Tougher Action Against Subutex Abuse

11 Aug 2006

Following a review of the use of Subutex (or buprenorphine hydrochloride) as a drug to treat opiate dependence, the Ministry of Home Affairs (MHA) and the Ministry of Health (MOH) have decided to impose stringent measures to curb the abuse of Subutex:

1.  From 14 August 2006, buprenorphine, the active ingredient in Subutex, will be made a Class A Controlled Drug under the First Schedule of the Misuse of Drugs Act (MDA). The importation, distribution, possession and consumption of Subutex will be an offence unless specifically exempted by the relevant authorities. Penalties for offences under MDA are listed in Annex A.

2.  MOH will implement a Subutex Voluntary Rehabilitation Programme (SVRP) to help all those currently on Subutex wean off their dependence and to stay free from opiates. Developed by a panel of psychiatrists, SVRP consists of a medical component which would be complemented by counseling, psychosocial therapy and group support by doctors and counselors to prevent relapse. There will be a two-week period (14 - 27 August 2006) for Subutex users to sign up for the SVRP. They can do so through existing doctors managing their opiate dependence.

3.  From 14 August 2006, doctors will not be permitted to prescribe and dispense any take-home dosages for existing patients. All patients who require Subutex will have to consume their medication under direct visual observation of the pharmacist, doctor and/or his treatment team on a daily basis[1]. Between 14 Aug 2006 to 27 Aug 2006, doctors who are currently treating patients who sign up for SVRP would be allowed to continue to prescribe and dispense Subutex to these patients until the day they commence their first SVRP appointment. From Aug 28, except for those who are enrolled in the SVRP, no other patient will have access to Subutex. Anyone caught in possession of Subutex without proper authorization will be prosecuted. Please refer to Annex B for more details on the SVRP. The hotline to call for the SVRP is 63258607.

Background Information on Subutex Abuse in Singapore

Subutex (or buprenorphine hydrochloride) was approved for use in 2000 by the Ministry of Health and introduced in 2002 as substitution treatment for opiate-dependent (i.e. heroin) drug abusers. The aim of substitution therapy is to reduce craving for heroin and facilitate improvement in social functioning such as employment and personal relationships.

However, drug addicts were found abusing Subutex by mixing it with other drugs and injecting the cocktail into their body. The intravenous misuse of drugs also gives rise to potential medical complications such as Hepatitis B and C, and HIV infection, and limb gangrene. Deaths have also been reported when addicts inject Subutex intravenously with other drugs. Some addicts discard the used syringes indiscriminately, causing public concern about health and safety issues. We saw the emergence of a needle culture, something which we have not seen in the past, even at the height of the heroin abuse problem.

To tighten control on Subutex prescription, MOH introduced the Clinical Practice Guidelines (CPG) on "Treatment of Opiate Dependence" in Nov 2005. The CPG describes good clinical practices and administrative controls to ensure appropriate prescription of Subutex. MOH also introduced the Central Addiction Registry for Drugs, Singapore (CARDS) which monitors the prescription of Subutex by doctors and enables them to identify patients who obtain additional supplies from different doctors. In addition, MOH requires Subutex-prescribing doctors to attend a mandatory 8-hour training course. Despite all the measures taken by MOH, the Subutex abuse situation on the ground persisted.

The Central Narcotics Bureau (CNB), in investigating into reports on the abuse of Subutex, discovered that the drug supply came primarily from licit sources. There was no known illicit supply of Subutex as there was no demand for it. Subutex could be obtained lawfully from General Practitioners. As Subutex is a licensed drug under the Medicines Act, CNB could not take action against the abusers of Subutex. Any effort to make Subutex a controlled drug must be accompanied by measures to tightly control its administration as a treatment regime. The alternative is to completely regulate and prohibit the distribution, possession and consumption of Subutex.

Singapore's Zero Tolerance Policy

Our national strategy against drug abuse is based on a holistic framework with a multi-pronged approach of preventive education, tough enforcement to arrest addicts and traffickers swiftly, treatment[2] and rehabilitation to reform the addicts, and aftercare to reintegrate reformed addicts back into society. In addition, we have introduced long term imprisonment and caning for recalcitrant addicts. This approach has proven successful, with addicts being clean upon release from the Drug Rehabilitation Centres. There is no easy solution to the problem of drug addiction. Beyond what the authorities can do, the individual has the responsibility of avoiding drugs knowing that it can only bring misery. Those who are addicted must be committed and determined to kick their habit.

In deciding on the approach to deal with the Subutex abuse problem, MHA and MOH have to ensure that current users/abusers of Subutex receive support and assistance to wean off their dependence on the drug. We have decided to take a holistic approach and make buprenorphine, the active ingredient in Subutex, a Class A Controlled Drug. It will be an offence to import, distribute, possess or consume Subutex unless specifically exempted by the relevant authorities. At the end of the SVRP, Subutex will only be available under very restrictive conditions; namely, buprenorphine will only be allowed to be used by medical specialists approved by the Director of Medical Service under stringent indications.

We strongly encourage all existing Subutex users to enroll for the SVRP with their existing doctors managing their opiate dependence. We urge families and friends of Subutex users to encourage them to sign up for the SVRP early and support them as they seek to re-integrate into society and lead a drug-free life.

[1] If the clinic is closed during weekends or public holidays, patients will be provided with a private prescription for direct observed treatment with Subutex at designated pharmacies.

[2] Notably, treatment within the Drug Rehabilitation Centres has not relied on the use of any substitute drugs.

SUBUTEX ENQUIRIES

MINISTRY OF HEALTH

MINISTRY OF HOME AFFAIRS

CENTRAL NARCOTICS BUREAU

ANNEX A - BUPRENORPHINE AS A CLASS A CONTROLLED DRUG

After Subutex (or Buprenorphone Hydrochloride) is listed as a controlled drug, first-time and second-time abusers arrested for Subutex consumption will undergo compulsory treatment at the Drug Rehabilitation Centres (DRCs). Recalcitrant abusers will face stiffer punishment under the Long Term Imprisonment (LT1) regime. Under the LT1 regime, third-time or more abusers could face a maximum sentence of 7 years imprisonment and 6 strokes of the cane if convicted. If they commit a subsequent offence of consumption after their conviction for a LT1 regime, they could face a maximum sentence of 13 years imprisonment and 12 strokes of the cane.

Those arrested for trafficking or possession of Subutex will face even stiffer penalties. If convicted, traffickers will face a minimum sentence of 5 years imprisonment and 5 strokes of the cane, and a maximum sentence of 20 years imprisonment and 15 strokes of the cane. Those convicted for possession of Subutex will face up to 10 years' imprisonment, $20,000 fine, or both.

For hardcore drug addicts, previous records for consumption of opiate drugs and synthetic drugs (ie ecstasy, Ketamine, Methamphetamine and Nimetazepam) will be taken into account during prosecution. LT Imprisonment will be imposed on these drug addicts to keep them out of circulation as well as to deter like-minded addicts from relapsing.

To deter proliferation of a needle culture among drug abusers, those found in possession of syringes, stained or otherwise, will face up to 3 years' imprisonment, $10,000 fine, or both.

ANNEX B - SUBUTEX VOLUNTARY REHABILITATION PROGRAMME (SVRP)

The Subutex Voluntary Rehabilitation Programme (SVRP) is specially designed for all Subutex users who sign up during the 14 - 27 August. The aim is to help them wean off their dependence on Subutex and remain abstinent from opiates.

Features of SVRP

A) Medical Component

For existing patients on Buprenorphine maintenance, they would have their dose of Subutex decreased over a period of time (detoxification phase). In general this phase would take around 5 - 7 days. Most patients will undergo detoxification in a supervised outpatient setting such as specialist outpatient clinics at IMH. However, some patients may require inpatient detoxification, such as those with high potential for complicated withdrawal (e.g. patients with concurrent poly-substance abuse or patients with history of complications during previous withdrawal experiences), presence of other co-morbid medical conditions (e.g. uncontrolled diabetes, infections etc) and those with history of depression and psychosis. The inpatient detoxification will be carried out at the Institute of Mental Health (IMH).

The patient would be reviewed regularly to assess progress. In cases with prolonged withdrawal symptoms, the treatment duration would be extended accordingly. Symptomatic medication would also be available for the patient.

Patients who default their appointment, are non-compliance with the treatment regime and/or are found to be abusing opiates, benzodiazepines or any other controlled /illicit drugs will be disqualified from SVRP.

B) Counseling Component

All patients are encouraged to continue with the counseling phase after detoxification. Residential care is recommended for patients with a higher dependency on Subutex and who require extended care after detoxification or are unable to lead opioid-free lifestyles. The residential programmes will be conducted in the appropriate sites such as Halfway Houses.

For patients with lower dependence on Subutex and/or those who need to carry on with their daily activities (e.g. work), non-residential programmes will be offered and conducted either in IMH or venues such as Singapore Anti-Narcotics Association (SANA) and Prisons Link Centres at Paya Lebar and Changi.