those testing positive for heroin than in those testing negative. This was found for both buprenorphine-positive (n=37; hateful dose 2.xi±0.78 mg/day vs 6.11±5.38 mg/twenty-four hour period; t=–6.94, P<0.005) likewise as buprenorphine-negative samples (due north=26; hateful dose 1.77±0.76 mg/day vs 6.17±5.49 mg/mean solar day; t=–v.09, P<0.005) [Table 3].
Tabular array iii
Boilerplate consecration daily dose of buprenorphine for buprenorphine-positive and buprenorphine-negative urine samples
However, no such difference was observed for the maximum dose of prescription buprenorphine (t=–3.435, P=0.74 and t=–0.214, P=0.847 for buprenorphine-positive and buprenorphine-negative urinalysis, respectively). Similarly, no difference was observed for prescribed dose of buprenorphine among dextropropoxyphene-positive (t=–0.19, P=.85) and dextropropoxyphene-negative (t=1.34, P=.eighteen) urine samples amid urine samples testing positive for buprenorphine. Also, no differences were observed for prescribed dose of buprenorphine amid dextropropoxyphene-positive (t=0.076, P=.94) and dextropropoxyphene-negative (t=ane.08, P=.32) urine samples amongst urine samples testing negative for buprenorphine.
The independent-samples t test failed to find whatsoever significant difference between the dose (induction dose as well as maximum dose) of the prescribed buprenorphine and buprenorphine urinalysis status (n=37, t=–0.032, P=0.974; northward=26, t=0.641, P=0.524).
DISCUSSION
The current study aimed at understanding the blueprint of use of OST and non-prescription opioid use among patients on buprenorphine maintenance. We used findings from urinalysis every bit an objective indicator for this purpose.
A total of 179 sequent urinalysis qualified for inclusion in the study. The charge per unit of not-prescription opioid apply was thirteen.4% in the current study. The rate of not-prescription opioid apply among individuals on buprenorphine therapy has been plant to vary across studies. It was institute to be around xx% in a comparative study of buprenorphine and methadone.[11] Another report past Gerra et al. reported it to be effectually 21%.[12]
All the samples in the current study were from opioid-dependent patients on OST with buprenorphine. Yet, urinalysis failed to discover buprenorphine in 44.7% of the samples. This noncompliance rate is much higher than the usually observed rate of 30%.[xiii] This suggests a significant proportion of the individuals were not using the prescribed buprenorphine. Diversion of the prescribed buprenorphine is a possible explanation for this finding. Such diversion of prescription buprenorphine has been reported from different countries, including Australia, England, Finland, France, Ireland, New Zealand, and Scotland.[4]
It is likely that some of those testing positive for dextropropoxyphene (with or without their sample beingness buprenorphine-positive) might exist using dextropropoxyphene in addition to the buprenorphine they were receiving through the OST plan. Reports of such 'dr. shopping' beliefs among opioid abusers have come from other settings besides.[fourteen] There could be different explanations for such behavior. To begin with, lack of departure in the prescribed dose of buprenorphine amid those testing positive and negative for dextropropoxyphene makes the possibility of inadequate dose of prescribed buprenorphine unlikely. Nevertheless, the stringent requirements of regular follow-upwardly for buprenorphine (daily to twice weekly) might bulldoze these individuals to ration their buprenorphine supply, substituting it in part with dextropropoxyphene. The possibility of diversion cannot exist ruled out. Some of those registered with buprenorphine OST might be diverting it, while using dextropropoxyphene themselves. This is a likely explanation for those testing positive for dextropropoxyphene and negative for buprenorphine. The high street value and restricted availability of buprenorphine in the open up market makes it a likely candidate for diversion.
Different patterns of treatment non-adherence to buprenorphine prescribed every bit OST have been observed. These include: (a) diversion to the blackness market, (b) not-adherence to prescriber'south recommendations virtually the dose to exist used, (c) concurrent utilise of other drugs or alcohol, and (d) unsanctioned assistants of buprenorphine (by injection or sniffing).[eighteen] Two of these possibilities, (b) and (c), are supported by the urinalysis findings of the current study. The possibility of diversion to the black market and injecting utilise could be confirmed through focus-group discussions (FGD) and primal informant interviews (KII) with the service users.
Use of an inadequate dose of buprenorphine, especially during the early phases of therapy, is a likely cause of continued use of heroin past opioid abusers. This was observed in the current written report, where the induction dose of prescribed buprenorphine was significantly lower among the heroin-positive urine samples. This was observed for those concomitantly testing positive for buprenorphine as well those testing negative for buprenorphine. Gerra et al. constitute high doses of buprenorphine to be more effective than depression doses in reducing not-prescription opioid use (f=nine.7, P<0.05).[12] Also buprenorphine-maintained patients who showed morphine-positive urines had significantly lower doses than those with negative urine screen findings (vii.vii±0.6 mg/day vs 11.3±0.five mg/day; t=2.53, P<0.05).[15] In the current study, the induction dose of buprenorphine was significantly lower amidst morphine-positive equally well equally buprenorphine-positive urine samples (mean dose ii.xi±0.78 mg/twenty-four hour period vs half-dozen.eleven±v.38 mg/day; t=–half-dozen.94, P<0.005). Similarly, the induction dose of buprenorphine was significantly lower among morphine-positive but buprenorphine-negative urine samples (hateful dose i.77±0.76 mg/day vs 6.17±5.49 mg/mean solar day; t=–5.09, P<0.005).
While some of these under-prescribed individuals may have used heroin as a 'pinnacle-upwardly,' others may accept discontinued using buprenorphine because of inadequate satisfaction of drug hunger and poor withdrawal management. Inadequate dosing of buprenorphine is a common reason for noncompliance and connected not-prescription opioid use.[15]
While use of low doses of buprenorphine at induction has been associated with poor retention in treatment,[xvi] rapid up-titration of buprenorphine has been found to amend compliance.[17] Prescription of an adequate dose of buprenorphine has been constitute to protect confronting doctor-shopping behavior amongst opioid abusers.[xv] The high ceiling effect for opioid agonist activity with buprenorphine makes it relatively safer in high doses.[18] Prescribers must be aware of this fact and should not under-prescribe. Notwithstanding, prescribers should as well exist alert to the possibility fatal accidents due to excessive dose of buprenorphine equally a result of intravenous misuse or concomitant use of other sedative drugs such equally benzodiazepines, which is always a possibility in this group.[19]
OST using buprenorphine-naloxone has been found to be safety and effective, with express diversion rates.[20,21] This could be an alternative to the utilize of plain buprenorphine for OST.
The employ of urine drug screening in the current study has helped us sympathise the pattern of utilise of prescription buprenorphine too as non-prescribed opioids (including illicit heroin) among those using OST. The reliability of self-written report about non-prescription drug use and compliance with prescribed buprenorphine has been, and remains, debatable.[5] International guidelines recommend routine use of some objective method to validate self-report of the service users regarding the drug employ patterns.[22] Urine drug screening is the near commonly used and generally virtually cost-effective method for this purpose.[23] The findings from the current report also support the routine utilize of some objective measure to approve self-reported drug use past those on OST. Though Indian guidelines on the apply of buprenorphine as OST are in accordance with the international recommendations, use of routine urine drug screening to ensure compliance is non recommended in these guidelines.[8] This could exist due to lack of resources and technical expertise in the land. However, there is a need to include routine urine drug analysis every bit an integral component of the OST programme. This would assist in improving monitoring and thus allow timely intervention.
The electric current study made apply of the urinalysis findings. It did not explore the perspectives of the service users on the issues. Information technology would be informative to explore these issues using FGD and KII amidst those on OST.
CONCLUSIONS
The findings from the current report provide important insights into the design of apply of OST as well equally that of non-prescribed opioids (including illicit heroin) among individuals on buprenorphine therapy. These findings support routine apply of urine drug screening among individuals on OST.
Footnotes
Source of Back up: Nil
Conflict of Interest: None alleged.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3284030/
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