Maximising access to drug treatment while minimising diversion of medications — new EMCDDA report looks at striking the balance

Opioid substitution treatment (OST) is a key evidence-based tool used to manage opioid dependence and improve related health and social consequences. Yet increasing reports of the diversion and misuse of the controlled drugs used in this treatment in Europe are a cause for concern. In a new report out today, the EMCDDA highlights the various dimensions of the issue and the importance of balanced policies that maximise access to treatment while minimising diversion and misuse.

According to the report: ‘The consequences of the diversion and misuse of prescription OST medications in Europe are a continuing public health concern and require heightened vigilance, particularly in light of the recent opioid epidemics in the United States’. The report looks at how OST is implemented in Europe, the motivations behind diversion and the measures in place to address the problem.

Around half of the 1.3 million high-risk opioid users in the EU are estimated to be receiving OST — 660 000 in 2018 — a considerably higher rate than in most other world regions. Provision of OST varies across Europe, being generally higher in the 15 countries that had joined the EU by 1995 and lower in the countries joining since 2004. According to WHO guidelines, OST should be available to all those in need, and treatment programmes should be designed to be as accessible as possible.

Evidence shows that OST can bring a number of benefits, such as reducing overdose and blood-borne infections and increasing retention in treatment. However, the report reveals that the demand for specialised treatment related to the misuse of OST medications and the number of deaths associated with these substances have been increasing over the past decade. The vast majority of those seeking help were long-term high-risk opioid users with a history of opioid dependence and past treatment experiences.

Available European data show that diverted prescription OST medications (e.g. methadone, buprenorphine) mainly originate from domestic supplies. In Europe, these medications for non-medical use are largely sourced from family and friends (via legitimate medical supply) or from drug dealers. Opioid users in treatment may also stray from clinical guidance and stockpile their prescribed OST medication for later personal use. And illegitimate medical sourcing (e.g. ‘doctor shopping’, prescription fraud) is often observed in countries with limited patient registration systems. Cross-border trafficking and the internet appear to play a lesser role in supply.

The most common motivation cited for misusing prescribed and non-prescribed OST medications was the intended therapeutic purpose: to ease withdrawal and maintain abstinence. Lack of access to OST and lower prices (than heroin) were also mentioned, as was ‘topping up’ insufficient prescribed doses. The latter highlights the issue that sub-optimal prescribing practices may inadvertently contribute to increased diversion.

European countries have implemented a number of strategies to control and prevent the diversion of OST medications, such as training for clinicians and patients and central registers of those receiving OST. Yet the report cautions against ‘one-size-fits-all’ policies, underlining the need for country-specific anti-diversion measures that address specific national causes of the problem.

The report concludes: ‘It is a challenge for, but also a responsibility of, the stakeholders involved in the provision of OST to ensure the availability and accessibility of this effective treatment while developing and implementing effective anti-diversion policies. Therefore, it is important that the principle of balance is applied’.