Developments in buprenorphine, methadone and hepatitis in France

Dear Colleagues,

"Le Flyer" is a French dependency newsletter (circ 10,000, also on internet www.rvh-synergie.org/) edited by the director of an addiction centre in Paris. The latest issue (no.23) has a provocative editorial predicting that 2006 will be a year of big changes for drug treatments in France.

We are told that a company called 'Arrow' specialising in generics will market a new brand of buprenorphine while the current French supplier, Schering Plough, intends to introduce a quick dissolving tablet or wafer. This has been talked about for several years by Reckitts staffers and would be most welcomed in Australia too. The editorial also predicts the introduction of the combination product with naloxone - which they term 'non-injectable' - at the risk of 'a bad quarter hour' - meaning withdrawals, I presume, in translation.

The proposal appears to be the same as in the US where the current guidelines recommend using pure buprenorphine for initiation but that continuing maintenance be done with the combination product (except in pregnant women or those who are sensitive to the combination). It is hard to imagine how the French authorities will convince doctors and patients to move from pure buprenorphine to a combination after so many years of apparently successful experience with the treatment using 'Subutex' in the community.

There is a press release on "Hépatite C: Xavier Bertrand (French Health Minister) souhaite que les patients soient majoritairement pris en charge en ville. PARIS, 8 décembre 2005 (APM)" [this calls for hepatitis treatment to be largely undertaken in the community in the future.]

"Le Flyer" also covers a comprehensive report by a committee of French experts on the prevention of both hepatitis B and C. It is pointed out that methadone has a better track record in several respects (reducing needle sharing; less illicit drug use; better retention). They therefore recommend that methadone become the treatment of first choice for people who are sero-negative (to keep them that way, I suppose is their logic). In my own view, it is also the treatment of choice for those who are sero-positive to prevent them passing it on.

In France buprenorphine can be prescribed in a community setting where methadone maintenance treatment (MMT) can only be commenced in a specialist clinic (as in New South Wales). This does not prevent gradual increases in methadone numbers in France or Australia since once stable, GPs can take over prescribing of methadone, just as might occur with insulin, warfarin, etc. In the US, methadone 'slots' are frozen by the number of clinics and the ban on GPs or pharmacies being involved. This is all the more tragic since America still has such a large unmet need for addiction services while these are relatively cheap and simple treatments with major benefits for individuals and society.

I have been sent some interesting old papers from the 1970s regarding the combination methadone and naloxone. Although it never really 'caught on', this may have seemed a logical concept considering methadone can be so toxic in overdose. One of the comparative studies showed that the addition of naloxone caused a significant reduction in the initial methadone peak on serial blood levels (the paper was way ahead of its time!). I wonder if this could explain the dose increases requested by nearly all 17 subjects in Bell's study when changed from pure buprenorphine to the combination product.

Comments by Andrew Byrne ..