Buprenorphine for the management of opioid withdrawal (2006)

[Jatelka]

A new entry has been added to Drugs Archive

Description:
Cochrane Review

Gowing L, Ali R, White J.

BACKGROUND: Managed withdrawal is a necessary step prior to drug-free treatment. It may also represent the end point of maintenance treatment.

OBJECTIVES: To assess the effectiveness of interventions involving the use of buprenorphine to manage opioid withdrawal, for withdrawal signs and symptoms, completion of withdrawal and adverse effects.

SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, including the Cochrane Drugs and Alcohol Group trials register, Issue 3, 2005), MEDLINE (January 1966 to August 2005), EMBASE (January 1985 to August 2005), PsycINFO (1967 to August 2005), CINAHL(1982 to July 2005) and reference lists of articles.

SELECTION CRITERIA: Experimental interventions involved the use of buprenorphine to modify the signs and symptoms of withdrawal in participants who were primarily opioid dependent. Comparison interventions involved reducing doses of methadone, alpha2 adrenergic agonists, symptomatic medications or placebo, or different buprenorphine-based regimes.

DATA COLLECTION AND ANALYSIS: One reviewer assessed studies for inclusion and methodological quality, and undertook data extraction. Inclusion decisions and the overall process was confirmed by consultation between all three reviewers. MAIN RESULTS: Eighteen studies (14 randomised controlled trials), involving 1356 participants, were included. Ten studies compared buprenorphine with clonidine; four compared buprenorphine with methadone; one compared buprenorphine with oxazepam; three compared different rates of buprenorphine dose reduction; two compared different starting doses of buprenorphine. (Two studies included more than one comparison.)Relative to clonidine, buprenorphine is more effective in ameliorating the symptoms of withdrawal, patients treated with buprenorphine stay in treatment for longer, particularly in an outpatient setting (SMD 0.82, 95% CI 0.57 to 1.06, P < 0.001), and are more likely to complete withdrawal treatment (RR 1.73, 95% CI 1.21 to 2.47, P = 0.003). At the same time there is no significant difference in the incidence of adverse effects, but drop-out due to adverse effects may be more likely with clonidine.Severity of withdrawal is similar for withdrawal managed with buprenorphine and withdrawal managed with methadone, but withdrawal symptoms may resolve more quickly with buprenorphine. There is a trend towards completion of withdrawal treatment being more likely with buprenorphine relative to methadone (RR 1.30, 95% CI 0.97 to 1.73, P = 0.08).

AUTHORS' CONCLUSIONS: Buprenorphine is more effective than clonidine for the management of opioid withdrawal. There appears to be no significant difference between buprenorphine and methadone in terms of completion of treatment, but withdrawal symptoms may resolve more quickly with buprenorphine.

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Reputation Comments on this post:

thank you for this interesting file,& all your work on adding to archives

[clint]

High-dose buprenorphine treatment is becoming the norm in some parts of the UK and Ireland, the failure of methadone substitution being patently obvious. An opiate withdrawal using SUBUTEX is fast and effective, especially when followed by a two week course of lofexidine; I am of the opinion that methadone is suitable for only maintenance therapy, for those who really are not ready to quit opiates completely. Methadone clinics see patients who are reluctant even to reduce from a relatively high dose in increments of 5mg every couple of weeks. Those with the motivation and determination respond well to Subutex treatment and in general can be opiate-free within three months or less; those on methadone can linger on quite high doses for years at a time.
There is also an argument that using heroin for withdrawal purposes, tried in several clinics over the past few years, is even better, as the reductions can be made with a minimum of discomfort, usually with an adjunct of low dosage diazepam and, if required, an hypnotic such as zolpidem or nitrazepam. When the diamorphine reduction reaches zero dosage, lofexidine can be administered on a nine day schedule - it is a most useful drug for taking the 'edge' off the final week or so of treatment.
I am most definitely in favor of using buprenorphine over any other method in the motivated patient, and there are many papers available to read online showing the relevant figures and success rates compared with methadone treatment.
Many of these patients actually ask to be put on a year's course of naltrexone. Now that's motivation!

[1ONE]

Comment:

i have used suboxone and am on maintence with it and it works wonders.

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