Dr. Andrew's Opinions: 2. Reconsidering the usefulness of adding naloxone to buprenorphine.

11 January 2022

2. Reconsidering the usefulness of adding naloxone to buprenorphine.

Part the second, Dr Byrne’s blog notes (abbreviated due to two articles I have found which have done most of the work I set out to do).

2. As I prepared my references about the addition of naloxone I happened upon a recent scholarly review paper by Blazes and Morrow from U Michigan at Ann Arbor (see link below which I highly recommend). Their review of the literature and clinical history of the combination product finds little evidence for the addition of naloxone. They emphasise the current opioid overdose crisis and the underutilization of buprenorphine in America.

These authors avoid mention of commercial, marketing and patent factors but state: “…we cannot unambiguously conclude that naloxone is an effective deterrent to parenteral misuse of buprenorphine. At best, naloxone may reduce or delay the subjective “high” users experience, but in the absence of any dramatic effect on abuse liability, this partial blockade of subjective euphoric effects is of dubious clinical value.”

To cast further doubts on the combination product one should consider the substantially higher post-treatment mortality found in combination-treated patients in WA when compared with those prescribed the pure drug (n=3455) over a nine year period. I could only find two comparative clinical trials, one a pilot study reporting significantly higher doses needed when transferring from the pure drug to combination (not blinded: see Bell below). The other was a large RCT reporting more withdrawal syndrome in those given combination buprenorphine versus the pure drug (25% vs 18% of subjects: see Fudala below).

I leave the reader to consider the evidence and decide what is best for their own patients.

Written by Andrew Byrne .. Regards for a safe New Year for 2022 for all my readers.

Frontiers | Reconsidering the Usefulness of Adding Naloxone to Buprenorphine | Psychiatry (frontiersin.org) Blazes and Morrow 2020

Buprenorphine alone or with naloxone: Which is safer? - PubMed (nih.gov)

Bell J, Byron G, Gibson A, Morris A. A pilot study of buprenorphine-naloxone combination tablet (Suboxone®) in treatment of opioid dependence. Drug Alcohol Rev 2004 23;3:311-318

Fudala PJ, Bridge TP, Herbert S, et al. Office-Based Treatment of Opiate Addiction with a Sublingual-Tablet Formulation of Buprenorphine and Naloxone. NEJM (2003) 349:949-958

Disclaimer

On this web site, Dr Byrne and colleagues have written summaries of many research articles, conferences and other events. These have been written largely to draw attention to peer-reviewed studies which may be relevant to clinical practice and public policy. While all care has been taken to be fair and accurate, readers are strongly advised to read the original publications before acting upon the information for clinical decisions.

Due to this brief form of communication, no responsibility can be taken for errors, mistakes or omissions.

Reputable sources of health information for the general public:

http://www.healthinsite.gov.au/ (opens in a new window)
HealthInsite, a search site for reliable health information, Australian Department of Health.
http://www.nlm.nih.gov/medlineplus/ (opens in a new window)
MedlinePlus, a search site for reliable health information, US National Library of Medicine.