11 February 1999

Gradual detoxification to 0.5mg buprenorphine 'effective' over 10 days

Diamant K, Fischer G, Schneider C, Lenzinger E, Pezawas L, Shindler S, Eder H. Outpatient Opiate Detoxification Treatment with Buprenorphine. European Addiction Research 1998 4:198-202



There are impressive outcomes reported in this Vienna study of well-motivated heroin addicts doing a structured 10 day out-patient graduated detoxification using buprenorphine sub-lingual tablets.

The authors of the study chose 50 motivated heroin or opium addicts and administered up to 10 days out-patient treatment with reducing doses of buprenorphine. Doses were titrated daily depending on the degree of withdrawal symptoms. The maximum dose was on day 2 at 2.6mg. Doses averaged 2mg daily for the first 5 days, then reducing to 1.5mg for 2 days, 1.0mg for 2 days and 0.5mg on the tenth day. For only 20% of cases was it the first formal attempt at withdrawal. Withdrawal symptoms were measured on the WANG scale and were most severe initially but waned substantially despite buprenorphine dose decreases.

Patients were also routinely given an antacid preparation (famotidine or 'Pepcidine') and night time sedation if required (prothipendyl - an antihistaminic sedative).

With 15 patients dropping out, this treatment was acceptable to 35 of the 50 patients (31 male, mean age 27) yielding an overall 70% 'success' rate. Even if only a half of these remained abstinent for the medium term, it could still be considered better outcome than traditional drug free treatment.

Buprenorphine is a semi-synthetic narcotic derived from thebaine. It is long acting (>36 hours) and has opioid agonist as well as antagonist effects, rather like pentazocine (Fortral). It has been available in Australia since 1992 as an injected or sublingual analgesic but it is not yet licensed for maintenance addiction treatment. Such maintenance treatment may require much higher doses, up to 32mg daily, so 0.2mg SL tablets are not suitable. In addition, this drug, as a Schedule 8 can only be used in addicts with prior permission from the health authorities in most Australian states.

A large multi-centre trial of the sub-lingual version has reported preliminary results which apparently confirm overseas experience showing safety and efficacy when compared with methadone maintenance. Buprenorphine also has a number of important advantages over methadone such as a longer duration of action, allowing second daily attendance, a lower potential for acute toxicity as well as a possible antidepressant effect. The researchers pointed out that this drug will not be a replacement for methadone, but may be a useful alternative for those in whom methadone is not suitable.

This drug's wider availability in Australia will greatly enhance our repertoire in dealing with drug addiction. In France it has been available on normal doctors prescription for over 3 years with apparently good results in up to 50,000 patients. In the meantime, less satisfactory drugs such as codeine compounds, propoxyphene, quinine, clonidine and metoclopramide may be used to mitigate some of the symptoms of withdrawal. It is to be hoped that this drug can be marketed in a suitable preparation for addiction as soon as possible.

comments by Andrew Byrne ..