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.
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