Time-limited buprenorphine replacement therapy for opioid dependence: 2-year follow-up outcomes in relation to programme completion and current agonist therapy status. Kornor H, Waal H, Sandvik L. Drug Alcohol Review 2007 26;2:135-142
Using buprenorphine short-term taper to facilitate early treatment engagement. Brigham GS, Amass L, Winhusen T, Harrer JM, Pelt A. Journal of Substance Abuse Treatment 2007 32;4:349-356
Dear Colleagues,
Kornor and colleagues report a 2 year follow-up of 75 patients entering supervised daily buprenorphine reduction treatment for heroin addiction. An original proposed 9 month reduction to abstinence program was extended to 10 months for compassionate reasons. Even so, only 9 (12%) had achieved and maintained abstinence at 2 years by self-report. Two were lost to follow-up and 5 (7%) died, 3 during the withdrawal phase. Half the total (37) had rejoined maintenance treatments at follow-up.
These authors imply that their research is aimed at countering restrictive policies on maintenance treatment. Norway normally only allows limited buprenorphine, in reduction courses to injectors over 24 years of age, at 3 months maximum per episode. While methadone is available for severely dependent subjects, apparently only a small proportion of the addicted population receive it. The authors conclude that continued treatment may have prevented some of the 5 deaths (3 overdoses, one suicide, one car accident). Based on the high rates of relapse following detoxification, Kornor and colleagues question the ethics of repeating this sort of reduction study in the future. Some critics (eg. Gossop) point to the limited outcomes from maintenance therapy, yet they tend to quote results of treatment given far short of accepted medical guidelines where less than optimal result are predictable.
Brigham, Amass and colleagues report on their first 64 buprenorphine “detox” patients compared retrospectively with two other groups given other treatments, including clonidine, during 2003/4. Their ‘detox’ group took a mean daily buprenorphine dose of 22mg over an average 14 days in ‘treatment’ and 80% were reported to take follow-up treatment. This compared with around 30% for the other groups given non-opioid medications.
This curious ‘study’ has limited meaning beyond indicating that giving ineffective treatment (clonidine assisted detoxification) makes patients unlikely to return for more treatment, which is hardly surprising.
These authors recognise the shortcomings of brief courses of opioids in describing “the critical need for treatment continuation following detoxification”. Their study protocol, however, rather than the stated detoxification, it was rather a ‘re-toxification’ with high doses of buprenorphine, even beyond the usual levels used for opioid maintenance. Thus by definition, their patients did not commence detoxification until after they left treatment. While reduction courses and formal detox should be available promptly to all, maintenance opioids should also be available as a ‘safety net’ where reductions fail to achieve patients’ original goal of abstinence.
The concept of arbitrary time-limited dose reductions goes against the very definition of addiction involving compulsive drug use with a certain degree of loss of control. Some will regain this control, but others will not. Despite a known higher mortality, apparently well-meaning folk continue to propose compulsory detoxification as a valid strategy. They either don’t consider that addiction exists, and/or that the consequent deaths in this group are unimportant. To do a comparable study of medication reduction using subjects with diabetes, depression or asthma would be unthinkable.
Since I have been critical of reduction courses and of using buprenorphine ‘first line’ in the past, I remain hard put to determine a rational strategy for opioid maintenance. As with other areas of therapeutics we are faced with decisions: why do we choose penicillin in place of erythromycin or aspirin against other effective analgesics? It is a combination of known efficacy of available treatments and the particular patient’s individual situation. Most often, in my experience, patients have tried methadone and/or buprenorphine so this can be some guide. The issue of pregnancy or heavy street drug use might sway one towards methadone but previous difficulties with methadone might sway one towards buprenorphine, despite its slightly lower efficacy.
So the great Dr Osler’s advice pertains: listen carefully and your patient will often tell you the diagnosis … and further, many will also tell you the treatment required.
Comments by Andrew Byrne ..
