Special Topics in Pain: Opioids

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Opioid Agonist Treatment for Patients With Dependence on Prescription Opioids.

Author(s): Nielsen S, et al.
Journal: JAMA. 2017;317(9):967-968. 7 references.
Reprint: Suzanne Nielsen, BPharm, PhD, National Drug and Alcohol Research Centre, University of New South Wales, 22-32 King St, Randwick, New South Wales, Australia 2031. Email: suzanne.nielsen@unsw.edu.au
Faculty Disclosure: Please see original article for disclosures. Abstracted by N Walea, who has nothing to disclose.
Objective: Review and evaluate the latest advances and newest information in the area of Opioids; Review and evaluate the latest advances and newest information in the area of Legal considerations


Editor’s Note: The number of articles concerning opioids is astounding and increasing exponentially. However, there are fewer articles on opioid dependence although that entity is also rising rapidly. A survey of the literature is helpful whether you treat or refer these individuals. Our abstractor has summed up the conclusions “According to this summary, for patients with dependence on prescription opioids, long term maintenance of opioid agonists is associated with less prescription opioid use and better adherence to medication and psychological therapies for opioid dependence compared with opioid taper or psychological treatments alone. Methadone maintenance was not associated with differences in therapeutic efficacy compared with buprenorphine maintenance treatment. The quality of evidence was low to moderate.”

Class: Pharmacology-opioids; opioid addiction

Opioid agonist treatment is recommended for treating prescription opioid dependence by the US Centers for Disease Control and Prevention. This article summarizes findings from a Cochrane review on current evidence for treatment of prescription opioid dependence using opioid agonist treatments.

The review detailed six randomized clinical trials conducted from 2002 to 2014 with a total of 607 participants (77% male, 33% female). The mean age was 32 (17-60 years) years and 86% white (both of these reported in three studies). The trials were conducted in the United States and Iran.

Three studies compared methadone with buprenorphine. No differences were found in the mean number of day of opioid use, 1.51 days  (SD, 4.97 days) for methadone vs 2.92 (SD, 6.38 days) for buprenorphine. Opioid use was measured by opioid-urine drug screening and was 34.2% (27 of 79 participants) for methadone vs 43.6% (51 of 117 participants) for buprenorphine. Self-reported opioid use was 16.7% (11 of 66 participants) for methadone vs 38.2% (34 of 89 participants) for buprenorphine.

Three studies compared buprenorphine maintenance with opioid taper or psychological treatment only. Buprenorphine maintenance treatment was associated with reduce opioid use by urine opioid-positive drug screening 40.2% (39 of 97 participants) vs 61.5% (67 of 109 participants) with opioid taper. Reduced opioid use by self-report was 37.0% (37 of 100 participants) vs 59.6% (62 of 104) with opioid taper. Buprenorphine maintenance therapy was associated with greater treatment adherence 75.5% (83 of 110 participants) vs 26.3% (36 of 137 participants) with opioid taper.

No difference was found in treatment outcomes between methadone and buprenorphine maintenance therapy in prescription opioid dependence treatment. Maintenance treatment was associated with better substance use and treatment adherence outcomes compared with shorter-term treatments.

Guidelines for the US Center for Substance Abuse Treatment and A Guideline for the Clinical Management of Opioid Addiction suggest that long-term treatment is preferable to withdrawal treatment alone and is consistent with the findings of this review. The American Society of Addiction Medicine guidelines concluded that evidence supports methadone and buprenorphine maintenance which is also consistent with the results of this review. They also state that treatment setting (supervised dosing in a drug treatment clinic vs treatment provided in a physician's office) is important when taking into account patient preference and safety considerations.  

Important Points:
According to this summary, for patients with dependence on prescription opioids, long term maintenance of opioid agonists is associated with less prescription opioid use and better adherence to medication and psychological therapies for opioid dependence compared with opioid taper or psychological treatments alone.

Methadone maintenance was not associated with differences in therapeutic efficacy compared with buprenorphine maintenance treatment. The quality of evidence was low to moderate.

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