Journal of Substance Abuse Treatment xxx (2013) xxx–xxx
Contents lists available at SciVerse ScienceDirect
Journal of Substance Abuse Treatment
The effect of an electronic medicine dispenser on diversion of
buprenorphine-naloxone—experience from a medium-sized Finnish City
Hanna Uosukainen, MSc. a,⁎, Hannu Pentikäinen, M.D. b, c, Ulrich Tacke, M.D., Ph.D. a, b
a
b
c
University of Eastern Finland, Kuopio Campus, School of Pharmacy, Faculty of Health Sciences, P.O. Box 1627, FI-70211 Kuopio, Finland
Addiction Psychiatry Unit, Kuopio University Hospital, Kuopio, Finland
Health Care Services, Criminal Sanctions Agency, Kuopio, Finland
a r t i c l e
i n f o
Article history:
Received 24 September 2012
Received in revised form 10 January 2013
Accepted 18 January 2013
Available online xxxx
Keywords:
Buprenorphine
Naloxone
Diversion
Electronic monitoring
Opiate substitution treatment
a b s t r a c t
Providing unobserved opioid substitution treatment (OST) safely is a major challenge. This study examined
whether electronic medicine dispensers (EMDs) can reduce diversion of take-home buprenorphine–naloxone
(BNX) in a medium-sized Finnish city. All BNX treated OST patients in Kuopio received their take-home BNX
in EMDs for 4 months. EMDs' effect on diversion was investigated using questionnaires completed by patients
(n = 37) and treatment staff (n = 19), by survey at the local needle exchange service and by systematic review
of drug screen data from the Kuopio University Hospital. The majority of patients (n = 21, 68%) and treatment
staff (n = 11, 58%) preferred to use EMDs for the safe storage of tablets. Five patients (16%) declared that
EMDs had prevented them from diverting BNX. However, EMDs had no detectable effect on the availability or
origin of illegal BNX or on the hospital-treated buprenorphine-related health problems. EMDs may improve
the safety of storage of take-home BNX, but their ability to prevent diversion needs further research.
© 2013 Elsevier Inc. All rights reserved.
1. Introduction
Buprenorphine is a widely used, effective and safe opioid
substitution treatment (OST) medicine (Johnson, Jaffe, & Fudala,
1992; Ling et al., 1998; Kakko, Svanborg, Kreek, & Heilig, 2003).
Buprenorphine has enabled the provision of OST in office-based
settings as well as in primary health care (Fudala et al., 2003; Lintzeris,
Ritter, Panjari, Clark, Kutin, & Bammer, 2004; Auriacombe, Fatseas,
Dubernet, Daulouede, & Tignol, 2004; Cozzolino et al., 2006; Fiellin
et al., 2008). This allows unobserved dosing which means that
patients can receive take-home doses of their OST medicines.
Unobserved dosing can offer substantial advantages. These are
increased accessibility to OST (Bell, Byron, Gibson, & Morris, 2004;
Gunderson, Wang, Fiellin, Bryan, & Levin, 2010) and positive effect on
social and occupational rehabilitation (Bell et al., 2004; Anstice, Strike,
& Brands, 2009). Retention in treatment is similar (Fiellin et al., 2006;
Bell et al., 2007; Moore et al., 2012) or even improved (Holland et al.,
2012) in comparison with observed dosing. OST patients value
unobserved dosing and consider it as an essential part of OST (Stone
Conflicts of interest: HU has received unrelated grant funding from Lundbeck Ltd. HP
has received lecture fees and congress expenses from Reckitt Benckiser, Pfizer and
Lundbeck Ltd.
⁎ Corresponding author. Tel.: +358 40 3553 775; fax: +358 17 162424.
E-mail address: hanna.uosukainen@uef.fi (H. Uosukainen).
& Fletcher, 2003; Treloar, Fraser, & Valentine, 2007; Madden, Lea,
Bath, & Winstock, 2008).
Diversion of OST medicines is defined as selling/trading, sharing or
giving these medicines to others (Larance, Degenhardt, Lintzeris,
Winstock, & Mattick, 2011b). Diversion is especially common in
treatment with buprenorphine with 24–28% of buprenorphine/
buprenorphine–naloxone patients reporting recent diversion (Winstock, Lea, & Sheridan, 2008; Larance et al., 2011a). Diversion of OST
medicines carries the risk of overdoses, dependence as well as
injection-related harm (Degenhardt et al., 2008). Increased abuse by
injecting has been shown with unobserved dosing of methadone
(Darke, Ross, & Hall, 1996; Lintzeris, Lenne, & Ritter, 1999; Darke,
Topp, & Ross, 2002; Ritter & Di Natale, 2005; Duffy & Baldwin, 2012). A
buprenorphine–naloxone (BNX) combination product was developed
(Suboxone) in order to deter the intravenous (IV) abuse of
buprenorphine and this was also hoped to prevent its diversion
(Bell et al., 2004). However, the addition of opioid-antagonist
naloxone does not completely prevent IV-use (Alho, Sinclair, Vuori,
& Holopainen, 2007; Bruce, Govindasamy, Sylla, Kamarulzaman, &
Altice, 2009) and also BNX diversion has been reported recently
(Larance et al., 2011a; Johanson, Arfken, di Menza, & Schuster, 2012).
Diversion and abuse of OST medicines jeopardize both the
outcomes and the reputation of OST (Mammen & Bell, 2009). The
situation in Finland is especially concerning, because the most
commonly used OST medicine, buprenorphine, was the main reason
for treatment seeking in 33% of all clients with substance use
0740-5472/$ – see front matter © 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jsat.2013.01.003
Please cite this article as: Uosukainen, H., et al., The effect of an electronic medicine dispenser on diversion of buprenorphine-naloxone—
experience from a medium-sized Finnish City, Journal of Substance Abuse Treatment (2013), http://dx.doi.org/10.1016/j.jsat.2013.01.003
2
H. Uosukainen et al. / Journal of Substance Abuse Treatment xxx (2013) xxx–xxx
problems in 2009 (Forsell, Virtanen, Jääskeläinen, Alho, & Partanen,
2010). Due to its widespread abuse, single-ingredient buprenorphine (BUP) was withdrawn from sale and since December 2007
only buprenorphine–naloxone (BNX) has been approved for OST in
Finland. Generally, patients receive OST free of charge in Finland
with the exception of those who receive their medication from
community pharmacies where they may have to make a contribution towards medication costs. Duration of OST depends solely on
patient's psychosocial rehabilitation. Take-home allowances are
granted to stable and highly motivated patients after several
weeks of daily supervised dosing, and from February 2008, clinically
stable patients have been able to receive BNX unsupervised from
community pharmacies.
Various approaches have been introduced to limit the abuse and
diversion of opioids, e.g. diaries, contracts, laboratory drug screens
(Fishman, Wilsey, Yang, Reisfield, Bandman, & Borsook, 2000), abusedeterrent formulations (e.g. sustained-release, transdermal and
sublingual film formulations) (Fudala & Johnson, 2006), prescription
monitoring programs (Fishman, Papazian, Gonzalez, Riches, & Gilson,
2004; Pradel et al., 2009) and the use of RFID (radio frequency
identification) technology or electronic adherence monitoring
(Fudala & Johnson, 2006). So far, previous studies on electronic
monitoring in OST have used it to obtain reliable and detailed
adherence data (Arnsten et al., 2001; Fiellin et al., 2006; Sorensen
et al., 2007). Our 4-week pilot study examining electronic compliance
monitoring in 12 BNX treated OST patients indicated that monitoring
was well accepted and subjectively increased compliance (Tacke,
Uosukainen, Kananen, Kontra, & Pentikäinen, 2009). After these
encouraging results we conducted a larger local intervention with
electronic medicine dispensers (EMDs). This study examined whether
EMDs can reduce diversion of take-home BNX in OST patients in a
medium-sized Finnish city.
2. Materials and methods
2.1. Participants and setting
This naturalistic, open-label clinical study was done in Kuopio, a
city of 90,000 inhabitants in Eastern Finland. Locally OST is provided
by three services: the addiction psychiatry outpatient clinic, the
Kuopio region addiction services trust, and the health centre of the
Kuopio municipality. All three treatment units as well as local
community pharmacies dispensing BNX (n = 3) participated in this
study. All OST patients registered at the treatment-services and
eligible for the study, were asked to participate. Inclusion criteria for
the patients were the following:
• diagnosis of opioid dependence (F11.22) according to International
Classification of Diseases (ICD-10) criteria;
• OST with a stable dose of BNX;
• OST started at least 1 month before the initiation of the study;
• one or more take-home allowance(s) per week.
During the intervention phase, EMDs were provided to all eligible
patients as part of the routine clinical care. In this manner, we ensured
that in the city of Kuopio take-home allowances of BNX were provided
in EMDs regardless of whether the patient consented to participate in
the study or not. Participating patients were interviewed (data to be
published separately) and asked to complete a questionnaire (see
Section 2.4.).
2.2. Electronic medicine dispenser (EMD)
The EMD used in the study was the Med-O-Wheel Smart (Addoz
Ltd, http://www.addoz.com/products/med-o-wheel_smart/). BNX
tablets (maximum of 1 week's dose for the reasons of stability)
were removed from blisters and the daily doses were put into the
compartments of the dosage cassettes and then inserted into the
EMDs. Dispensers were programmed according to patients' individual
dosing times. The right compartment with the daily dose could be
moved into the opening position by pressing the cover of the device
during a 3-hour time window around the preset dosing time. After the
time window, EMDs switched into the “closed”-mode automatically
and tablets were inaccessible until the next preset time window.
Therefore, missed or skipped doses remained locked within EMDs.
The device was made of hard plastic and included a locking system to
prevent tampering and access to tablets outside the preset time
window. Treatment staff (nurses, pharmacists) loaded and programmed EMDs which took approximately 5–10 minutes per device
depending on the patient's dose.
2.3. Procedures
In August and September 2010 all eligible patients were asked to
give their written informed consent. A few weeks later, dispensing of
BNX take-home doses in EMDs was started and continued for the next
4 months. In all other aspects of OST, normal standard care was
continued, including the possibility for an increase in the number of
take-home allowances. All study protocol violations (skipped doses,
tampering with the device etc.) were handled individually according
to local treatment guidelines with a reduction of take-home
allowances as the most usual consequence.
The availability of illegal buprenorphine in the city of Kuopio and
possible changes due to the trial were examined by an anonymous
questionnaire, handed out at the local needle exchange service. All
clients, visiting this service during the two 2-week study periods in
August 2010 (pre-EMD phase) and in December 2010 (EMD phase),
were asked to fill in the questionnaire.
Information on the drug screens taken at the Kuopio University
Hospital was collected retrospectively and consisted of the time
period of EMD use (EMD-phase 1.10.-31.12.2010) and control periods
before (pre-EMD-phase 1.7.-31.8.2010) and after (post-EMD phase
1.2.-30.4.2011) the intervention. Samples for the urine drug screens
were taken at the emergency department and the intensive care unit
at Kuopio University Hospital, which is the only local provider of acute
and emergency services. Positive drug screens were regarded as
indicators for hospital-treated drug-related health problems. We
assumed that any licit or illicit buprenorphine user in Kuopio with an
acute health problem requiring hospital treatment would be
subjected to a urine drug-screen, if his or her condition was suspected
to be drug-related. Drug screens included buprenorphine (with and
without naloxone), other opioids (methadone, oxycodone, heroin,
codeine, morphine), other illicit drugs (amphetamine, methamphetamine, cannabis, MDMA) and benzodiazepines. Urine-samples were
analyzed with the Cobas 6000 clinical chemistry analyzer (Roche/
Hitachi) at the Eastern Finland Laboratory Centre. For buprenorphineanalysis CEDIA Buprenorphine Drugs of Abuse Assay reagents
(Thermo Scientific) and the kinetic interaction of micro particles in
a solution (KIMS) reagents (Roche Diagnostics) were used.
The study protocol was approved by the Research Ethics
Committee of the North-Savo Hospital District. The Clinical Trials
protocol registration number of the study is NCT01182402 (www.
clinicaltrials.gov).
2.4. Measures
At the end of the EMD phase in January 2011 patients were asked
to complete an anonymous questionnaire to give their opinions on
EMDs' potential to prevent the diversion of BNX in general (agree, no
opinion, disagree), the safety of its use compared to paper sachets
(agree, no opinion, disagree), whether EMDs had prevented them
from diverting or others to get hold of their BNX (yes, no) and the
possibility of tampering with the device (easy, difficult, impossible).
Please cite this article as: Uosukainen, H., et al., The effect of an electronic medicine dispenser on diversion of buprenorphine-naloxone—
experience from a medium-sized Finnish City, Journal of Substance Abuse Treatment (2013), http://dx.doi.org/10.1016/j.jsat.2013.01.003
H. Uosukainen et al. / Journal of Substance Abuse Treatment xxx (2013) xxx–xxx
Tampering was defined as getting access to tablets in the device
outside the time window. A slightly modified version of the
questionnaire was distributed to treatment staff (nurses and
pharmacists involved in the study) to request their opinions on the
same issues and whether they thought EMDs could be used as part of
routine OST (agree, no opinion, disagree).
Questions in the questionnaire distributed at the local needle
exchange service were based on the study by Alho et al. (2007). To
ensure the content validity of the questionnaire, it was developed in
close collaboration with service-staff (nurses and physicians). For the
purpose of distinguishing between buprenorphine products, the
abbreviation BNX was used for buprenorphine–naloxone (Suboxone)
and BUP for single-ingredient buprenorphine used in OST (Subutex).
BUP is only available by special permission from the Finnish
Medicines Agency for the treatment of pregnant women. We
requested information on the frequency of buprenorphine use and
products (BNX, BUP) used during the previous month, the most
frequently used product, present availability (good, moderate, poor)
and origin (OST versus other) of BNX and amount of money
respondents were willing to pay for one tablet of BUP (8 mg) or
BNX (8/2 mg).
2.5. Data analyses
Mann–Whitney U-test was used for analyzing continuous variables and Pearson chi-square (χ 2) test and Fischer's exact test for
categorical variables. A significance level of 0.05 was used for all tests.
Analyses were done with the Statistical Package for the Social Sciences
(SPSS version 19).
3. Results
3.1. Study participants
A total of 37 patients (88% of all eligible patients) agreed to
participate in the study. Their demographic information is given in
Table 1. Five patients refused to participate (four men and one
woman). Three patients were pregnant during the study and received
their take-home buprenorphine (BUP) in EMDs. A total of 45 persons
used EMDs during the study period. One patient claimed that the EMD
had been stolen; all other EMDs were returned after the study period.
Major damage to the EMD occurred in two cases and several instances
of minor damage were recorded.
Table 1
Demographic background information of study participants and their opinions on
electronic medicine dispenser (EMD) use.
Demographics (n = 37)
Males, n (%)
Age, mean (SD)
Caucasian race (Finnish), n (%)
Length of opioid substitution treatment (OST) (years),
mean (SD)
Daily dose of buprenorphine–naloxone (BNX) (mg),
mean (SD)
Patients' opinions (n = 31)
EMD prevented me from diverting OST medicines
EMD prevented others to get hold of my OST medicines
In general EMD can prevent diversion of OST medicines
It feels safer to keep OST medicines in the EMD compared
to paper sachet
Tampering with EMD is
Easy
Difficult
Impossible
Missing answer
21
30.0
37
3.0
(57)
(5.1)
(100)
(2.9)
17.2 (4.3)
n (%)
5 (16)
7 (23)
18 (58)
21 (68)
6 (19)
6 (19)
18 (58)
1 (3)
3
3.2. Views of patients and treatment staff
Thirty-one patients (84%) completed and returned the questionnaire. Five patients (16%) reported that the EMD had prevented them
from diverting their medicines (Table 1). However, 18 patients (58%)
thought that EMDs can generally prevent diversion. Twenty-one
patients (68%) regarded EMDs as safer option for the storage of takehome doses than paper sachets which had been the routine
dispensing practice before the trial.
Altogether 19 completed questionnaires (3 from pharmacies, 16
from treatment units) were returned by treatment staff (response
rate of 84% estimated according to the number of returned
questionnaires and staff involved in the study). Staff did not think
that EMDs could prevent diversion (16 respondents, 84%). Nevertheless, 58% of them (n = 11) preferred to dispense take-home doses of
OST medicines in EMDs compared to paper sachets and 74% of them
(n = 14) reported that EMDs could be used as part of routine OST.
3.3. Survey at the needle exchange service
The response rate for the first survey in the pre-EMD phase
was 46% (35 responses), and for the second survey in the EMD
phase 39% (27 responses). In the first survey three respondents
reported that they did not use buprenorphine and they were
excluded from the analyses. Respondents in both surveys were
mostly males (56% and 64%, respectively) and younger than
30 years old (56% and 74%, respectively).
Nearly all respondents in both surveys abused BNX (100% and
96%, respectively), and 47% (n = 15) and 59% (n = 16) of them were
daily buprenorphine users (Table 2). In the pre-EMD phase more
respondents indicated BNX was their most commonly used
buprenorphine product (n = 26, 87%) compared to the EMD phase
(n = 16, 59%), (p = 0.033). There were more users of illegal BUP in
the EMD phase than in the pre-EMD phase (67% versus 47%, p =
0.188). According to the views of respondents the availability of
illegal BNX (p = 0.371) and its origin from OST (p = 1.000) did not
change between the surveys.
3.4. Drug screens
During the data collection periods altogether 198 positive drug
screen results from 121 individuals were registered. Overall, the
results did not change between the three phases (before versus
during versus after) of the study (χ 2[df = 6] = 1.429, p = 0.964). About
Table 2
Patterns of buprenorphine abuse, views about availability and suitable price for BNX
(Suboxone) and BUP (Subutex) tablets reported by survey respondents at the needle
exchange service in the pre-EMD phase and EMD phase, (EMD = electronic medicine
dispenser).
Variable
BNX user, n (%)
BUP user, n (%)
Daily buprenorphine user, n (%)
BNX most commonly used
buprenorphine product, n (%)
Availability of BNX is good, n (%)
BNX originated from OST, n (%)
Mean price (€) of one BNX
tablet (8/2 mg) (SD)
Mean price (€) of one BUP
tablet (8 mg) (SD)
Pre-EMD phase
(n = 32)
32
15
15
26
(100)
(47)
(47)
(87)b
EMD phase
(n = 27)
26
18
16
16
(96)
(67)
(59)
(59)
p-Valuea
0.458
0.188
0.435
0.033
6 (19)
6 (19)
42.92 (11.67)
8 (30)
5 (19)c
43.34 (7.09)
0.371
1.000
0.943
50.71 (14.45)
55.27 (10.23)
0.110
a
Fischer's exact test for categorical variables, Mann–Whitney U-test for continuous
variables.
b
The responses of two persons are missing.
c
The response of one person is missing.
Please cite this article as: Uosukainen, H., et al., The effect of an electronic medicine dispenser on diversion of buprenorphine-naloxone—
experience from a medium-sized Finnish City, Journal of Substance Abuse Treatment (2013), http://dx.doi.org/10.1016/j.jsat.2013.01.003
4
H. Uosukainen et al. / Journal of Substance Abuse Treatment xxx (2013) xxx–xxx
10% of the drug screens (range 8.8–11.4%) were buprenorphinepositive during all the study periods (Fig. 1). Positive drug screens for
other opioids (range 20.0–23.8%), benzodiazepines (range 47.9–
53.8%) and other drugs (range 13.8–18.8%) remained stable between
the three phases of the study.
4. Discussion
To our knowledge this is the first study to have examined whether
the comprehensive use of EMDs has a detectable effect on the
diversion of BNX. EMDs did not have effect on the buprenorphinerelated health problems treated at the Kuopio University Hospital or
on the availability and origin of illegal BNX. However, during the use
of EMDs five patients (16%) reported that EMDs had prevented them
from diverting BNX and a slightly increasing trend of BUP (single
ingredient buprenorphine) instead of BNX abuse was reported by
needle exchange service clients.
A small number of patients (n = 5, 16%) reported that EMDs had
prevented them from diverting their medicines, which represents
about half of the proportion of BNX patients that reported diversion
(30%) in the study by Larance et al. (2011a). Nevertheless, also
treatment practices such as the extent of unsupervised dosing affect
the proportion of diversion (Bell, 2010) and therefore, the comparability of these numbers may be limited. Most patients (68%) felt that it
was safer to store take-home doses in EMDs compared to paper
sachets. Possibly, locked devices were helpful since patients with
take-home allowances may have been asked or threatened to pass on
their medicines to other users or dealers. Using EMDs may help to
reduce this pressure.
Treatment staff also appreciated the safety of dosing with EMDs
although they were generally pessimistic about the potential of EMDs
to prevent diversion. This critical view may have been linked to
treatment staff being aware that some patients were tampering with
the device. This pitfall was recognized early in the trial. Tampering
was performed by forcing the disk with compartments for daily doses
into the “open” position by using e.g. a thin pencil. This could not be
detected later by visual inspection. However, we believe very few
patients did this, because most patients reported that tampering with
the device was difficult or impossible. Based on these experiences
from the trial, the manufacturer (Addoz Ltd) made technical changes
to make the device more tamper-proof. However, the possibility of
tampering with the device should be taken into account when using
EMDs in clinical practice.
Pre-EMD 10.4 %
EMD 8.8 %
22.9 %
47.9 %
23.8 %
18.8 %
53.8 %
13.8 %
When planning the study, one of our goals was to reduce the
availability of illegal buprenorphine and therefore reduce the number
of hospital-treated buprenorphine-related health problems. However,
this was not observed in the study. The failure to document changes in
buprenorphine-positive drug screens may be related to the fact that
also patients from outside Kuopio are treated in the hospital
emergency department, which may have diluted our results. In
addition, our sample size may have been too small to detect changes.
BNX was more commonly abused than BUP at both surveys at the
needle exchange service. This is not surprising since BNX has been the
only licit buprenorphine formulation for OST in Finland since
December 2007. However, BNX was the most commonly abused
product more often in the pre-EMD phase than in the EMD phase (p =
0.033). The abuse of BUP appeared more common in the EMD phase
although this difference was not statistically significant (p = 0.188).
Therefore, there seemed to be a slight shift from BNX to BUP abuse
during the study which could support the hypothesis that EMDs may
have decreased the availability of BNX from diversion and this could
have triggered a shift to other buprenorphine products. Another
explanation could be the better availability of BUP in the EMD phase
for reasons unrelated to the trial. Since there are many factors
influencing illegal drug markets (European Monitoring Centre for
Drugs and Drug Addiction, 2010), these explanations remain
speculative. We did not see any change in relation to the availability,
price and source of illegal BNX. Possible explanations include
tampering with the device, storing of tablets for later diversion and
buprenorphine trafficking from other cities or abroad.
4.1. Limitations and strengths
This study has certain limitations. The main weakness of EMDs is
that they could only detect whether tablets were removed from the
device, not how and when the medicine was actually taken. The use of
EMDs for a time period of 4 months may have been too short to detect
their impact on the street-use of buprenorphine or on the hospitaltreated buprenorphine-related health problems. Buprenorphinepositive drug screens served as a surrogate outcome for buprenorphine-related health problems. The small sample size limited the
opportunity for statistical testing and there may not have been
enough power to detect changes in outcome measures. Although this
study can be regarded as one city's experience with EMDs, its strength
lies in comprehensiveness since all eligible local patients were asked
to participate and participation rate was high (88%). All BNX patients
in the city without exception received their take-home doses in EMDs
as part of their routine treatment and, therefore, buprenorphine takehome doses were not granted without EMDs. Several different
indicators were used to measure diversion; however, considering
the small sample size, qualitative measurements could have been
used as well. The number of responses to the surveys at the needle
exchange service was quite low (46%, 39%) but rates were satisfactory
considering the target population.
4.2. Conclusions and future directions
Post-EMD 11.4 %
0%
20.0 %
20 %
50.0 %
40 %
Buprenorphine
Benzodiazepines
60 %
18.6 %
80 %
100 %
Other opioids
Others
Fig. 1. Proportions of drug screen results positive for buprenorphine, other opioids
(methadone, oxycodone, heroin, codeine, morphine), benzodiazepines and others
(amphetamine, methamphetamine, cannabis, MDMA) during pre-EMD (n = 48), EMD
(n = 80) and post-EMD phases (n = 70), (EMD = electronic medicine dispenser).
The use of EMDs provided a feasible method for improving the safe
storage of take-home doses of BNX in a naturalistic clinical setting.
According to patients' self-report EMDs may prevent some OST
patients from diverting their take-home doses. However, there was no
clear impact on hospital-treated buprenorphine-related health problems or the availability and price of illegal BNX. Larger studies are
needed on the prevention of diversion of OST medicines in different
treatment settings. Further refinement of the device may be needed,
especially to increase tamper-resistance. Other uses of EMDs could be
explored, such as in the treatment of chronic non-malignant pain with
opioid-analgesics.
Please cite this article as: Uosukainen, H., et al., The effect of an electronic medicine dispenser on diversion of buprenorphine-naloxone—
experience from a medium-sized Finnish City, Journal of Substance Abuse Treatment (2013), http://dx.doi.org/10.1016/j.jsat.2013.01.003
H. Uosukainen et al. / Journal of Substance Abuse Treatment xxx (2013) xxx–xxx
Acknowledgments
The study was supported by grants from the Yrjö Jahnsson
Foundation (costs related to the use of EMDs and other study
expenses) and the Graduate School in Pharmaceutical Research in
Finland. The authors would like to thank the treatment staff at
treatment units and pharmacies involved in the study, Mr. Antti
Törmänen (Addoz Ltd) and PhD Toivo Halonen (Islab Ltd) for
technical assistance, and PhD J. Simon Bell and PhD Ewen MacDonald
for revising the language. Parts of the manuscript were published as
an abstract at the ISAM 2012 Annual Meeting.
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Please cite this article as: Uosukainen, H., et al., The effect of an electronic medicine dispenser on diversion of buprenorphine-naloxone—
experience from a medium-sized Finnish City, Journal of Substance Abuse Treatment (2013), http://dx.doi.org/10.1016/j.jsat.2013.01.003