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#223 Buprenorphine-Naloxone (Suboxone®) for Pharmaceutical Opioid Use Disorder

Is buprenorphine (with or without naloxone) effective as maintenance therapy in pharmaceutical opioid use disorder?

Retention in treatment at 15 weeks was seen in 75% taking buprenorphine compared to 26% in detoxification and/or counselling, with 37% reporting ongoing substance use compared to 60% in control. Outcomes between buprenorphine and methadone in this population are similar. The evidence is at moderate to high risk of bias. 

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Systematic review of six randomized controlled trials (RCTsof 607 patients with pharmaceutical opioid dependence (23% female, mean age 32, mean study duration 15 weeks). Source of opioids often not described (example prescribed versus diverted).1 
  • Comparing buprenorphine to detoxification and/or psychological treatment: 
    • Retention in treatment (three RCTs, 247 patients): 75% versus 26% control, Number Needed to Treat (NNT)=3. 
    • Self-reported substance use (three RCTs, 204 patients): 37% versus 60% controlNNT=5. 
    • End of treatment opioid-positive drug screen (three RCTs, 206 patients): 40% versus 61% controlNNT=5. 
    • No difference: Days of unsanctioned opioid use or drug-related risk behaviours. 
    • Unspecified adverse effects (one RCT, 53 patients): 0% versus 8% control. 
  • Comparing buprenorphine to methadone: 
    • No difference: Retention in treatment, substance use, risk behaviours, health scales or adverse effects. 
  • No data on mortality, quality of life, function, or overdose reported.1 
  • Limitations: All RCTs open-label; high drop-out rates; one study only included illicit buprenorphine users 
Buprenorphine in mainly heroin users:  
  • Systematic review (five RCTs):  
    • Nopioid-related deaths (four RCTs);2  
    • Four deaths (placebo) versus zero (buprenorphine) after one year (one RCT, 40 patients).2,3  
  • Versus methadone: No difference in mortality (one RCT, secondary analysis).4  
  • Adding naloxone (an opioid antagonist) to buprenorphine has little impact orally due to poor absorption but can cause withdrawal if crushed for IV use.5 
  • In Ontario, 33% of people with opioid-related death had active opioid prescriptions.6 
    • 58% of those had only prescribed opioids on post-mortem toxicology.6 
  • Observational studies (included heroin users and multiple confounders) report:  
    • Decreased mortality with opioid agonist therapy.7,8 
    • Lower mortality with buprenorphine/naloxone compared to methadone.9 
  • In heroin users, methadone results in more treatment retention than buprenorphine, NNT=4-10 at 12-24 weeks.2,10  
  • Buprenorphine/naloxone dosing information available online.11 

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  • Caitlin R Finley BHSc MSc
  • Christina Korownyk MD CCFP
  • Adrienne J Lindblad BSP ACPR PharmD

1. Neilsen S, Larance B, Degenhardt L. et al. Cochrane Database Syst Rev. 2016; 5:CD011117.

2. Mattick RP, Breen C, Kimber J, et al. Cochrane Database Syst Rev. 2014; 3:CD002209.

3. Kakko J, Svanborg KD, Kreek MJ, et al. Lancet. 2003; 361:662-8.

4. Hser YI, Evans E, Huang D, et al. Addiction. 2016; 111(4):695-705.

5. Kahan M, Srivastava A, Ordean A, et al. Can Fam Physician. 2011 Mar; 57(3):281-9.

6. Gomes T, Khuu W, Martins D, et al. BMJ. 2018; 362:k3207.

7. Ma J, Bao YP, Wang RJ, et al. Mol Psychiatry. 2018 Jun 22. [Epub ahead of print].

8. Sordo L, Barrio G, Bravo MJ, et al. BMJ. 2017; 357:i1550.

9. Hickman M, Steer C, Tilling K, et al. Addiction. 2018 Aug; 113(8):1461-76.

10. Woody G, Bruce D, Korthuis PT, et al. J Acquir immune Defic Syndr. 2014; 66:288-93.

11. British Columbia Centre on Substance Use and BC Ministry of Health. A guideline for the clinical management of opioid use disorder. Published June 5, 2017. Available at: Last Accessed: September 19, 2018.

Authors do not have any conflicts of interest to declare.

Les auteurs n’ont aucun conflit d’intérêts à déclarer.