International Journal of Drug Policy 26 (2015) 434–435
Contents lists available at ScienceDirect
International Journal of Drug Policy journal homepage: www.elsevier.com/locate/drugpo
Viewpoint
Increasing access to opioid maintenance treatment: The role of primary care in France P. Roux a,b,c,∗ , C. Lions a,b,c , M.P. Carrieri a,b,c a b c
INSERM U912 (SESSTIM), Marseille, France Université Aix Marseille, IRD, UMR-S912, Marseille, France ORS PACA, Observatoire Régional de la Santé Provence Alpes Côte d’Azur, Marseille, France
Evidence-based research has underlined both the need to increase access to care for people who use drugs (PWUD) and to “normalize” care for drug dependence as a means to control health risks (Connock et al., 2007; Mattick, Breen, Kimber, & Davoli, 2014). Controlling health risks helps counter two main public health concerns: Opioid overdose and uncontrolled HCV epidemics among PWUD. Prescription opioid overdose is prevalent, especially in the US where, in 2010, they were implicated in 16,651 overdose deaths (Volkow, Frieden, Hyde, & Cha, 2014). A recent national US report showed that “for every unintentional overdose death related to an opioid analgesic, nine people are admitted for substance abuse treatment, 35 visit emergency departments, 161 report drug use or dependence, and 461 report nonmedical uses of opioid analgesics” (“CDC grand rounds, 2012”). The ratio between the number of admissions for substance misuse treatment and the number of nonmedical uses of opioid analgesics is extremely high. It is somewhat surprising to note that compared to access to prescription opioids (PO) for pain relief, which are easily obtained through primary care physicians (Slevin & Ashburn, 2011), opioid maintenance treatment (OMT) is limited, especially in the US where fewer than 10% of all opioid dependent people receive OMT (Burki, 2012; Nosyk et al., 2013). Olsen and Sharfstein (2014) in a recent viewpoint on opioid overdose, and commenting on the death of the American actor Philip Seymour Hoffman from an overdose, suggested that the stigma associated with opioid use disorder and its treatment remains a major barrier to effective care and overdose prevention. The US has already started to destigmatize opioid use thanks to a decision to allow trained primary care physicians to prescribe buprenorphine. In addition, a recent laboratory study demonstrated that buprenorphine could be an effective medication for those patients who need to be treated for chronic pain and opioid dependence (Roux et al., 2013). However, there are still too few of these professionals to meet demand (Ducharme & Abraham, 2008). Moreover, although many patients may respond better to
∗ Corresponding author at: INSERM U912 (SESSTIM), Marseille, France. Tel.: +33 496102876. E-mail address: [email protected] (P. Roux). http://dx.doi.org/10.1016/j.drugpo.2015.01.014 0955-3959/© 2015 Elsevier B.V. All rights reserved.
methadone (Mattick et al., 2014) its consumption is supervised in the US, and access to methadone treatment is subject to long waiting lists. Regarding the HCV epidemic, incidence rates remain high, especially in young adult injection drug users (Page, Morris, Hahn, Maher, & Prins, 2013). This reflects the persistence of risky behaviours among those misusing opioids. Nelson et al. (2011) showed in a systematic review of HCV prevalence, that in 12 countries rates among PWUD were higher than 80%. Today, it is recognized that the uptake of OMT, especially of methadone maintenance treatment (MMT) (Alavian et al., 2013), and high coverage of needle and syringe programs can substantially reduce the risk of hepatitis C virus transmission among injecting drug users (Turner et al., 2011). To improve the acceptability of OMT among PWUD, it is important to reduce the stigma associated with care for opioid dependence (Luoma, Kulesza, Hayes, Kohlenberg, & Larimer, 2014; Williamson, Thom, Stimson, & Uhl, 2014) alongside increasing access to OMT. Although methadone (Mattick, Breen, Kimber, & Davoli, 2009) and buprenorphine (Mattick et al., 2014) are recognized as gold standards for opioid dependence and are included in the World Health Organization’s 18th WHO Essential Medicines List (“WHO Model List of Essential Medicines, 2013”), access to OMT and other therapeutic strategies is limited. In terms of treatment efficacy, no additional benefits have been found when comparing OMT provided alone versus complementing the maintenance treatment with standard psychosocial support (Amato, Minozzi, Davoli, & Vecchi, 2011). Conversely, offering a combination of buprenorphine with tailored, intensive psychosocial treatment seems to be effective in terms of relapse prevention (Kakko, Svanborg, Kreek, & Heilig, 2003). In addition, other treatments have proven their efficiency for opioid-dependent individuals in terms of retention in treatment. This is especially true of heroin-assisted treatment, which was introduced in Switzerland in 1994 (Rehm et al., 2001) and is an effective option for chronically-addicted patients for whom other treatments have failed (Haasen, Verthein, Eiroa-Orosa, Schafer, & Reimer, 2010; Rehm et al., 2001). In France, the introduction of buprenorphine treatment into primary care has led to a dramatic reduction in the number of
P. Roux et al. / International Journal of Drug Policy 26 (2015) 434–435
overdoses (Auriacombe, Fatseas, Dubernet, Daulouede, & Tignol, 2004). Also, moving the care for opioid dependence into primary care settings, which also serve the general population, has an additional benefit in that it can facilitate access to treatment for other health issues for this group. However, problems still exist and are reflected in the persistence of risky behaviours in the opioiddependent population and the related high prevalence of HCV among PWUD (Jauffret-Roustide et al., 2013). In France, methadone treatment is only available in specialist centres. Consequently, many patients who need methadone do not receive it, either because they prefer to remain in primary care receiving buprenorphine or because of geography, as specialist methadone delivery services are absent in rural areas. For these reasons, in 2010, the French Ministry of Health appointed a group of researchers and clinicians to design and implement a trial to assess the feasibility of locating methadone treatment in primary care by comparing methadone treatment in specialist centres (standard care (SC)) with methadone treatment administered by trained primary care (PC) physicians (Roux et al., 2012). Among the 195 opioid-dependent individuals enrolled in the study, preliminary results at 3 months of follow-up showed that abstinence from street opioids was comparable in the SC (52.38%) and PC groups (70.87%) (OR [IC95%] = 0.45 [0.17–1.18]; p = 0.10). In addition, 3-months retention in MMT was higher in the PC group (log-rank test = 0.0003). We also observed a decrease in the mean [standard deviation] number of health problems (11 [7]; 8 [6]; p < 10−3 ) and of withdrawal symptoms (2 [3]; 0 [1]; p < 10−3 ) after 3 months of methadone treatment. These findings illustrate the importance of removing the existing barriers to access to OMT and to reducing the stigma associated with opioid dependence. Improved access to care for opioid dependence through primary care can bring closer the treatment of drug dependence with other chronic illnesses, for example, diabetes, hypertension and HIV, and this should enable health care providers to treat patients with opioid dependence just as they treat patients with any other disease. In turn, this should help to make opioid dependence less stigmatized and more easily accepted by family members, communities and the patients themselves. Role of funding sources This study received external funding from the French National Agency for Research for Aids and Viral Hepatitis (ANRS) and the French Ministry of Health. Conflict of interest The authors declare they have nothing to disclose regarding funding or conflict of interest with respect to this manuscript. References Alavian, S. M., Mirahmadizadeh, A., Javanbakht, M., Keshtkaran, A., Heidari, A., Mashayekhi, A., et al. (2013). Effectiveness of methadone maintenance treatment in prevention of hepatitis C virus transmission among injecting drug users. Hepatitis Monthly, 13(8), e12411. Amato, L., Minozzi, S., Davoli, M., & Vecchi, S. (2011). Psychosocial combined with agonist maintenance treatments versus agonist maintenance treatments alone for treatment of opioid dependence. Cochrane Database of Systematic Reviews, (10), CD004147. http://dx.doi.org/10.1002/14651858.CD004147.pub4 Auriacombe, M., Fatseas, M., Dubernet, J., Daulouede, J. P., & Tignol, J. (2004). French field experience with buprenorphine. American Journal on Addictions, 13(Suppl. 1), S17–S28.
435
Burki, T. (2012). Russia’s drug policy fuels infectious disease epidemics. Lancet Infectious Diseases, 12(4), 275–276. (2012). CDC grand rounds: Prescription drug overdoses – A U.S. epidemic. Morbidity and Mortality Weekly Report, 61(1), 10–13, pii:mm6101a3. Connock, M., Juarez-Garcia, A., Jowett, S., Frew, E., Liu, Z., Taylor, R. J., et al. (2007). Methadone and buprenorphine for the management of opioid dependence: a systematic review and economic evaluation. Health Technol Assess, 11(9), 1–171, iii–iv. Ducharme, L. J., & Abraham, A. J. (2008). State policy influence on the early diffusion of buprenorphine in community treatment programs. Substance Abuse Treatment, Prevention, and Policy, 3, 17. http://dx.doi.org/10.1186/1747-597X-3-17 Haasen, C., Verthein, U., Eiroa-Orosa, F. J., Schafer, I., & Reimer, J. (2010). Is heroin-assisted treatment effective for patients with no previous maintenance treatment? Results from a German randomised controlled trial. European Addiction Research, 16(3), 124–130. http://dx.doi.org/10.1159/000313334 Jauffret-Roustide, M., Pillonel, J., Weill-Barillet, L., Luéon, L., Le Strat, Y., Brunet, S., et al. (2013). Estimation de la séroprévalence du VIH et de l’hépatite C chez les usagers de drogues en France – Premiers résultats de l’enquête ANRS-Coquelicot 2011. BEH. Kakko, J., Svanborg, K. D., Kreek, M. J., & Heilig, M. (2003). 1-Year retention and social function after buprenorphine-assisted relapse prevention treatment for heroin dependence in Sweden: A randomised, placebo-controlled trial. Lancet, 361(9358), 662–668. http://dx.doi.org/10.1016/S0140-6736(03)12600-1 Luoma, J. B., Kulesza, M., Hayes, S. C., Kohlenberg, B., & Larimer, M. (2014). Stigma predicts residential treatment length for substance use disorder. American Journal of Drug Alcohol Abuse, 40(3), 206–212. http://dx.doi.org/10.3109/ 00952990.2014.901337 Mattick, R. P., Breen, C., Kimber, J., & Davoli, M. (2009). Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database of Systematic Reviews, 2, CD002209. http://dx.doi.org/10.1002/ 14651858.CD002209 Mattick, R. P., Breen, C., Kimber, J., & Davoli, M. (2014). Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database of Systematic Reviews, 2, CD002207. Nelson, P. K., Mathers, B. M., Cowie, B., Hagan, H., Des Jarlais, D., Horyniak, D., et al. (2011). Global epidemiology of hepatitis B and hepatitis C in people who inject drugs: Results of systematic reviews. Lancet, 378(9791), 571–583. http://dx.doi. org/10.1016/S0140-6736(11)61097-0. pii:S0140-6736(11)61097-0 Nosyk, B., Anglin, M. D., Brissette, S., Kerr, T., Marsh, D. C., Schackman, B. R., et al. (2013). A call for evidence-based medical treatment of opioid dependence in the United States and Canada. Health Affairs (Millwood), 32(8), 1462–1469. http://dx.doi.org/10.1377/hlthaff.2012.0846 Olsen, Y., & Sharfstein, J. M. (2014). Confronting the stigma of opioid use disorder – And its treatment. JAMA, 311(14), 1393–1394. http://dx.doi.org/10.1001/ jama.2014.2147 Page, K., Morris, M. D., Hahn, J. A., Maher, L., & Prins, M. (2013). Injection drug use and hepatitis C virus infection in young adult injectors: Using evidence to inform comprehensive prevention. Clinical Infectious Diseases, 57(Suppl. 2), S32–S38. http://dx.doi.org/10.1093/cid/cit300 Rehm, J., Gschwend, P., Steffen, T., Gutzwiller, F., Dobler-Mikola, A., & Uchtenhagen, A. (2001). Feasibility, safety, and efficacy of injectable heroin prescription for refractory opioid addicts: A follow-up study. Lancet, 358(9291), 1417–1423. http://dx.doi.org/10.1016/S0140-6736(01)06529-1 Roux, P., Michel, L., Cohen, J., Mora, M., Morel, A., Aubertin, J. F., et al. (2012). Initiation of Methadone in primary care (ANRS-Methaville): A phase III randomized intervention trial. BMC Public Health, 12(1), 488. http://dx.doi.org/10.1186/ 1471-2458-12-488, pii:1471-2458-12-488 Roux, P., Sullivan, M. A., Cohen, J., Fugon, L., Jones, J. D., Vosburg, S. K., et al. (2013). Buprenorphine/naloxone as a promising therapeutic option for opioid abusing patients with chronic pain: Reduction of pain, opioid withdrawal symptoms, and abuse liability of oral oxycodone. Pain, 154(8), 1442–1448. Slevin, K. A., & Ashburn, M. A. (2011). Primary care physician opinion survey on FDA opioid risk evaluation and mitigation strategies. Journal of Opioid Management, 7(2), 109–115. Turner, K. M., Hutchinson, S., Vickerman, P., Hope, V., Craine, N., Palmateer, N., et al. (2011). The impact of needle and syringe provision and opiate substitution therapy on the incidence of hepatitis C virus in injecting drug users: Pooling of UK evidence. Addiction, 106(11), 1978–1988. http://dx.doi.org/10.1111/ j.1360-0443.2011.03515.x Volkow, N. D., Frieden, T. R., Hyde, P. S., & Cha, S. S. (2014). Medication-assisted therapies – Tackling the opioid-overdose epidemic. New England Journal of Medicine, 370(22), 2063–2066. http://dx.doi.org/10.1056/NEJMp1402780 (2013). WHO Model List of Essential Medicines (18th ed.). WHO. Williamson, L., Thom, B., Stimson, G. V., & Uhl, A. (2014). Stigma as a public health tool: Implications for health promotion and citizen involvement. International Journal of Drug Policy, 25(3), 333–335.
Contents lists available at ScienceDirect
International Journal of Drug Policy journal homepage: www.elsevier.com/locate/drugpo
Viewpoint
Increasing access to opioid maintenance treatment: The role of primary care in France P. Roux a,b,c,∗ , C. Lions a,b,c , M.P. Carrieri a,b,c a b c
INSERM U912 (SESSTIM), Marseille, France Université Aix Marseille, IRD, UMR-S912, Marseille, France ORS PACA, Observatoire Régional de la Santé Provence Alpes Côte d’Azur, Marseille, France
Evidence-based research has underlined both the need to increase access to care for people who use drugs (PWUD) and to “normalize” care for drug dependence as a means to control health risks (Connock et al., 2007; Mattick, Breen, Kimber, & Davoli, 2014). Controlling health risks helps counter two main public health concerns: Opioid overdose and uncontrolled HCV epidemics among PWUD. Prescription opioid overdose is prevalent, especially in the US where, in 2010, they were implicated in 16,651 overdose deaths (Volkow, Frieden, Hyde, & Cha, 2014). A recent national US report showed that “for every unintentional overdose death related to an opioid analgesic, nine people are admitted for substance abuse treatment, 35 visit emergency departments, 161 report drug use or dependence, and 461 report nonmedical uses of opioid analgesics” (“CDC grand rounds, 2012”). The ratio between the number of admissions for substance misuse treatment and the number of nonmedical uses of opioid analgesics is extremely high. It is somewhat surprising to note that compared to access to prescription opioids (PO) for pain relief, which are easily obtained through primary care physicians (Slevin & Ashburn, 2011), opioid maintenance treatment (OMT) is limited, especially in the US where fewer than 10% of all opioid dependent people receive OMT (Burki, 2012; Nosyk et al., 2013). Olsen and Sharfstein (2014) in a recent viewpoint on opioid overdose, and commenting on the death of the American actor Philip Seymour Hoffman from an overdose, suggested that the stigma associated with opioid use disorder and its treatment remains a major barrier to effective care and overdose prevention. The US has already started to destigmatize opioid use thanks to a decision to allow trained primary care physicians to prescribe buprenorphine. In addition, a recent laboratory study demonstrated that buprenorphine could be an effective medication for those patients who need to be treated for chronic pain and opioid dependence (Roux et al., 2013). However, there are still too few of these professionals to meet demand (Ducharme & Abraham, 2008). Moreover, although many patients may respond better to
∗ Corresponding author at: INSERM U912 (SESSTIM), Marseille, France. Tel.: +33 496102876. E-mail address: [email protected] (P. Roux). http://dx.doi.org/10.1016/j.drugpo.2015.01.014 0955-3959/© 2015 Elsevier B.V. All rights reserved.
methadone (Mattick et al., 2014) its consumption is supervised in the US, and access to methadone treatment is subject to long waiting lists. Regarding the HCV epidemic, incidence rates remain high, especially in young adult injection drug users (Page, Morris, Hahn, Maher, & Prins, 2013). This reflects the persistence of risky behaviours among those misusing opioids. Nelson et al. (2011) showed in a systematic review of HCV prevalence, that in 12 countries rates among PWUD were higher than 80%. Today, it is recognized that the uptake of OMT, especially of methadone maintenance treatment (MMT) (Alavian et al., 2013), and high coverage of needle and syringe programs can substantially reduce the risk of hepatitis C virus transmission among injecting drug users (Turner et al., 2011). To improve the acceptability of OMT among PWUD, it is important to reduce the stigma associated with care for opioid dependence (Luoma, Kulesza, Hayes, Kohlenberg, & Larimer, 2014; Williamson, Thom, Stimson, & Uhl, 2014) alongside increasing access to OMT. Although methadone (Mattick, Breen, Kimber, & Davoli, 2009) and buprenorphine (Mattick et al., 2014) are recognized as gold standards for opioid dependence and are included in the World Health Organization’s 18th WHO Essential Medicines List (“WHO Model List of Essential Medicines, 2013”), access to OMT and other therapeutic strategies is limited. In terms of treatment efficacy, no additional benefits have been found when comparing OMT provided alone versus complementing the maintenance treatment with standard psychosocial support (Amato, Minozzi, Davoli, & Vecchi, 2011). Conversely, offering a combination of buprenorphine with tailored, intensive psychosocial treatment seems to be effective in terms of relapse prevention (Kakko, Svanborg, Kreek, & Heilig, 2003). In addition, other treatments have proven their efficiency for opioid-dependent individuals in terms of retention in treatment. This is especially true of heroin-assisted treatment, which was introduced in Switzerland in 1994 (Rehm et al., 2001) and is an effective option for chronically-addicted patients for whom other treatments have failed (Haasen, Verthein, Eiroa-Orosa, Schafer, & Reimer, 2010; Rehm et al., 2001). In France, the introduction of buprenorphine treatment into primary care has led to a dramatic reduction in the number of
P. Roux et al. / International Journal of Drug Policy 26 (2015) 434–435
overdoses (Auriacombe, Fatseas, Dubernet, Daulouede, & Tignol, 2004). Also, moving the care for opioid dependence into primary care settings, which also serve the general population, has an additional benefit in that it can facilitate access to treatment for other health issues for this group. However, problems still exist and are reflected in the persistence of risky behaviours in the opioiddependent population and the related high prevalence of HCV among PWUD (Jauffret-Roustide et al., 2013). In France, methadone treatment is only available in specialist centres. Consequently, many patients who need methadone do not receive it, either because they prefer to remain in primary care receiving buprenorphine or because of geography, as specialist methadone delivery services are absent in rural areas. For these reasons, in 2010, the French Ministry of Health appointed a group of researchers and clinicians to design and implement a trial to assess the feasibility of locating methadone treatment in primary care by comparing methadone treatment in specialist centres (standard care (SC)) with methadone treatment administered by trained primary care (PC) physicians (Roux et al., 2012). Among the 195 opioid-dependent individuals enrolled in the study, preliminary results at 3 months of follow-up showed that abstinence from street opioids was comparable in the SC (52.38%) and PC groups (70.87%) (OR [IC95%] = 0.45 [0.17–1.18]; p = 0.10). In addition, 3-months retention in MMT was higher in the PC group (log-rank test = 0.0003). We also observed a decrease in the mean [standard deviation] number of health problems (11 [7]; 8 [6]; p < 10−3 ) and of withdrawal symptoms (2 [3]; 0 [1]; p < 10−3 ) after 3 months of methadone treatment. These findings illustrate the importance of removing the existing barriers to access to OMT and to reducing the stigma associated with opioid dependence. Improved access to care for opioid dependence through primary care can bring closer the treatment of drug dependence with other chronic illnesses, for example, diabetes, hypertension and HIV, and this should enable health care providers to treat patients with opioid dependence just as they treat patients with any other disease. In turn, this should help to make opioid dependence less stigmatized and more easily accepted by family members, communities and the patients themselves. Role of funding sources This study received external funding from the French National Agency for Research for Aids and Viral Hepatitis (ANRS) and the French Ministry of Health. Conflict of interest The authors declare they have nothing to disclose regarding funding or conflict of interest with respect to this manuscript. References Alavian, S. M., Mirahmadizadeh, A., Javanbakht, M., Keshtkaran, A., Heidari, A., Mashayekhi, A., et al. (2013). Effectiveness of methadone maintenance treatment in prevention of hepatitis C virus transmission among injecting drug users. Hepatitis Monthly, 13(8), e12411. Amato, L., Minozzi, S., Davoli, M., & Vecchi, S. (2011). Psychosocial combined with agonist maintenance treatments versus agonist maintenance treatments alone for treatment of opioid dependence. Cochrane Database of Systematic Reviews, (10), CD004147. http://dx.doi.org/10.1002/14651858.CD004147.pub4 Auriacombe, M., Fatseas, M., Dubernet, J., Daulouede, J. P., & Tignol, J. (2004). French field experience with buprenorphine. American Journal on Addictions, 13(Suppl. 1), S17–S28.
435
Burki, T. (2012). Russia’s drug policy fuels infectious disease epidemics. Lancet Infectious Diseases, 12(4), 275–276. (2012). CDC grand rounds: Prescription drug overdoses – A U.S. epidemic. Morbidity and Mortality Weekly Report, 61(1), 10–13, pii:mm6101a3. Connock, M., Juarez-Garcia, A., Jowett, S., Frew, E., Liu, Z., Taylor, R. J., et al. (2007). Methadone and buprenorphine for the management of opioid dependence: a systematic review and economic evaluation. Health Technol Assess, 11(9), 1–171, iii–iv. Ducharme, L. J., & Abraham, A. J. (2008). State policy influence on the early diffusion of buprenorphine in community treatment programs. Substance Abuse Treatment, Prevention, and Policy, 3, 17. http://dx.doi.org/10.1186/1747-597X-3-17 Haasen, C., Verthein, U., Eiroa-Orosa, F. J., Schafer, I., & Reimer, J. (2010). Is heroin-assisted treatment effective for patients with no previous maintenance treatment? Results from a German randomised controlled trial. European Addiction Research, 16(3), 124–130. http://dx.doi.org/10.1159/000313334 Jauffret-Roustide, M., Pillonel, J., Weill-Barillet, L., Luéon, L., Le Strat, Y., Brunet, S., et al. (2013). Estimation de la séroprévalence du VIH et de l’hépatite C chez les usagers de drogues en France – Premiers résultats de l’enquête ANRS-Coquelicot 2011. BEH. Kakko, J., Svanborg, K. D., Kreek, M. J., & Heilig, M. (2003). 1-Year retention and social function after buprenorphine-assisted relapse prevention treatment for heroin dependence in Sweden: A randomised, placebo-controlled trial. Lancet, 361(9358), 662–668. http://dx.doi.org/10.1016/S0140-6736(03)12600-1 Luoma, J. B., Kulesza, M., Hayes, S. C., Kohlenberg, B., & Larimer, M. (2014). Stigma predicts residential treatment length for substance use disorder. American Journal of Drug Alcohol Abuse, 40(3), 206–212. http://dx.doi.org/10.3109/ 00952990.2014.901337 Mattick, R. P., Breen, C., Kimber, J., & Davoli, M. (2009). Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database of Systematic Reviews, 2, CD002209. http://dx.doi.org/10.1002/ 14651858.CD002209 Mattick, R. P., Breen, C., Kimber, J., & Davoli, M. (2014). Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database of Systematic Reviews, 2, CD002207. Nelson, P. K., Mathers, B. M., Cowie, B., Hagan, H., Des Jarlais, D., Horyniak, D., et al. (2011). Global epidemiology of hepatitis B and hepatitis C in people who inject drugs: Results of systematic reviews. Lancet, 378(9791), 571–583. http://dx.doi. org/10.1016/S0140-6736(11)61097-0. pii:S0140-6736(11)61097-0 Nosyk, B., Anglin, M. D., Brissette, S., Kerr, T., Marsh, D. C., Schackman, B. R., et al. (2013). A call for evidence-based medical treatment of opioid dependence in the United States and Canada. Health Affairs (Millwood), 32(8), 1462–1469. http://dx.doi.org/10.1377/hlthaff.2012.0846 Olsen, Y., & Sharfstein, J. M. (2014). Confronting the stigma of opioid use disorder – And its treatment. JAMA, 311(14), 1393–1394. http://dx.doi.org/10.1001/ jama.2014.2147 Page, K., Morris, M. D., Hahn, J. A., Maher, L., & Prins, M. (2013). Injection drug use and hepatitis C virus infection in young adult injectors: Using evidence to inform comprehensive prevention. Clinical Infectious Diseases, 57(Suppl. 2), S32–S38. http://dx.doi.org/10.1093/cid/cit300 Rehm, J., Gschwend, P., Steffen, T., Gutzwiller, F., Dobler-Mikola, A., & Uchtenhagen, A. (2001). Feasibility, safety, and efficacy of injectable heroin prescription for refractory opioid addicts: A follow-up study. Lancet, 358(9291), 1417–1423. http://dx.doi.org/10.1016/S0140-6736(01)06529-1 Roux, P., Michel, L., Cohen, J., Mora, M., Morel, A., Aubertin, J. F., et al. (2012). Initiation of Methadone in primary care (ANRS-Methaville): A phase III randomized intervention trial. BMC Public Health, 12(1), 488. http://dx.doi.org/10.1186/ 1471-2458-12-488, pii:1471-2458-12-488 Roux, P., Sullivan, M. A., Cohen, J., Fugon, L., Jones, J. D., Vosburg, S. K., et al. (2013). Buprenorphine/naloxone as a promising therapeutic option for opioid abusing patients with chronic pain: Reduction of pain, opioid withdrawal symptoms, and abuse liability of oral oxycodone. Pain, 154(8), 1442–1448. Slevin, K. A., & Ashburn, M. A. (2011). Primary care physician opinion survey on FDA opioid risk evaluation and mitigation strategies. Journal of Opioid Management, 7(2), 109–115. Turner, K. M., Hutchinson, S., Vickerman, P., Hope, V., Craine, N., Palmateer, N., et al. (2011). The impact of needle and syringe provision and opiate substitution therapy on the incidence of hepatitis C virus in injecting drug users: Pooling of UK evidence. Addiction, 106(11), 1978–1988. http://dx.doi.org/10.1111/ j.1360-0443.2011.03515.x Volkow, N. D., Frieden, T. R., Hyde, P. S., & Cha, S. S. (2014). Medication-assisted therapies – Tackling the opioid-overdose epidemic. New England Journal of Medicine, 370(22), 2063–2066. http://dx.doi.org/10.1056/NEJMp1402780 (2013). WHO Model List of Essential Medicines (18th ed.). WHO. Williamson, L., Thom, B., Stimson, G. V., & Uhl, A. (2014). Stigma as a public health tool: Implications for health promotion and citizen involvement. International Journal of Drug Policy, 25(3), 333–335.
