The confluence of the heroin injection epidemic and the human immunodeficiency virus HIV infection epidemic has increased the call for expanded access to effective treatments for both conditions.
In France, which has the most extensive experience, buprenorphine has been associated with a dramatic decrease in deaths due to overdose, and buprenorphine diversion appears to be associated with inadequate dosage, social vulnerability, and "Flow siamois sexual offenders" from multiple providers. Other treatment models in the United States, Australia, Germany, and Italy and buprenorphine use in specific populations are also reviewed in the present article.
In countries experiencing a dual epidemic of heroin and HIV infection, such as former states of the Soviet Union and other eastern European and Asian countries, access to buprenorphine and methadone may be one potential tool for reducing the spread of HIV infection among injection drug users and for better engaging them in medical care.
Of an estimated 13 million injection drug users IDUs —primarily heroin users—worldwide [ 1 ], IDU prevalence estimates have remained relatively stable in western Europe, the United States, Canada, Flow siamois sexual offenders Australia; elsewhere, however, they are increasing at alarming rates, especially in eastern Europe and Asia, where the number of opioid-dependent IDUs already accounts for half of the estimated worldwide total.
Although some of this increase may be explained by better reporting [ 2 ], the figures probably reflect a rapid increase in the number of heroin users between anddriven by multiple factors, including major socioeconomic structural changes and a broadening of economic structures to improve the flow of trade among countries [ 3 ].
For example, a fold increase in the number of registered opioid-dependent individuals was reported in China during this period. In central and eastern Europe, a similar rapid increase in the number of opioid users could be attributed to increased quantities of heroin appearing on the black market from Afghanistan and passing through the borders of the newly independent Baltic states and the former Soviet Union, particularly during — The street price of the drug decreased 3-fold and remained extremely low in Central Asian countries [ 4 ].
Molecular epidemiological analysis suggests that, in some Asian countries, the dual epidemics of injection drug use and HIV infection was associated with overland heroin export routes [ 5 ]. The high prevalence of sexually transmitted infections among some bridging groups increases the risk of the spread of HIV infection [ 7 ]. As in industrialized countries [ 8 ], a high prevalence of drug use may result in a considerable burden for the user, the user's family, and the community, in terms of morbidity and mortality, social dysfunction, criminal activity, homelessness, incarceration, and law enforcement expenditures.
Certainly, morbidity and mortality rates among individuals who use heroin—particularly by injection—are significantly higher than those among the general population, because of the frequency of overdose [ 8—10 ]; HIV infection [ 11—13 ] and other infections, as viral hepatitis [ 1214—16 ], botulism [ 17 ], necrotizing fasciitis [ 18 ], endocarditis, and tuberculosis [ 1920 ]; and an increased risk of violence, including suicide [ 21 ] and homicide.
These medical, social, and legal issues are often more difficult to manage in developing and transitional countries, because of the higher social costs associated with drug use and the limited resources available for addressing it. Responses to opioid dependence have varied considerably, especially in countries where HIV infection has been driven mainly by injection drug use, ranging from excessive reliance on incarceration in most countries to, more recently, pragmatic, harm-reduction approaches [ 3422 ].
The Asia Harm Reduction Network has emphasized that the considerable prejudice and stigma attached to drug use are reinforced by reliance on the criminal justice system. Severe penalties for risk behaviors associated with HIV infection transmission and drug-related offenses may be counterproductive, because they may discourage individuals from seeking treatment. In contrast, a comprehensive range of substitution treatments has contributed to curbing the spread of HIV infection and other infectious diseases among IDUs in the European Union, as well as in North America and Flow siamois sexual offenders [ 23—29 ].
All 25 countries in the European Union now provide needle syringe programs and methadone maintenance treatment MMT or buprenorphine maintenance treatment BMT. Methadone, the agonist-based treatment option that has been available the longest worldwide, which has a track record of success in the management of opioid dependence, is cost-effective [ 3031 ], reduces involvement in the drug market and drug acquisition-related crime [ 3233 ], and facilitates patients' socioeconomic integration and functioning [ 3435 ].
Methadone treatment is highly regulated in most countries, "Flow siamois sexual offenders" demand generally outpaces the ability to supply treatment. Despite its track record, substitution treatment is viewed negatively in many countries, and this is true for both the general population and medical professionals.
Some countries, such as Vietnam, have accepted recommendations for substitution treatment but have yet to deploy it on a meaningful scale. The absence of national guidelines and the existence of excessive regulation of treatment may contribute to continued restrictions on substitution treatment.
The global availability of buprenorphine has steadily increased and is now included in the 14th World Health Organization Model List Of Essential Medicines [ 47 ]. The sublingual tablet formulation of buprenorphine Subutex; Reckitt Benckiser is currently approved in 44 countries spanning 6 continents and is already marketed in Flow siamois sexual offenders of these countries C.
Chapleo, personal communication, 19 October A combination tablet containing buprenorphine and naloxone in a 4: This combination formulation capitalizes on the different parenteral-to-sublingual potency profiles of buprenorphine and naloxone [ 48—53 ]. Buprenorphine is rapidly becoming a frontline treatment option in many countries, especially in those where access to MMT has been limited or unavailable.
The aim of the present article is to review the international experience with buprenorphine and attitudes toward agonist treatment in general, with reference to its use in strategies to prevent HIV infection transmission and to increase access to antiretroviral therapy among opioid-dependent HIV-infected individuals.
The provision of buprenorphine to special populations, such as inmates, pregnant women, HIV-infected individuals, and those with psychiatric comorbidity, is also discussed.
The need for harm reduction was accepted in France inas a result of the notable increase in HIV infection prevalence among opioid-dependent IDUs. Improved access Flow siamois sexual offenders sterile injection equipment was followed by the simultaneous expansion of methadone use Flow siamois sexual offenders introduction of buprenorphine inwith both programs completely subsidized by the French government.
The timeline of French substitution treatment programs is illustrated in figure 1. Physicians providing drug dependence treatment are not required to receive special training, there is no limit to the number of patients a physician may treat with buprenorphine, and there are no requirements for urine drug testing or counseling.
However, dispensing pharmacists are expected to provide buprenorphine daily during the induction phase the first several days and to directly observe its intake to ensure adherence before commencing unsupervised administration. Pharmacists play a crucial role in informing the prescribing physician about possible buprenorphine "Flow siamois sexual offenders." These policies have now been maintained for more than a decade.
Impact of buprenorphine in France. See also [ 69 ]. A French consensus conference in recommended Flow siamois sexual offenders closer liaison between pharmacists and prescribers, possibly prompted by recent legislation covering substitution treatment that requires patients to choose their own prescribing physician as well as their pharmacist. Overall, this prescription-based model of care enabled a substantial increase in the number of patients receiving buprenorphine through primary care providers, far exceeding treatment access to methadone programs in specialist centers.
Beforea total of 65, individuals received buprenorphine treatment, whereas only received methadone treatment.
Inan estimated 90, patients received buprenorphine treatment in France, compared with 10, who received methadone treatment [ Flow siamois sexual offenders ]. The rapid spread of buprenorphine treatment in France has been associated with individual, social, and economic benefits, as was summarized at the consensus conference [ 73 ] and in a recent review [ 74 ].
These results provide a powerful demonstration of the safety of buprenorphine treatment provided on a national basis in primary care [ 76 ]. The social benefits of buprenorphine are hypothesized to derive from mainstreaming drug dependence treatment into primary care and destigmatizing the recovery process. In addition, the second study showed that patients receiving buprenorphine experienced an increase in the number of relationships with individuals without drug or alcohol problems, a greater likelihood of spending free time alone rather than with other drug users, and a significant decrease in the number of days of for drug-related problems and in the number of days of criminal activity [ 78 ].
The greater flexibility of buprenorphine dispensing, which provides patients greater autonomy and time to organize their lives and increases the possibility of reintegration into the community through employment, may have contributed to the positive results. The French system of substitution treatment Flow siamois sexual offenders created an opportunity to increase the historic low levels of access to care due to an absence of treatment choices, including care for medical complications related to drug use.
As a consequence, many physicians in France now simultaneously prescribe both buprenorphine or methadone treatment and antiretroviral therapy for their HIV-infected patients [ 79 ].