Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence

Mattick RP, Kimber J, Breen C, Davoli M

Published Online:

July 16, 2008

Buprenorphine can reduce heroin use compared with placebo, although it is less effective than methadone. Methadone is widely used as a replacement for heroin in medically-supported maintenance or detoxification programs. Two other drugs are sometimes used to try and help lower use of heroin, specifically buprenorphine and LAAM (levo-alpha-acetylmethadol). Buprenorphine is an opioid drug that is not as powerful as heroin and methadone, although the effects of buprenorphine may last longer. Buprenorphine can be taken once every two days. The review of trials found that buprenorphine at medium (8mg -15mg) and high doses (16mg) can reduce heroin use effectively compared with placebo, although it is less effective than methadone, especially if methadone is prescribed at adequate dose levels of between 60mg and 120mg per day.

Abstract (click to read)

Background:

Buprenorphine has been reported as an alternative to methadone for maintenance treatment of opioid dependence, but differing results are reported concerning its relative effectiveness indicating the need for an integrative review.

Objectives:

To evaluate the effects of buprenorphine maintenance against placebo and methadone maintenance in retaining patients in treatment and in suppressing illicit drug use.

Search strategy:

We searched the following databases up to October 2006: Cochrane Drugs and Alcohol Review Group Register, the Cochrane Controlled Trials Register, MEDLINE, EMBASE, Current Contents, Psychlit, CORK , Alcohol and Drug Council of Australia, Australian Drug Foundation, Centre for Education and Information on Drugs and Alcohol, Library of Congress databases, reference lists of identified studies and reviews, authors were asked about any other published or unpublished relevant RCT.

Selection criteria:

Randomised clinical trials of buprenorphine maintenance versus placebo or methadone maintenance.

Data collection and analysis:

Authors separately and independently evaluated the papers and extracted data for meta-analysis.

Main results:

Twenty four studies met the inclusion criteria (4497 participants), all were randomised clinical trials, all but six were double-blind. The method of allocation concealment was not clearly described in the majority (20) of the studies, but where it was reported the methodological quality was good.
Buprenorphine was statistically significantly superior to placebo medication in retention of patients in treatment at low doses (RR=1.50; 95% CI: 1.19 - 1.88), medium (RR=1.74; 95% CI: 1.06 - 2.87), and high doses (RR=1.74; 95% CI: 1.02 - 2.96). The high statisitical heterogenity prevented the calculation of a cumulative estimate. However, only medium and high dose buprenorphine suppressed heroin use significantly above placebo.
Buprenorphine given in flexible doses was statistically significantly less effective than methadone in retaining patients in treatment (RR= 0.80; 95% CI: 0.68 - 0.95), but no different in suppression of opioid use for those who remained in treatment.
Low dose methadone is more likely to retain patients than low dose buprenorphine (RR= 0.67; 95% CI: 0.52 - 0.87). Medium dose buprenorphine does not retain more patients than low dose methadone, but may suppress heroin use better. There was no advantage for medium dose buprenorphine over medium dose methadone in retention (RR=0.79; 95% CI:0.64 - 0.99) and medium dose buprenorphine was inferior in suppression of heroin use.

Authors' conclusions:

Buprenorphine is an effective intervention for use in the maintenance treatment of heroin dependence, but it is less effective than methadone delivererd at adequate dosages.

This record should be cited as:

Mattick RP, Kimber J, Breen C, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD002207. DOI: 10.1002/14651858.CD002207.pub3

Assessed as up to date:

December 6, 2007

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Primary Review Group:

Drugs and Alcohol Group

PEARLS - Practical Evidence About Real Life Situations (click to read)

Clinical question:

How effective is buprenorphine in the maintenance treatment of heroin dependence?

Bottom line:

Buprenorphine at medium (8-15mg) and high doses (16mg) can reduce heroin use compared with placebo, although it is less effective than methadone, especially if methadone is prescribed at adequate dose levels of between 60mg and 120mg per day.

Caveat:

Buprenorphine given in flexible (variable) doses was statistically significantly less effective than methadone in retaining patients in treatment, but no different in suppression of opioid use for those who remained in treatment.

Context:

Buprenorphine is a partial opioid agonist which is not as powerful as heroin or methadone. It has a longer half-life (24-37 hours) than methadone (22-25 hours), and can therefore be taken once every 2 days. Buprenorphine is offered alongside methadone for maintenance treatment of heroin dependence in programmes throughout the UK, Europe and Australia, but not yet in New Zealand.

Cochrane Systematic Review:

Mattick RP et al. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Reviews 2008, Issue 2. Article No. CD002207. DOI: 10.1002/14651858. CD002207.pub3. This review contains 24 studies involving 4497 participants.

Authored by:

Brian R McAvoy

Cochrane Primary Health Care Field

Health topics:

Tobacco, drugs, & alcohol dependence > Opioids, opiates, heroin > Maintenance

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence

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