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Psarianos A, Chryssanthopoulos C, Theocharis A, Paparrigopoulos T, Philippou A. Effects of a Two-Month Exercise Training Program on Concurrent Non-Opiate Substance Use in Opioid-Dependent Patients during Substitution Treatment. J Clin Med 2024; 13:941. [PMID: 38398255 PMCID: PMC10888880 DOI: 10.3390/jcm13040941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 01/14/2024] [Accepted: 01/25/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND This randomized controlled trial aimed to evaluate the effects of a two-month exercise intervention on the concurrent non-opiate substance use (alcohol, cocaine, cannabis, and benzodiazepines) in opioid users during their medication treatment. METHODS Ninety opioid users (41 females) in methadone and buprenorphine medication treatment were randomly divided into four groups: (a) buprenorphine experimental (BEX; n = 26, aged 41.9 ± 6.1 yrs); (b) buprenorphine control (BCON; n = 25, aged 41.9 ± 5.6 yrs); (c) methadone experimental (MEX; n = 20, aged 46.7 ± 6.6 yrs); and (d) methadone control (MCON; n = 19, aged 46.1 ± 7.5 yrs). The experimental groups (BEX and MEX) followed an aerobic exercise training program on a treadmill for 20 min at 70% HRmax, 3 days/week for 8 weeks. Socio-demographic, anthropometric, and clinical characteristics, as well as non-opioid drug use in days and quantity per week, were assessed before and after the intervention period. RESULTS Following the exercise training, the weekly non-opioid substance consumption (days) decreased (p < 0.05) in both exercise groups and was lower in BEX compared to MEX, while no differences were observed (p > 0.05) between the control groups (BCON vs. MCON) or compared to their baseline levels. Similarly, the daily amount of non-opiate substance intake was reduced (p < 0.05) post-training in BEX and MEX, whereas it did not differ (p > 0.05) in BCON and MCON compared to the baseline. CONCLUSIONS The two-month exercise intervention reduced the non-opioid drug use in both the methadone and buprenorphine substitution groups compared to the controls, suggesting that aerobic exercise training may be an effective strategy for treating patients with OUDs.
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Affiliation(s)
- Alexandros Psarianos
- 1st Department of Psychiatry, Medical School, National and Kapodistrian University of Athens, 11528 Athens, Greece; (A.P.); (T.P.)
- Greek Organization Against Drugs (OΚAΝA), 10433 Athens, Greece;
| | - Costas Chryssanthopoulos
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece;
| | | | - Thomas Paparrigopoulos
- 1st Department of Psychiatry, Medical School, National and Kapodistrian University of Athens, 11528 Athens, Greece; (A.P.); (T.P.)
| | - Anastassios Philippou
- Department of Physiology, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece;
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Nielsen S, Tse WC, Larance B. Opioid agonist treatment for people who are dependent on pharmaceutical opioids. Cochrane Database Syst Rev 2022; 9:CD011117. [PMID: 36063082 PMCID: PMC9443668 DOI: 10.1002/14651858.cd011117.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND There are ongoing concerns regarding pharmaceutical opioid-related harms, including overdose and dependence, with an associated increase in treatment demand. People dependent on pharmaceutical opioids appear to differ in important ways from people who use heroin, yet most opioid agonist treatment research has been conducted in people who use heroin. OBJECTIVES: To assess the effects of maintenance opioid agonist pharmacotherapy for the treatment of pharmaceutical opioid dependence. SEARCH METHODS We updated our searches of the following databases to January 2022: the Cochrane Drugs and Alcohol Group Specialised Register, CENTRAL, MEDLINE, four other databases, and two trial registers. We checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs). SELECTION CRITERIA We included RCTs with adults and adolescents examining maintenance opioid agonist treatments that made the following two comparisons. 1. Full opioid agonists (methadone, morphine, oxycodone, levo-alpha-acetylmethadol (LAAM), or codeine) versus different full opioid agonists or partial opioid agonists (buprenorphine) for maintenance treatment. 2. Full or partial opioid agonist maintenance versus non-opioid agonist treatments (detoxification, opioid antagonist, or psychological treatment without opioid agonist treatment). DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. MAIN RESULTS We identified eight RCTs that met inclusion criteria (709 participants). We found four studies that compared methadone and buprenorphine maintenance treatment, and four studies that compared buprenorphine maintenance to either buprenorphine taper (in addition to psychological treatment) or a non-opioid maintenance treatment comparison. We found low-certainty evidence from three studies of a difference between methadone and buprenorphine in favour of methadone on self-reported opioid use at end of treatment (risk ratio (RR) 0.49, 95% confidence interval (CI) 0.28 to 0.86; 165 participants), and low-certainty evidence from four studies finding a difference in favour of methadone for retention in treatment (RR 1.21, 95% CI 1.02 to 1.43; 379 participants). We found low-certainty evidence from three studies showing no difference between methadone and buprenorphine on substance use measured with urine drug screens at end of treatment (RR 0.81, 95% CI 0.57 to 1.17; 206 participants), and moderate-certainty evidence from one study of no difference in days of self-reported opioid use (mean difference 1.41 days, 95% CI 3.37 lower to 0.55 days higher; 129 participants). There was low-certainty evidence from three studies of no difference between methadone and buprenorphine on adverse events (RR 1.13, 95% CI 0.66 to 1.93; 206 participants). We found low-certainty evidence from four studies favouring maintenance buprenorphine treatment over non-opioid treatments in terms of fewer opioid positive urine drug tests at end of treatment (RR 0.66, 95% CI 0.52 to 0.84; 270 participants), and very low-certainty evidence from four studies finding no difference on self-reported opioid use in the past 30 days at end of treatment (RR 0.63, 95% CI 0.39 to 1.01; 276 participants). There was low-certainty evidence from three studies of no difference in the number of days of unsanctioned opioid use (standardised mean difference (SMD) -0.19, 95% CI -0.47 to 0.09; 205 participants). There was moderate-certainty evidence from four studies favouring buprenorphine maintenance over non-opioid treatments on retention in treatment (RR 3.02, 95% CI 1.73 to 5.27; 333 participants). There was moderate-certainty evidence from three studies of no difference in adverse effects between buprenorphine maintenance and non-opioid treatments (RR 0.50, 95% CI 0.07 to 3.48; 252 participants). The main weaknesses in the quality of the data was the use of open-label study designs, and difference in follow-up rates between treatment arms. AUTHORS' CONCLUSIONS There is very low- to moderate-certainty evidence supporting the use of maintenance agonist pharmacotherapy for pharmaceutical opioid dependence. Methadone or buprenorphine did not differ on some outcomes, although on the outcomes of retention and self-reported substance use some results favoured methadone. Maintenance treatment with buprenorphine appears more effective than non-opioid treatments. Due to the overall very low- to moderate-certainty evidence and small sample sizes, there is the possibility that the further research may change these findings.
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Affiliation(s)
- Suzanne Nielsen
- Monash Addiction Research Centre, Monash University, Frankston, Australia
| | - Wai Chung Tse
- Monash Addiction Research Centre, Monash University, Frankston, Australia
- School of Medicine, Monash University, Melbourne, Australia
| | - Briony Larance
- School of Psychology, Faculty of the Arts, Social Sciences and Humanities, University of Wollongong, Wollongong, Australia
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Bis-Cyclic Guanidine Heterocyclic Peptidomimetics as Opioid Ligands with Mixed μ-, κ- and δ-Opioid Receptor Interactions: A Potential Approach to Novel Analgesics. Int J Mol Sci 2022; 23:ijms23179623. [PMID: 36077029 PMCID: PMC9455983 DOI: 10.3390/ijms23179623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 08/19/2022] [Accepted: 08/20/2022] [Indexed: 11/25/2022] Open
Abstract
The design and development of analgesics with mixed-opioid receptor interactions has been reported to decrease side effects, minimizing respiratory depression and reinforcing properties to generate safer analgesic therapeutics. We synthesized bis-cyclic guanidine heterocyclic peptidomimetics from reduced tripeptides. In vitro screening with radioligand competition binding assays demonstrated variable affinity for the mu-opioid receptor (MOR), delta-opioid receptor (DOR), and kappa-opioid receptor (KOR) across the series, with compound 1968-22 displaying good affinity for all three receptors. Central intracerebroventricular (i.c.v.) administration of 1968-22 produced dose-dependent, opioid receptor-mediated antinociception in the mouse 55 °C warm-water tail-withdrawal assay, and 1968-22 also produced significant antinociception up to 80 min after oral administration (10 mg/kg, p.o.). Compound 1968-22 was detected in the brain 5 min after intravenous administration and was shown to be stable in the blood for at least 30 min. Central administration of 1968-22 did not produce significant respiratory depression, locomotor effects or conditioned place preference or aversion. The data suggest these bis-cyclic guanidine heterocyclic peptidomimetics with multifunctional opioid receptor activity may hold potential as new analgesics with fewer liabilities of use.
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Retention in opioid agonist treatment: a rapid review and meta-analysis comparing observational studies and randomized controlled trials. Syst Rev 2021; 10:216. [PMID: 34362464 PMCID: PMC8348786 DOI: 10.1186/s13643-021-01764-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 07/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although oral opioid agonist therapies (OATs), buprenorphine and methadone, are effective first-line treatments, OAT remains largely underutilized due to low retention rates and wide variation across programs. This rapid review therefore sought to summarize the retention rates reported by randomized controlled trials (RCTs) and controlled observational study designs that compared methadone to buprenorphine (or buprenorphine-naloxone). METHODS We searched four electronic databases (EMBASE, MEDLINE, Cochrane Central Register of Controlled Trials, CINAHL, up to April 2018) for RCTs and controlled observational studies that compared oral fixed-dose methadone to buprenorphine versus methadone (or buprenorphine-naloxone). Data were extracted separately for two different definitions of retention in treatment: (1) length of time retained in the study and (2) presence on the final day of a study. Separate random effects meta-analyses were performed for RCTs and controlled observational studies. Data from controlled observational studies where retention was measured as the length of time retained in the study were not amenable to meta-analysis. RESULTS Among 7603 studies reviewed, 10 RCTs and 3 observational studies met inclusion criteria (n = 5065) and compared fixed-dose oral buprenorphine with methadone. Across studies, the average retention rate was highly variable (RCTs: buprenorphine 20.0-82.5% and methadone 30.7-83.8%; observational studies: buprenorphine 20.2-78.3% and methadone 48.3-74.8%). For time period retained in the study, we observed no significant difference in treatment retention for buprenorphine versus methadone in RCTs (standardized mean difference [SMD] = - 0.07; 95% CI - 0.35-0.21, p = 0.63; quality of evidence: low). For presence on the final study day, we observed no significant difference between buprenorphine and methadone treatment retention in RCTs (risk ratio [RR] = 0.89; 95% CI 0.73-1.08, p = 0.24; quality of evidence: low) and controlled observational studies (RR = 0.75; 95% CI 0.36-1.58, p = 0.45). CONCLUSION Meta-analysis of existing RCTs suggests retention in oral fixed-dose opioid agonist therapy with methadone appears to be generally equal to buprenorphine (or buprenorphine-naloxone), with wide variation across studies. Similarly, a meta-analysis of three controlled observational studies indicated no difference in treatment retention although there was significant heterogeneity among the included studies. The length of follow-up did not appear to affect the retention rate. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018104452 .
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Guillery SPE, Hellweg R, Kronenberg G, Bohr U, Kunte H, Enge S. Quality of Life in Opioid Replacement Therapy: A Naturalistic Cross-Sectional Comparison of Methadone/Levomethadone, Buprenorphine, and Diamorphine Patients. Eur Addict Res 2021; 27:371-380. [PMID: 33784698 DOI: 10.1159/000514192] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 12/15/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Research on quality of life (QoL) of chronically ill patients provides an opportunity to evaluate the efficacy of long-term treatments. Although it is established that opioid replacement therapy is an effective treatment for opioid-dependent patients, there is little knowledge about physical and psychological functioning of QoL for different treatment options. OBJECTIVES Altogether, 248 opioid-dependent patients receiving substitution treatment with either methadone/levomethadone (n = 126), diamorphine (n = 85), or buprenorphine (n = 37) were recruited in 6 German therapy centers. METHODS Sociodemographic data were collected. QoL - physical and psychological functioning - for different substitutes was assessed using the Profile of the Quality of Life in the Chronically Ill (PLC) questionnaire. RESULTS Patient groups were similar regarding age and duration of opioid dependence. Employment rate was significantly higher (p < 0.005, φ = 0.22) in the buprenorphine group (46%) compared to methadone (18%). Dosage adjustments were more frequent (p < 0.001, φ = 0.29) in diamorphine (55%) than in methadone (30%) or buprenorphine (19%) patients. Buprenorphine and diamorphine patients rated their physical functioning substantially higher than methadone patients (p < 0.001, η2 = 0.141). Diamorphine patients reported a higher psychological functioning (p < 0.001, η2 = 0.078) and overall life improvement (p < 0.001, η2 = 0.060) compared to methadone, but not compared to buprenorphine patients (both p > 0.25). CONCLUSION Measurement of important QoL aspects indicates significant differences for physical and psychological functioning in patients receiving the substitutes methadone/levomethadone, diamorphine, and buprenorphine. This could be relevant for the differential therapy of opioid addiction.
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Affiliation(s)
- Stephanie Paula Elisabeth Guillery
- Department of Psychology, Faculty of Natural Sciences, MSB Medical School Berlin MSB Medical School Berlin, Berlin, Germany.,Charité Center 15 for Neurology, Neurosurgery and Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Rainer Hellweg
- Charité Center 15 for Neurology, Neurosurgery and Psychiatry, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Golo Kronenberg
- College of Life Sciences, University of Leicester, and Leicestershire Partnership NHS Trust, Leicester, United Kingdom
| | | | - Hagen Kunte
- Department of Psychology, Faculty of Natural Sciences, MSB Medical School Berlin MSB Medical School Berlin, Berlin, Germany
| | - Sören Enge
- Department of Psychology, Faculty of Natural Sciences, MSB Medical School Berlin MSB Medical School Berlin, Berlin, Germany
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Chew HC. Subutex® Abuse Presenting to the Emergency Department: A Case Series. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490790701400306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction Subutex® (sublingual buprenorphine hydrochloride) tablets are prescribed to alleviate symptoms of opiate withdrawal in addicts undergoing a cessation programme. Although Subutex® is safe and effective, parenteral abuse is an emerging phenomenon. A variety of complications may present due to the different areas that patients inject themselves. Aim We present a case series of four patients who presented to the emergency department following complications of Subutex® abuse. The complications included deep venous thrombosis, limb ischaemia and epidural abscess with osteomyelitis of the spine. Discussion Sublingual buprenorphine was launched in Singapore in 2002. It is currently the preferred alternative to methadone for treating opiate dependency locally. Despite safeguards, instances of abuse of buprenorphine exist. These medications can be passed or sold to others not on a cessation programme. Two of the 4 patients in this series obtained Subutex® illegally. Parenteral abuse of Subutex® is of grave concern. In Australia and France, between 23–37% of Subutex® users have abused it in this fashion. Conclusion Subutex® abuse is not uncommon in Singapore. Complications especially from parenteral use can occur and may result in serious morbidity. A high index of suspicion among physicians must be maintained in patients with unusual limb infections, ischaemia or venous thrombosis. Tighter regulations on prescription and consumption of Subutex® may be useful in preventing these complications, in addition to increasing public awareness and education of the risks of parenteral abuse for patients on cessation programme.
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Distress Intolerance Moderation of Attention to Emotion: An Eye-Tracking Study. COGNITIVE THERAPY AND RESEARCH 2017. [DOI: 10.1007/s10608-017-9869-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Nielsen S, Larance B, Degenhardt L, Gowing L, Kehler C, Lintzeris N. Opioid agonist treatment for pharmaceutical opioid dependent people. Cochrane Database Syst Rev 2016:CD011117. [PMID: 27157143 DOI: 10.1002/14651858.cd011117.pub2] [Citation(s) in RCA: 114] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND There are increasing concerns regarding pharmaceutical opioid harms including overdose and dependence, with an associated increase in treatment demand. People dependent on pharmaceutical opioids appear to differ in important ways from people who use heroin, yet most opioid agonist treatment research has been conducted in people who use heroin. OBJECTIVES To assess the effects of maintenance agonist pharmacotherapy for the treatment of pharmaceutical opioid dependence. SEARCH METHODS The search included the Cochrane Drugs and Alcohol Group's Specialised Register of Trials; the Cochrane Central Register of Controlled Trials (CENTRAL, 2015, Issue 5); PubMed (January 1966 to May 2015); EMBASE (Ovid) (January 1974 to May 2015); CINAHL (EBSCOhost) (1982 to May 2015); ISI Web of Science (to May 2014); and PsycINFO (Ovid) (1806 to May 2014). SELECTION CRITERIA We included randomised controlled trials examining maintenance opioid agonist treatments that made the following two comparisons:1. full opioid agonists (methadone, morphine, oxycodone, levo-alpha-acetylmethadol (LAAM), or codeine) versus different full opioid agonists or partial opioid agonists (buprenorphine) for maintenance treatment and2. full or partial opioid agonist maintenance versus placebo, detoxification only, or psychological treatment (without opioid agonist treatment). DATA COLLECTION AND ANALYSIS We used standard Cochrane methodological procedures. MAIN RESULTS We identified six randomised controlled trials that met inclusion criteria (607 participants).We found moderate quality evidence from two studies of no difference between methadone and buprenorphine in self reported opioid use (risk ratio (RR) 0.37, 95% confidence interval (CI) 0.08 to 1.63) or opioid positive urine drug tests (RR 0.81, 95% CI 0.56 to 1.18). There was low quality evidence from three studies of no difference in retention between buprenorphine and methadone maintenance treatment (RR 0.69, 95% CI 0.39 to 1.22). There was moderate quality evidence from two studies of no difference between methadone and buprenorphine on adverse events (RR 1.10, 95% CI 0.64 to 1.91).We found low quality evidence from three studies favouring maintenance buprenorphine treatment over detoxification or psychological treatment in terms of fewer opioid positive urine drug tests (RR 0.63, 95% CI 0.43 to 0.91) and self reported opioid use in the past 30 days (RR 0.54, 95% CI 0.31 to 0.93). There was no difference on days of unsanctioned opioid use (standardised mean difference (SMD) -0.31, 95% CI -0.66 to 0.04). There was moderate quality evidence favouring buprenorphine maintenance over detoxification or psychological treatment on retention in treatment (RR 0.33, 95% CI 0.23 to 0.47). There was moderate quality evidence favouring buprenorphine maintenance over detoxification or psychological treatment on adverse events (RR 0.19, 95% CI 0.06 to 0.57).The main weaknesses in the quality of the data was the use of open-label study designs. AUTHORS' CONCLUSIONS There was low to moderate quality evidence supporting the use of maintenance agonist pharmacotherapy for pharmaceutical opioid dependence. Methadone or buprenorphine appeared equally effective. Maintenance treatment with buprenorphine appeared more effective than detoxification or psychological treatments.Due to the overall low to moderate quality of the evidence and small sample sizes, there is the possibility that the further research may change these findings.
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Affiliation(s)
- Suzanne Nielsen
- National Drug and Alcohol Research Centre, UNSW, Building R3, 22 - 32 King Street, Randwick, NSW, Australia, 2031
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Eans SO, Ganno ML, Mizrachi E, Houghten RA, Dooley CT, McLaughlin JP, Nefzi A. Parallel Synthesis of Hexahydrodiimidazodiazepines Heterocyclic Peptidomimetics and Their in Vitro and in Vivo Activities at μ (MOR), δ (DOR), and κ (KOR) Opioid Receptors. J Med Chem 2015; 58:4905-17. [PMID: 25996309 DOI: 10.1021/jm501637c] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
In the development of analgesics with mixed-opioid agonist activity, peripherally selective activity is expected to decrease side effects, minimizing respiratory depression and reinforcing properties generating significantly safer analgesic therapeutics. We synthesized diazaheterocyclics from reduced tripeptides. In vitro screening with radioligand competition binding assays demonstrated variable affinity for μ (MOR), δ (DOR), and κ (KOR) opioid receptors across the series, with the diimidazodiazepine 14 (2065-14) displaying good affinity for DOR and KOR. Central (icv), intraperitoneal (ip), or oral (po) administration of 14 produced dose-dependent, opioid-receptor mediated antinociception in the mouse, as determined from a 55 °C warm-water tail-withdrawal assay. Only trace amounts of compound 14 was found in brain up to 90 min later, suggesting poor BBB penetration and possible peripherally restricted activity. Central administration of 14 did not produce locomotor effects, acute antinociceptive tolerance, or conditioned-place preference or aversion. The data suggest these diazaheterocyclic mixed activity opioid receptor agonists may hold potential as new analgesics with fewer liabilities of use.
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Affiliation(s)
- Shainnel O Eans
- Torrey Pines Institute for Molecular Studies, 11350 SW Village Parkway, Port St. Lucie, Florida 34987, United States
| | - Michelle L Ganno
- Torrey Pines Institute for Molecular Studies, 11350 SW Village Parkway, Port St. Lucie, Florida 34987, United States
| | - Elisa Mizrachi
- Torrey Pines Institute for Molecular Studies, 11350 SW Village Parkway, Port St. Lucie, Florida 34987, United States
| | - Richard A Houghten
- Torrey Pines Institute for Molecular Studies, 11350 SW Village Parkway, Port St. Lucie, Florida 34987, United States
| | - Colette T Dooley
- Torrey Pines Institute for Molecular Studies, 11350 SW Village Parkway, Port St. Lucie, Florida 34987, United States
| | - Jay P McLaughlin
- Torrey Pines Institute for Molecular Studies, 11350 SW Village Parkway, Port St. Lucie, Florida 34987, United States
| | - Adel Nefzi
- Torrey Pines Institute for Molecular Studies, 11350 SW Village Parkway, Port St. Lucie, Florida 34987, United States
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Fingleton N, Matheson C, Jaffray M. Changes in mental health during opiate replacement therapy: A systematic review. DRUGS: EDUCATION, PREVENTION AND POLICY 2014. [DOI: 10.3109/09687637.2014.899986] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev 2014; 2014:CD002207. [PMID: 24500948 PMCID: PMC10617756 DOI: 10.1002/14651858.cd002207.pub4] [Citation(s) in RCA: 658] [Impact Index Per Article: 65.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Buprenorphine maintenance treatment has been evaluated in randomised controlled trials against placebo medication, and separately as an alternative to methadone for management of opioid dependence. OBJECTIVES To evaluate buprenorphine maintenance compared to placebo and to methadone maintenance in the management of opioid dependence, including its ability to retain people in treatment, suppress illicit drug use, reduce criminal activity, and mortality. SEARCH METHODS We searched the following databases to January 2013: Cochrane Drugs and Alcohol Review Group Specialised Register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Current Contents, PsycLIT, CORK, Alcohol and Drug Council of Australia, Australian Drug Foundation, Centre for Education and Information on Drugs and Alcohol, Library of Congress, reference lists of identified studies and reviews. We sought published/unpublished randomised controlled trials (RCTs) from authors. SELECTION CRITERIA Randomised controlled trials of buprenorphine maintenance treatment versus placebo or methadone in management of opioid-dependent persons. DATA COLLECTION AND ANALYSIS We used Cochrane Collaboration methodology. MAIN RESULTS We include 31 trials (5430 participants), the quality of evidence varied from high to moderate quality.There is high quality of evidence that buprenorphine was superior to placebo medication in retention of participants in treatment at all doses examined. Specifically, buprenorphine retained participants better than placebo: at low doses (2 - 6 mg), 5 studies, 1131 participants, risk ratio (RR) 1.50; 95% confidence interval (CI) 1.19 to 1.88; at medium doses (7 - 15 mg), 4 studies, 887 participants, RR 1.74; 95% CI 1.06 to 2.87; and at high doses (≥ 16 mg), 5 studies, 1001 participants, RR 1.82; 95% CI 1.15 to 2.90. However, there is moderate quality of evidence that only high-dose buprenorphine (≥ 16 mg) was more effective than placebo in suppressing illicit opioid use measured by urinanalysis in the trials, 3 studies, 729 participants, standardised mean difference (SMD) -1.17; 95% CI -1.85 to -0.49, Notably, low-dose, (2 studies, 487 participants, SMD 0.10; 95% CI -0.80 to 1.01), and medium-dose, (2 studies, 463 participants, SMD -0.08; 95% CI -0.78 to 0.62) buprenorphine did not suppress illicit opioid use measured by urinanalysis better than placebo.There is high quality of evidence that buprenorphine in flexible doses adjusted to participant need,was less effective than methadone in retaining participants, 5 studies, 788 participants, RR 0.83; 95% CI 0.72 to 0.95. For those retained in treatment, no difference was observed in suppression of opioid use as measured by urinalysis, 8 studies, 1027 participants, SMD -0.11; 95% CI -0.23 to 0.02 or self report, 4 studies, 501 participants, SMD -0.11; 95% CI -0.28 to 0.07, with moderate quality of evidence.Consistent with the results in the flexible-dose studies, in low fixed-dose studies, methadone (≤ 40 mg) was more likely to retain participants than low-dose buprenorphine (2 - 6 mg), (3 studies, 253 participants, RR 0.67; 95% CI: 0.52 to 0.87). However, we found contrary results at medium dose and high dose: there was no difference between medium-dose buprenorphine (7 - 15 mg) and medium-dose methadone (40 - 85 mg) in retention, (7 studies, 780 participants, RR 0.87; 95% CI 0.69 to 1.10) or in suppression of illicit opioid use as measured by urines, (4 studies, 476 participants, SMD 0.25; 95% CI -0.08 to 0.58) or self report of illicit opioid use, (2 studies, 174 participants, SMD -0.82; 95% CI -1.83 to 0.19). Similarly, there was no difference between high-dose buprenorphine (≥ 16 mg) and high-dose methadone (≥ 85 mg) in retention (RR 0.79; 95% CI 0.20 to 3.16) or suppression of self-reported heroin use (SMD -0.73; 95% CI -1.08 to -0.37) (1 study, 134 participants).Few studies reported adverse events ; two studies compared adverse events statistically, finding no difference between methadone and buprenorphine, except for a single result indicating more sedation among those using methadone. AUTHORS' CONCLUSIONS Buprenorphine is an effective medication in the maintenance treatment of heroin dependence, retaining people in treatment at any dose above 2 mg, and suppressing illicit opioid use (at doses 16 mg or greater) based on placebo-controlled trials.However, compared to methadone, buprenorphine retains fewer people when doses are flexibly delivered and at low fixed doses. If fixed medium or high doses are used, buprenorphine and methadone appear no different in effectiveness (retention in treatment and suppression of illicit opioid use); however, fixed doses are rarely used in clinical practice so the flexible dose results are more relevant to patient care. Methadone is superior to buprenorphine in retaining people in treatment, and methadone equally suppresses illicit opioid use.
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Affiliation(s)
- Richard P Mattick
- University of New South WalesNational Drug and Alcohol Research CentreSydneyNew South WalesAustralia2052
| | - Courtney Breen
- University of New South WalesNational Drug and Alcohol Research CentreSydneyNew South WalesAustralia2052
| | - Jo Kimber
- University of New South WalesNational Drug and Alcohol Research CentreSydneyNew South WalesAustralia2052
| | - Marina Davoli
- Lazio Regional Health ServiceDepartment of EpidemiologyVia di Santa Costanza, 53RomeItaly00199
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Fareed A, Vayalapalli S, Casarella J, Drexler K. Effect of buprenorphine dose on treatment outcome. J Addict Dis 2012; 31:8-18. [PMID: 22356665 DOI: 10.1080/10550887.2011.642758] [Citation(s) in RCA: 88] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The goal of this meta-analysis is to provide evidence based information about proper dosing for buprenorphine maintenance treatment to improve treatment outcome. To be selected for the review and inclusion in the meta-analysis, articles had to be randomized, controlled, or double-blind clinical trials, with buprenorphine as the study drug; the length of buprenorphine maintenance treatment had to be 3 weeks or longer; doses of buprenorphine had to be clearly stated; outcome measures had to include retention rates in buprenorphine treatment; outcome measures had to include illicit opioid use based on analytical determination of drugs of abuse in urine samples as outcome variables; and outcome measures had to include illicit cocaine use based on analytical determination of drugs of abuse in urine samples as outcome variables. Twenty-nine articles were excluded because they did not meet the inclusion criteria. The authors present the results of 21 articles that met inclusion criteria. The higher buprenorphine dose (16-32 mg per day) predicted better retention in treatment compared with the lower dose (less than 16 mg per day) (P = .009, R(2) adjusted = 0.40), and the positive urine drug screens for opiates predicted dropping out of treatment (P = .019, R(2) Adjusted = 0.40). Retention in treatment predicted less illicit opioid use (P = .033, R(2) Adjusted = 0.36), and the positive urine drug screens for cocaine predicted more illicit opioid use (P = .021, R(2) Adjusted = 0.36). Strong evidence exists based on 21 randomized clinical trials that the higher buprenorphine dose may improve retention in buprenorphine maintenance treatment.
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Affiliation(s)
- Ayman Fareed
- Emory University, School of Medicine, Atlanta VA Medical Center, Decatur, Georgia 30033, USA.
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13
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Baewert A, Jagsch R, Winklbaur B, Kaiser G, Thau K, Unger A, Aschauer C, Weninger M, Metz V. Influence of Site Differences between Urban and Rural American and Central European Opioid-Dependent Pregnant Women and Neonatal Outcome Characteristics. Eur Addict Res 2012; 18:130-9. [PMID: 22354163 PMCID: PMC3696360 DOI: 10.1159/000335082] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2011] [Accepted: 10/28/2011] [Indexed: 11/19/2022]
Abstract
BACKGROUND Multi-center trials enable the recruitment of larger study samples, although results might be influenced by site-specific factors. METHODS Site differences of a multi-center prospective double-blind, double-dummy randomized controlled trial (7 centers: Central Europe (Vienna)/USA (3 urban/3 rural centers)) comparing safety and efficacy of methadone and buprenorphine in pregnant opioid-dependent women and their neonates. RESULTS Urban US women had the highest rate of concomitant opioid (p = 0.050) and cocaine consumption (p = 0.003), the highest dropout rate (p = 0.001), and received the lowest voucher sums (p = 0.001). Viennese neonates had significantly higher Apgar scores 1 min (p = 0.001) and 5 min after birth (p < 0.001) and were more often born by cesarean section (p = 0.024). Rural US newborns had a significantly shorter neonatal abstinence syndrome treatment duration compared to Viennese and urban US sites (p = 0.006), in addition to other site-specific differences, suggesting a more severely affected group of women in the urban US sites. CONCLUSION This clinical trial represents a role model for pharmacological treatment in this unique sample of pregnant women and demonstrates the clinical importance of considering site-specific factors in research and clinical practice.
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Affiliation(s)
- Andjela Baewert
- Department of Psychiatry and Psychotherapy, Medical University Vienna, Austria,*Andjela Baewert, Department of Psychiatry and Psychotherapy, Medical University Vienna, Währinger Gürtel 18–20, AT–1090 Vienna (Austria), Tel. +43 1 40400 3547, E-Mail
| | | | | | - Gerda Kaiser
- Department of Psychiatry and Psychotherapy, Medical University Vienna, Austria
| | - Kenneth Thau
- Department of Psychiatry and Psychotherapy, Medical University Vienna, Austria
| | - Annemarie Unger
- Department of Psychiatry and Psychotherapy, Medical University Vienna, Austria
| | - Constantin Aschauer
- Department of Psychiatry and Psychotherapy, Medical University Vienna, Austria
| | - Manfred Weninger
- Department of Neonatology, Medical University Vienna, Vienna, Austria
| | - Verena Metz
- Department of Psychiatry and Psychotherapy, Medical University Vienna, Austria
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14
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Fareed A, Vayalapalli S, Casarella J, Drexler K. Treatment outcome for flexible dosing buprenorphine maintenance treatment. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2011; 38:155-60. [PMID: 22175698 DOI: 10.3109/00952990.2011.643988] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND AND OBJECTIVES Achieving the best treatment outcome with the least cost should be the goal for buprenorphine office-based treatment. METHODS We conducted an observational retrospective chart review to compare the treatment outcome for patients (n = 56) receiving high dose of buprenorphine (above 16 mg daily) and patients (n = 21) receiving moderate doses (8-16 mg daily). RESULTS The percentages of the first four urine drug screens (UDS) positive for opiates were significantly higher for the high-dose group than for the moderate-dose group (F = 7.93, df = 7, p < .0001). However, the percentages of the most recent four UDS positive for opiates were not statistically significant (F = .62, df = 7, p = .74). The difference in the percentages of the first and last UDS for the high-dose group showed significant reduction from admission to most recently but there was no significant difference for the moderate-dose group (t = 3.1, df = 105, p = .002 for the high-dose group and t = 1.1, df = 40, p = .27 for the moderate-dose group). CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE Using flexible buprenorphine dosing schedule with the option of titrating the dose up to 32 mg daily may offer better treatment outcome for patients who would not respond to the lower dose range.
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Affiliation(s)
- Ayman Fareed
- Department of Psychiatry, Emory University School of Medicine/Atlanta VA Medical center, Decatur, GA 30033, USA.
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15
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Fareed A, Vayalapalli S, Casarella J, Amar R, Drexler K. Heroin anticraving medications: a systematic review. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2010; 36:332-41. [PMID: 20955107 DOI: 10.3109/00952990.2010.505991] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Heroin craving is a trigger for relapse and dropping out of treatment. Methadone has been the standard medication for the management of heroin craving. OBJECTIVES We explored the medication options other than methadone which may have heroin anticraving properties. METHODS To be selected for the review, articles had to include outcome measures of the effect of the studied medication on subjective and/or objective opiate craving and be of the following two types: (1) randomized, controlled, and/or double-blind clinical trials (RCTs) examining the relationship between the studied medication and heroin craving; (2) nonrandomized and observational studies (NRSs) examining the relationship between the studied medication and heroin craving. Thirty-three articles were initially included in the review. Twenty-one were excluded because they did not meet the inclusion criteria. We present the results of 12 articles that met all the inclusion criteria. RESULTS Some new medications have been under investigation and seem promising for the treatment of opiate craving. Buprenorphine is the second most studied medication after methadone for its effect on opiate craving. At doses above 8 mg daily, it seems very promising and practical for managing opiate craving in patients receiving long-term opioid maintenance treatment. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE In doses higher than 8 mg daily, buprenorphine is an appropriate treatment for opiate craving. More research with rigorous methodology is needed to study the effect of buprenorphine on heroin craving. Also more studies are needed to directly compare buprenorphine and methadone with regard to their effects on heroin craving.
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Affiliation(s)
- Ayman Fareed
- Department of Psychiatry, Emory University, School of Medicine/Atlanta VA Medical center, Decatur, GA 30033, USA.
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16
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Unger A, Jung E, Winklbaur B, Fischer G. Gender issues in the pharmacotherapy of opioid-addicted women: buprenorphine. J Addict Dis 2010; 29:217-30. [PMID: 20407978 DOI: 10.1080/10550881003684814] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Gender, a biological determinant of mental health and illness, plays a critical role in determining patients' susceptibility, exposure to mental health risks, and related outcomes. Regarding sex differences in the epidemiology of opioid dependence, one third of the patients are women of childbearing age. Women have an earlier age of initiation of substance use and a more rapid progression to drug involvement and dependence than men. Generally few studies exist which focus on the special needs of women in opioid maintenance therapy. The aim of this paper is to provide an overview of treatment options for opioid-dependent women, with a special focus on buprenorphine, and to look at recent findings related to other factors that should be taken into consideration in optimizing the treatment of opioid-dependent women. Issues addressed include the role of gender in the choice of medication assisted treatment, sex differences in pharmacodynamics and pharmacokinetics of buprenorphine drug interactions, cardiac interactions, induction of buprenorphine in pregnant patients, the neonatal abstinence syndrome and breastfeeding. This paper aims to heighten the awareness for the need to take gender into consideration when making treatment decisions in an effort to optimize services and enhance the quality of life of women suffering from substance abuse.
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Affiliation(s)
- Annemarie Unger
- Department of Psychiatry and Psychotherapy, Medical University of Vienna, Vienna, Austria
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17
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Cameron IM, Matheson CI, Bond CM, Lawrie T, McNamee P, Robinson A, Robertson G, Eagles LE. Pilot randomised controlled trial of community pharmacy administration of buprenorphine versus methadone. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2010. [DOI: 10.1211/ijpp.14.4.0003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Abstract
Objectives
The established regime for opiate substitute prescribing for drug misusers is daily methadone administered under supervision in community pharmacies. Buprenorphine has recently been introduced as an alternative. However there is a lack of evidence of the effectiveness of buprenorphine maintenance therapy (BMT) in the UK treatment setting. This study aimed to assess methods for a randomised controlled trial (RCT) and the feasibility of pharmacy-based supervised self-administration (SSA) of buprenorphine compared to methadone.
Setting
Specialist substance misuse service, general practices and community pharmacies in Aberdeen, Scotland.
Method
The design was a pilot RCT. Opiate-dependent drug misusers, newly referred for maintenance treatment were randomised to receive BMT or methadone maintenance therapy (MMT). Clients and pharmacists were interviewed at baseline and at the end of a 12-week intervention period. Clients completed the quality of life measure EQ-5D. Pharmacy activities were timed.
Key findings
Twenty-one opiate-dependent clients were recruited (BMT = 11, MMT = 10). Recruitment levels improved as the trial progressed. Clients' treatment preferences were evident. Withdrawals occurred early with BMT. Clients found SSA of buprenorphine acceptable, but found daily administration more manageable than three times weekly. Pharmacists found the dispensing of buprenorphine to be an acceptable role, but felt less certain of ensuring against diversion with buprenorphine than they were with methadone. Pharmacy activities associated with buprenorphine took longer than those associated with methadone (mean = 7 min 25 s versus mean = 3 min 27 s, respectively).
Conclusion
Recruitment to a trial comparing MMT to BMT for opiate-dependent clients within a UK treatment setting is feasible. Clients and pharmacists found buprenorphine acceptable.
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Affiliation(s)
- Isobel M Cameron
- Department of Mental Health, University of Aberdeen, Scotland, UK
| | - Catriona I Matheson
- Department of General Practice and Primary Care, University of Aberdeen, Scotland, UK
| | - Christine M Bond
- Department of General Practice and Primary Care, University of Aberdeen, Scotland, UK
| | - Thane Lawrie
- Department of General Practice and Primary Care, University of Aberdeen, Scotland, UK
| | - Paul McNamee
- Health Economics Research Unit, University of Aberdeen, Scotland, UK
| | - Andrew Robinson
- Substance Misuse Service, Royal Cornhill Hospital, Aberdeen, Scotland, UK
| | - George Robertson
- Substance Misuse Service, Royal Cornhill Hospital, Aberdeen, Scotland, UK
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18
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Chadderton A. Clinical issues in using buprenorphine in the treatment of opiate dependence. Drug Alcohol Rev 2009. [DOI: 10.1080/713659381] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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20
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Jones HE, Martin PR, Heil SH, Kaltenbach K, Selby P, Coyle MG, Stine SM, O'Grady KE, Arria AM, Fischer G. Treatment of opioid-dependent pregnant women: clinical and research issues. J Subst Abuse Treat 2008; 35:245-59. [PMID: 18248941 PMCID: PMC2633026 DOI: 10.1016/j.jsat.2007.10.007] [Citation(s) in RCA: 128] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2007] [Revised: 10/11/2007] [Accepted: 10/28/2007] [Indexed: 12/22/2022]
Abstract
This article addresses common questions that clinicians face when treating pregnant women with opioid dependence. Guidance, based on both research evidence and the collective clinical experience of the authors, which include investigators in the Maternal Opioid Treatment: Human Experimental Research (MOTHER) project, is provided to aid clinical decision making. The MOTHER project is a double-blind, double-dummy, flexible-dosing, parallel-group clinical trial examining the comparative safety and efficacy of methadone and buprenorphine for the treatment of opioid dependence in pregnant women and their neonates. The article begins with a discussion of appropriate assessment during pregnancy and then addresses clinical management stages including maintenance medication selection, induction, and stabilization; opioid agonist medication management before, during, and after delivery; pain management; breast-feeding; and transfer to aftercare. Lastly, other important clinical issues including managing co-occurring psychiatric disorders and medication interactions are discussed.
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Affiliation(s)
- Hendree E Jones
- Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA.
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21
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Mattick RP, Kimber J, Breen C, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev 2008:CD002207. [PMID: 18425880 DOI: 10.1002/14651858.cd002207.pub3] [Citation(s) in RCA: 304] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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 statistical heterogeneity 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 delivered at adequate dosages.
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Affiliation(s)
- R P Mattick
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales, Australia, 2052.
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22
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Leonardi C, Hanna N, Laurenzi P, Fagetti R. Multi-centre observational study of buprenorphine use in 32 Italian drug addiction centres. Drug Alcohol Depend 2008; 94:125-32. [PMID: 18162330 DOI: 10.1016/j.drugalcdep.2007.10.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2006] [Revised: 10/23/2007] [Accepted: 10/25/2007] [Indexed: 10/22/2022]
Abstract
AIM To examine how buprenorphine is currently being used across Italy, and to identify simultaneously best practice protocols to guide physicians in optimising the safety and efficacy of this treatment option. DESIGN Retrospective, observational, multi-centre study. PARTICIPANTS A total of 979 opioid-dependent patients were included from 32 centres involving the initiation of 1122 treatments. FINDINGS During the study period 33.4% of patients relapsed during the induction phase. Lower induction doses resulted in markedly higher relapse rates (51.2% of those who received 2 mg versus 20.6% of those who received 10mg of buprenorphine relapsed). Over 89% of patients who received 16 mg of buprenorphine during the induction phase successfully went on to maintenance treatment. The percentage of drug-positive urines also decreased over time on buprenorphine treatment (cocaine-positive urines decreased from 25.8% at study entrance to 0% at 24 months). Psychosocial support in addition to buprenorphine pharmacotherapy further decreased the risk of relapse and was associated with lower levels of heroin craving. Retention in treatment was increased by less-than-daily dosing of buprenorphine. CONCLUSIONS Higher induction doses of buprenorphine significantly decreased relapse rates and increased the percentage of patients achieving maintenance treatment. Psychosocial support and/or less-than-daily dosing also appeared to promote positive treatment outcomes.
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Affiliation(s)
- C Leonardi
- District Unit for the Prevention and Treatment of Drug Dependence and Alcoholism, Drug Addiction Centre D/XI-ASL Rome C, Via Appia Antica, 220, 00178 Rome, Italy.
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23
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Giacomuzzi S, Kemmler G, Ertl M, Riemer Y. Opioid addicts at admission vs. slow-release oral morphine, methadone, and sublingual buprenorphine maintenance treatment participants. Subst Use Misuse 2006; 41:223-44. [PMID: 16393744 DOI: 10.1080/10826080500391845] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
With use of a randomized study design, quality of life (QOL) and physical symptoms of opioid addicts at admission were compared with slow-release oral morphine, methadone, and sublingual buprenorphine maintenance program participants after 6 months of treatment. The study was conducted from February to July 2004 in the outpatient drug user treatment center at University Department of Psychiatry at Innsbruck, providing maintenance treatment programs and detoxification in Tyrol, Austria. One hundred twenty opioid users seeking treatment were compared with 120 opioid-dependent patients retained for 6 months on a slow-release oral morphine, methadone, or sublingual buprenorphine maintenance program. The German version ("Berlin Quality of Life Profile") of the Lancashire Quality of Life Profile was used, and illicit opioid use was determined by urinalysis. Physical symptoms were measured by using the Opioid Withdrawal Scale. Urinalyses revealed a significantly lower consumption of cocaine and opioids in all three substitution groups than in patients at admission (p < 0.001 and p < or = 0.004, respectively). Both the buprenorphine and the methadone maintenance group showed significantly more favorable values than opioid clients at admission for stomach cramps (p < or = 0.002), muscular tension (p < or = 0.027), general pain (p < or = 0.001), feelings of coldness (p < or = 0.000), heart pounding (p < or = 0.008), runny eyes (p < or = 0.047), and aggressions (p < or = 0.009). Patients who received slow-release oral morphine treatment generally showed the least favorable QOL scores compared with patients at admission or sublingual buprenorphine and methadone clients. Patients in the sublingual buprenorphine or methadone program showed nearly the same QOL scores. The buprenorphine and the methadone maintenance group showed significantly more favorable values than opioid clients at admission regarding leisure time (p < or = 0.019), finances (p < or = 0.014), mental health (p < or = 0.010), and overall satisfaction (p < or = 0.010). Slow-release oral morphine is a well-established treatment for pain, but more research is required to evaluate it as a treatment for heroin dependence. The present data indicate that slow-release oral morphine could have some disadvantages compared with sublingual buprenorphine and methadone in QOL, physical symptoms, and additional consumption. The results further suggest that buprenorphine treatment is as effective as methadone in effects on quality of life and physical symptoms.
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Affiliation(s)
- S Giacomuzzi
- University Department of Psychiatry, Innsbruck, Austria.
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24
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Seifert J, Metzner C, Paetzold W, Borsutzky M, Ohlmeier M, Passie T, Hauser U, Becker H, Wiese B, Emrich H, Schneider U. Mood and affect during detoxification of opiate addicts: a comparison of buprenorphine versus methadone. Addict Biol 2005; 10:157-64. [PMID: 16191668 DOI: 10.1080/13556210500123191] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Twenty-six in-patients with Diagnostic and Statistical Manual version IV (DSM-IV) criteria for opioid dependence were selected at random to receive either a combination of an 11-day low-dose buprenorphine and a 14-day carbamazepine regimen (n = 14) or a combination of an 11-day methadone and a 14-day carbamazepine regimen (n = 12) in a double-blind, randomized 14-day in-patient detoxification treatment. Patients with buprenorphine and carbamazepine showed a significantly better psychological state after the first and second weeks of treatment. Above all, the buprenorphine-treated patients demonstrated a less marked tiredness, sensitiveness and depressive state as well as a more prominent elevated mood during the detoxification process. Seven non-completers (after 7 days: four of 12 = 33.3%; after 14 days: seven of 12 = 58.3%) were treated with methadone and carbamazepine and five non-completers (after 7 days: two of 14 = 14.3%; after 14 days: five of 14 = 35.7%) received buprenorphine and carbamazepine. The difference in the overall dropout rate after day 14 was not significant. The present study supports the hypothesis that the combination of buprenorphine and carbamazepine leads to a better clinical outcome than does a combination of methadone and carbamazepine in the detoxification of opioid addicts with additional multiple drug abuse. The buprenorphine and carbamazepine-regimen provides a more effective short-term relief of affective disturbances than does methadone and carbamazepine. No severe side effects occurred during the treatment period in both groups.
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Affiliation(s)
- J Seifert
- Department of Clinical Psychiatry and Psychotherapy, Hannover Medical School, Germany.
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Pavlic M, Libiseller K, Grubwieser P, Rabl W. Cross-reactivity of the CEDIA buprenorphine assay with opiates: an Austrian phenomenon? Int J Legal Med 2005; 119:378-81. [PMID: 15834736 DOI: 10.1007/s00414-005-0544-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2004] [Accepted: 03/29/2005] [Indexed: 11/24/2022]
Abstract
When testing the Microgenics CEDIA assay for immunological buprenorphine analysis, cross-reactivity between the buprenorphine reagents and opiates was observed at concentrations higher than 120 mg/l morphine, 320 mg/l methadone, 30 mg/l codeine, 60 mg/l dihydrocodeine and 520 mg/l morphine-3-glucuronide. The cross-reactivity with morphine has the greatest impact on routine screening as opiate maintenance therapy in Austria is also performed with slow-release oral morphine. The use of a second cutoff value of 30 mug/l for urine samples that are (immunologically) positive for opiates is therefore suggested, compared to the cutoff value of 5 microg/l proposed by the manufacturer.
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Affiliation(s)
- M Pavlic
- Institute of Legal Medicine, Innsbruck Medical University, Muellerstrabe 44, 6020 Innsbruck, Austria.
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Jones HE, Johnson RE, Jasinski DR, Milio L. Randomized controlled study transitioning opioid-dependent pregnant women from short-acting morphine to buprenorphine or methadone. Drug Alcohol Depend 2005; 78:33-8. [PMID: 15769555 DOI: 10.1016/j.drugalcdep.2004.08.027] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2004] [Revised: 08/24/2004] [Accepted: 08/26/2004] [Indexed: 10/26/2022]
Abstract
This study compared the safety and withdrawal discomfort associated with transitioning pregnant opioid-dependent women from short-acting morphine onto buprenorphine or methadone under well-controlled double-blind conditions. Participants (n=18) were patients in a comprehensive treatment setting and were part of a larger randomized controlled trial comparing the neonatal abstinence syndrome in mothers treated with individualized doses of sublingual buprenorphine or oral methadone. Methadone was first given to all patients within 24h of treatment admission. After written informed consent was signed (3-5 days post-admission), methadone was discontinued and Immediate Release Morphine (IRM) was initiated. The initial total daily dose of IRM was six times the last daily methadone dose. The daily dose of IRM was divided in four daily doses. Induction onto double-blind, double dummy (i.e., two medications were administered with only one being active) methadone or buprenorphine was accomplished over 3 days (i.e., induction). Withdrawal scores during the IRM and induction onto randomized medication were judged mild and not statistically different for both methadone (mean dose 53.5 mg) and buprenorphine (mean dose 10.9 mg). No significant differences between medication groups were observed when individual withdrawal items were examined. No observed differences in safety measures including fetal movement, maternal physiological parameters of body temperature, heart rate and blood pressure were observed between groups. Transitioning opioid-dependent pregnant women from IRM to methadone or buprenorphine during the second trimester of pregnancy can be conducted with similar comfort and safety.
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Affiliation(s)
- Hendree E Jones
- The Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA.
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Mattick RP, Kimber J, Breen C, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev 2004:CD002207. [PMID: 15266465 DOI: 10.1002/14651858.cd002207.pub2] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Buprenorphine has recently been reported to be an alternative to methadone and LAAM for maintenance treatment of opioid dependent individuals, 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 2001, inclusive: Cochrane Drugs and Alcohol Review Group Register, the Cochrane Controlled Trials Register, MEDLINE, EMBASE, Current Contents, Psychlit, CORK [www. state.vt.su/adap/cork], Alcohol and Drug Council of Australia (ADCA) [www.adca.org.au], Australian Drug Foundation (ADF -VIC) [www.adf.org.au], Centre for Education and Information on Drugs and Alcohol (CEIDA) [www.ceida.net.au], Australian Bibliographic Network (ABN), and Library of Congress databases, available NIDA monographs and the College on Problems of Drug Dependence Inc. proceedings, the reference lists of all identified studies and published reviews and authors of identified RCT's were asked about any other published or unpublished relevant RCT. SELECTION CRITERIA Randomised clinical trials of buprenorphine maintenance compared with either placebo or methadone maintenance for opioid dependence. DATA COLLECTION AND ANALYSIS Reviewers evaluated the papers separately and independently, rating methodological quality of concealment of allocation; data were extracted independently for meta-analysis and double-entered. MAIN RESULTS Thirteen studies met the inclusion criteria, all were randomised clinical trials, all but one were double-blind. The method of concealment of allocation was not clearly described in 11 of the studies, otherwise methodological quality was good. Buprenorphine given in flexible doses appeared statistically significantly less effective than methadone in retaining patient in treatment (RR= 0.82; 95% CI: 0.69-0.96). Low dose buprenorphine is not superior to low dose methadone. High dose buprenorphine does not retain more patients than low dose methadone, but may suppress heroin use better. There was no advantage for high dose buprenorphine over high dose methadone in retention (RR=0.79; 95% CI:0.62-1.01), and high dose buprenorphine was inferior in suppression of heroin use. Buprenorphine was statistically significantly superior to placebo medication in retention of patients in treatment at low doses (RR=1.24; 95% CI: 1.06-1.45), high doses (RR=1.21; 95% CI: 1.02-1.44), and very high doses (RR=1.52; 95% CI: 1.23-1.88). However, only high and very high dose buprenorphine suppressed heroin use significantly above placebo. REVIEWERS' CONCLUSIONS Buprenorphine is an effective intervention for use in the maintenance treatment of heroin dependence, but it is not more effective than methadone at adequate dosages.
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Affiliation(s)
- R P Mattick
- National Drug and Alcohol Research Centre, University of New South Wales, National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales, Australia, 2052
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Giacomuzzi SM, Riemer Y, Ertl M, Kemmler G, Rössler H, Hinterhuber H, Kurz M. Buprenorphine versus methadone maintenance treatment in an ambulant setting: a health-related quality of life assessment. Addiction 2003; 98:693-702. [PMID: 12751987 DOI: 10.1046/j.1360-0443.2003.00352.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND To compare the effects on quality of life (QOL) of oral methadone with sublingual buprenorphine. METHODS We performed an open-label, non-randomized, two-site (methadone-buprenorphine) study. During 6 months we assessed the quality of life status of 53 opioid-dependent patients admitted to a methadone or buprenorphine maintenance programme using the German version (Berlin Quality of Life Profile) of the Lancashire Quality of Life Profile. Physical symptoms were measured using the Opioid Withdrawal Scale. Five hundred and thirty urine screening tests were carried out randomly to detect additional consumption. RESULTS Sixty-seven opioid-dependent subjects (38 on methadone and 29 on buprenorphine) were enrolled in the study, and 53 completed it (30 subjects treated with buprenorphine and 23 subjects with racemic methadone). The subjects were comparable on all baseline measures. At the first follow-up (week 8), the buprenorphine-maintained group showed significantly less additional consumption of opioids (P = 0.013) compared with the methadone group. Patients retained in the buprenorphine or methadone programme (week 24) showed no significant differences in all quality of life scores. At the end of the study period, the buprenorphine-maintained group showed significantly less additional consumption of opioids (P = 0.001) and cocaine (P = 0.018) compared with the methadone group. The outcome measures for withdrawal symptoms after 24 weeks of treatment with buprenorphine showed slight advantages in stomach cramps, fatigue or tiredness, feelings of coldness and heart pounding. CONCLUSIONS These results suggest that buprenorphine treatment is as effective as methadone regarding effects on quality of life and withdrawal symptoms. Buprenorphine has the potential to reduce the harm caused by drug abuse. Further research is needed to determine if buprenorphine is more effective than methadone in particular subgroups of patients.
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Affiliation(s)
- S M Giacomuzzi
- University Department of Psychiatry, Innsbruck, Austria.
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Krook AL, Brørs O, Dahlberg J, Grouff K, Magnus P, Røysamb E, Waal H. A placebo-controlled study of high dose buprenorphine in opiate dependents waiting for medication-assisted rehabilitation in Oslo, Norway. Addiction 2002; 97:533-42. [PMID: 12033654 DOI: 10.1046/j.1360-0443.2002.00090.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
AIMS To evaluate whether buprenorphine. even without additional control and psychosocial treatment and support, alleviates the problems faced by patients waiting for medication assisted rehabilitation (MAR). DESIGN A randomized, double-blind, 12-week study of Subutex versus placebo without additional support as an interim therapy. PARTICIPANTS One hundred and six patients, 70 males and 36 females, waiting for MAR in Oslo. The average age was 38 years with an average history of heroin use of 20 years. Fifty-five patients were assigned to buprenorphine and 51 to a placebo. INTERVENTION Subutex or placebo sublingual tablets were given under supervision in a daily dose of 16 mg with the exception of a double dose on Saturday and no dose on Sunday. MEASUREMENT Retention, compliance, self-reported drug-abuse, wellbeing and mental health. FINDINGS The average number of days of participation was significantly higher in the buprenorphine group, 42 (median: 29) compared to 14 (median: 11) for the placebo group (P < 0.001). The retention of patients after 12 weeks was 16 patients in the buprenorphine group and one patient in the placebo group. The buprenorphine group had a larger decrease in reported opioid use (p < 0.001) and in reported use of other drugs, tablets and alcohol abuse (p < 0.01). The group also showed a stronger increase in wellbeing (p < 0.01) and life satisfaction (p < 0.05). None of the participants died. CONCLUSION The patients waiting for MAR benefited significantly from the buprenorphine as an interim therapy according to retention, self-reported use of drugs and wellbeing. However, the patients had difficulties in remaining in treatment over time without psychosocial support.
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Affiliation(s)
- A L Krook
- Centre of Medication Assisted Rehabilitation in Oslo, Rusmiddeltetaten, Oslo County, Norway
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West SL, O'Neal KK, Graham CW. A meta-analysis comparing the effectiveness of buprenorphine and methadone. JOURNAL OF SUBSTANCE ABUSE 2001; 12:405-14. [PMID: 11452842 DOI: 10.1016/s0899-3289(01)00054-2] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Increases in the use of illicit opiates have refocused attention on these drugs. One outgrowth of this attention has been the increased consideration of pharmacotherapies to provide alternatives to methadone maintenance. Buprenorphine is one new tool used in the attenuation of illicit opiate use. Like methadone, buprenorphine produces cross-tolerance to other opiates. However, it may have advantages over methadone including a longer duration, limited withdrawal syndrome, and increased safety. Buprenorphine's ability to serve as a replacement drug for illicit opiate use is well documented, and efforts have recently been made to compare the drug with methadone. The purpose of this study was to provide a meta-analysis of all available research reporting a controlled comparison of buprenorphine and methadone. This analysis provided a rating of the comparative efficacy of each drug, thus giving clinicians an additional guide when selecting an appropriate course of treatment. Findings suggest a relative equality in the efficacy of buprenorphine and methadone, although patients receiving methadone were less likely to test positive for illicit opiate use. Past experience with methadone maintenance acted as a moderating variable, however, such that those receiving buprenorphine were more likely to stay drug-free in studies that included patients with prior methadone experience.
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Affiliation(s)
- S L West
- Texas Tech University, Lubbock, TX, USA
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Agar M, Bourgois P, French J, Murdoch O. Buprenorphine: "field trials" of a new drug. QUALITATIVE HEALTH RESEARCH 2001; 11:69-84. [PMID: 11147165 DOI: 10.1177/104973201129118948] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
Buprenorphine is being introduced as a new treatment drug for narcotics addiction in the United States. The authors were asked by the National Institute on Drug Abuse to conduct a field trial to determine if buprenorphine might play a role in street markets. Because no street use of the drug existed in the United States, the authors used three sources of information: (a) "street readings" of clinical studies, (b) Internet discussion lists, and (c) research in other countries. By using an emergent style of analysis that relies on replication of patterns across disparate data sources, it was determined that buprenorphine has desirable characteristics from a street addict point of view. An evaluation of the field trial 5 years later evaluates its accuracy.
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Affiliation(s)
- M Agar
- Department of Anthropology, History and Social Medicine, University of San Francisco's School of Medicine, USA.
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Harris DS, Jones RT, Welm S, Upton RA, Lin E, Mendelson J. Buprenorphine and naloxone co-administration in opiate-dependent patients stabilized on sublingual buprenorphine. Drug Alcohol Depend 2000; 61:85-94. [PMID: 11064186 DOI: 10.1016/s0376-8716(00)00126-5] [Citation(s) in RCA: 99] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Buprenorphine and naloxone sublingual (s.l.) dose formulations may decrease parenteral buprenorphine abuse. We evaluated pharmacologic interactions between 8 mg s.l. buprenorphine combined with 0, 4, or 8 mg of naloxone in nine opiate-dependent volunteers stabilized on 8 mg s.l. buprenorphine for 7 days. Combined naloxone and buprenorphine did not diminish buprenorphine's effects on opiate withdrawal nor alter buprenorphine bioavailability. Opiate addicts stabilized on buprenorphine showed no evidence of precipitated opiate withdrawal after s.l. buprenorphine-naloxone combinations. Buprenorphine and naloxone bioavailability was approximately 40 and 10%, respectively. Intravenous buprenorphine and naloxone produced subjective effects similar to those of s.l. buprenorphine and did not precipitate opiate withdrawal.
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Affiliation(s)
- D S Harris
- Drug Dependence Research Center, Langley Porter Psychiatric Institute, and Department of Biopharmaceutical Sciences, University of California, San Francisco, 401 Parnassus Avenue, 94143-0984, San Francisco, CA 94143-0984, USA
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Lieb R, Isensee B, von Sydow K, Wittchen HU. The Early Developmental Stages of Psychopathology Study (EDSP): a methodological update. Eur Addict Res 2000; 6:170-82. [PMID: 11124570 DOI: 10.1159/000052043] [Citation(s) in RCA: 154] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The objectives of the community-based Early Developmental Stages of Psychopathology (EDSP) Study are described along with a detailed account of the overall design, special design features, sample characteristics and instruments used. The EDSP employed a prospective-longitudinal design to study substance use and other mental disorders in a representative population sample of 3,021 subjects aged 14-24 years (birth cohorts 1970-1981) at 'baseline' - the outset of the study. Two follow-up investigations were conducted after the baseline investigation covering an overall period of 3-4 years. Special design features are the linkage with a family supplement (EDSP-FS) as well as neurobiological laboratory studies of high-risk subjects.
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Affiliation(s)
- R Lieb
- Clinical Psychology and Epidemiology Unit, Max Planck Institute of Psychiatry, Munich, Germany.
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Consideration of a North American heroin-assisted clinical trial for the treatment of opiate-dependent individuals. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2000; 11:357-370. [PMID: 10967518 DOI: 10.1016/s0955-3959(00)00057-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Untreated opiate addiction remains a major public health problem in North America (US and Canada). Increased morbidity and mortality as well as criminal behavior related to untreated opiate dependence constitute significant social and economic burdens. While the principal treatment modality to opiate addiction in North America has been methadone treatment since the 1960s, its reach and effectiveness has been limited; at any given time, only about 25% (US) and 15-20% (Canada) of all opiate addicts are in methadone treatment. Reasons for low levels of treatment participation among this subset of users include perceptions among users that treatment programs are punitive and that the medication is fraught with side effects. In the meantime, alternatives to methadone have been recently approved or are in development, including levo-alpha acetylmethadol and buprenorphine. However, the extent to which they will solve the current problem is still unknown, and therefore development of additional treatment strategies needs to continue. Recent studies of heroin-assisted treatment in Europe (Switzerland, the Netherlands and Great Britain) produced preliminary yet encouraging results in attracting and retaining long-term, treatment-resistant addicts in treatment, as well as improving treatment outcomes. However encouraging, the North American context differs from Europe. A study performed in North America would provide critical information on whether utilizing injectable opiates enhances the overall therapeutic attractiveness and effectiveness of substance abuse treatment to a subset of recalcitrant users. Implications of positive results would expand the continuum of effective interventions in the US and Canada, and increase the number of long-term, treatment-resistant opiate addicts in treatment.
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