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Nalbuphine (Nubain): non-prescribed use, injecting, and risk behaviors for blood-borne viruses.

Article Excerpt
For approximately 25 years, nalbuphine hydrochloride (Nubain[R]), a synthetic opiate with agonist-antagonist properties, was prescribed for pain relief in several countries in North and Central America, Europe, and elsewhere. The drug was distributed in parenteral solutions only, so that injection was the primary method of administration. In December 2004, Bristol-Myers Squibb, the manufacturer of Nubain[R], discontinued worldwide production of the drug. Company staff in a United Kingdom (UK) office later reported that low profits generated from Nubain[R] prescriptions contributed to the decision to discontinue production--at least in Europe (communication with Bristol-Myers UK office, October 19, 2005). Bristol-Myers Squibb still holds the license for Nubain[R], however, other pharmaceutical companies may distribute nalbuphine, if licensed under different names.

Early reports concluded that there were "no known cases of street abuse" involving nalbuphine (Peachey 1987:352), and the drug was believed to produce low levels of dependency (Jasinski & Mansky 1972; Schmidt et al. 1985). (1) However, the number of prescriptions for nalbuphine increased during the 1990s in some countries, leading some scholars to suggest that the drug had greater "addictive potential" than previously assumed (Camacho et al. 2001:469; Wines et al. 1999:161). Very few studies have focused on nalbuphine misuse, and research that has addressed the issue has focused primarily on individuals with a history of body building, weightlifting, or anabolic steroid use. (2)

Three studies have documented nalbuphine misuse among bodybuilders or anabolic steroid users in England or Wales (McBride et al. 1996; Monaghan et al. 2000; Williams et al. 2000). Combined, the data from the studies were collected from a total of 17 respondents or clients. Years of use (range 1 to 8 years) was reported by Williams et al. (2000) and peak daily dosage reached or exceeded I00 mg for some respondents in all three studies. Intravenous use often followed subcutaneous or intramuscular injection, and frequent daily injections were common. Although the authors of one study reported that a few respondents had "shared" injecting equipment (Williams et al. 2000:20), data regarding injecting behaviors generally were not described in the studies. Clients initiated nalbuphine injections primarily to treat pain associated with injury or weightlifting (McBride et al. 1996; Williams et al. 2000). However, Monaghan et al. (2000: section 5.8) found that persons who had injected nalbuphine did not describe the drug as a "useful training aid," and most interviewees in that study condemned the use of nalbuphine, likening the drug to heroin and assigning "junkie" status to users of the drug.

Misuse of nalbuphine also has been reported among anabolic steroid users in the United States. Wines et al. (1999) interviewed 11 respondents who were users of anabolic steroids and nalbuphine. Respondents were recruited from other research projects that addressed the use of anabolic steroids, a drug treatment inpatient unit, and a psychiatric outpatient setting. Respondents' ages ranged from 19 to 42 years, and five of the 11 respondents were female. Similar to research conducted in the UK described above, daily dosage of nalbuphine often exceeded 100 mg per day. Eight of the 11 respondents reported that nalbuphine was the first drug that they had used intravenously. In a separate study of 227 males in treatment for opiate dependency, 21 reported a history of anabolic-androgenic steroid use. The majority of this group reported that they had used opiates to reduce the negative effects, e.g., insomnia, depression, irritability, of their steroid use (Arvary & Pope 2000).

Taken together, this body of research suggests that nalbuphine misuse has been associated largely with bodybuilders or weightlifters, although misuse of the drug does not appear to be widespread within these groups. Some but not all of the individuals who participated in these studies also had used anabolic steroids.

In the mid- to late 1990s, anecdotal and media reports as well as observations by health professionals suggested the possibility of a pattern of nalbuphine misuse in Derry, a city located in Northern Ireland. (3) Prior to this time, drug treatment professionals in the region had not come across the use of nalbuphine among clients presenting for treatment. Because clients presenting for treatment were injecting the drug, treatment professionals also were concerned about the transmission of blood-borne viruses through injecting practices. In Northern Ireland, public health and epidemiological data on nalbuphine use and misuse are not collected. A Northern Ireland general population survey of 3,516 persons aged 15-64 found that self-reported lifetime use of nalbuphine was slightly higher in the Western health board that includes the city of Derry (.2% overall; .4% among males and younger persons), compared to the three other health board areas (overall 0-.1%) (MORI MRC, n.d.). A total of 591 individuals residing in the Western board participated in the survey, therefore these figures are small, i.e., representing fewer than three respondents. Additionally, surveys may underestimate drug use/misuse. Arrest and seizure data involving nalbuphine have limited relevance because nalbuphine is not controlled under the (United Kingdom) Misuse of Drugs Act (the drug is also nonscheduled in the United States). Thus, possessing the drug for personal use is not a criminal offense, although the supply of nalbuphine without medical authorization does violate the Misuse of Drugs Act. As of November 2004, police in the Derry area recalled only one criminal conviction involving nalbuphine (communication with the Police Service of Northern Ireland,...