CAT Project – Addiction treatment with buprenorphine
Evidence Based Practice Critically Appraised Topic
Buprenorphine in the treatment of opioid addiction
Carrie DeFoe, RN, BSN, FNP-S
University of Mary
DeFoe
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CAT Project – Addiction treatment with buprenorphine
DeFoe
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Evidenced Based Practice Critically Appraised Topic: Buprenorphine in the treatment of
opioid dependence.
Date: March 6, 2014
Clinical Scenario
A 31-year-old male presents to the clinic for help with his opioid addiction and has heard of the
drug Subutex. He says that he wants to get off the painkillers because is engaged with a baby on
the way and he “finally” has a good job. The patient tells you that he has tried “stopping cold
turkey but the withdrawals were too bad.” He also reports trying counseling in the past without
success.
Clinical Question
In patients with opioid addiction, does pharmacologic subutex (buprehnorphine) therapy versus
methadone or placebo ameliorate opioid withdrawal symptoms and prevent relapse?
Articles
Gowing, L. (2009). Buprenorphine for the management of opioid withdrawal. Cochrane
Database Of Systematic Reviews, (3), doi:10.1002/14651858.CD002025.pub4
Mattick, R. (2014). Buprenorphine maintenance versus placebo or methadone maintenance for
opioid dependence. Cochrane Database Of Systematic Reviews, (2),
doi:10.1002/14651858.CD002207.pub4
Summary and Appraisal of Key Evidence
Study 1
Gowing (2009) states that opioid dependence is a major health issue in our society,
especially in the 15 to 34 year age group, mostly due to its high mortality rate, transmission of
HIV and Hepatitis C, health care costs, crime costs, and law enforcement costs. The article states
that detoxification alone is not an effective treatment option for opioid dependence. This
Cochrane review used randomized and quasi-randomized controlled clinical trials involving
participants who were primarily opioid dependent and who underwent managed withdrawal. The
review focused on experimental interventions using buprenorphine compared to tapering doses
of other medications such as methadone, alpha2-adrenergic agonists, placebo, or various
buprenorphine doses. Trials were retrieved from electronic database searches including: The
Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and PsycINFO. The
review utilized twenty-two studies involving 1736 participants. A total of 956 participants were
treated with buprenorphine. The comparisons considered in this study were diverse, comparing
buprenorphine to methadone, clonidine, lofexidine, and various rates of buprenorphine dose
reduction. Meta-analysis was possible for only two comparisons: buprenorphine versus
methadone and buprenorphine versus clonidine.
The risk of assessment bias for objective outcomes was considered low for all studies.
The risk assessment bias for subjective outcomes included intensity of withdrawal, occurrence
and severity of adverse effects. Duration and completion of therapy were identified as potential
biases but none of the studies were found to have a high risk of bias as a result of missing data.
CAT Project – Addiction treatment with buprenorphine
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The study concluded that both buprenorphine and methadone medications have similar
capacities to ameliorate withdrawal symptoms. Neither medication was found to have severe
adverse effects when used for the management of opioid withdrawal. In regards to completion of
treatment, buprenorphine was found to have higher completion rates than methadone but more
research is needed. When compared to clonidine, buprenorphine was associated with greater
retention and completion of treatment. Also, low dose buprenorphine was found to be more
effective than clonidine at ameliorating withdrawal symptoms. Clinical evidence was not graded
in this review.
Strengths and weakness can be evaluated. A majority of the studies included in this
review were performed during inpatient stays, limiting useful data for outpatient treatment of
opioid addiction. Dosages of buprenorphine taper were varied among studies and participants.
The studies included were evaluating the effectiveness in patients withdrawing from heroin but
not other opiates.
Study 2
In a Cochrane Database of Systematic Reviews, Mattick (2014) evaluated buprenorphine
treatment versus placebo and as an alternative to methadone in the management of opioid
dependence. Selection criteria included randomized control trials of buprenorphine maintenance
treatment versus placebo or methadone in opioid dependent persons. The review included 31
trials involving 5430 participants. Participants in the studies were addicted to either heroin or
other opiates. Electronic searches were conducted using CENTRAL, The Cochrane Library, and
EMBASE.
The interventions in the studies ranged from two to fifty-two weeks. A large number of
the studies used fix doses of medication creating some limitations because common clinical
practice involves flexible dosing. Three of the studies used a very low dose Buprenorphine, 1
mg, as the placebo. The review felt this was a conservative dose and unlikely to bias the results.
All studies involved were judged to be low risk of bias.
This review concluded that buprenorphine is an effective maintenance therapy when
compared to placebo. Methadone maintenance therapy at flexible doses, when compared to
buprenorphine, was found to be more effective in retaining participants in treatment (high
quality, grade 4 evidence). The review supported buprenorphine in substitution maintenance and
found it to be relatively safe. There was moderate evidence (grade 3) showing no difference
between buprenorphine and methadone when participants’ urine drug screens tested positive for
cocaine, morphine, and benzodiazepine. Also, the numbers of self reported heroin use during the
studies showed no difference between the two medications (grade 3).
Results
Both Cochrane reviews compared buprenorphine to methadone in the management of
opioid withdrawal, specifically in heroin withdrawal. Buprenorphine was consistently found to
be as effective as methadone in ameliorating withdrawal symptoms. Mattick (2014) found
methadone to have higher completion of treatment rate. Gowing (2009) found Buprenorphine to
relieve withdrawal symptoms faster and have a higher rate of treatment completion. Adverse
effects with the two drugs are minimal in both studies. Gowing (2009) compared buprenorphine
to Clonidine and buprenorphine to be more effective. Mattick (2014) compared buprenorphine to
placebo and concluded that buprenorphine was more effective.
CAT Project – Addiction treatment with buprenorphine
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Clinical Bottom Line
Both methadone and buprenorphine are effective treatments for opioid withdrawal and
addiction management. It is up to clinical judgment to determine which medication is best suited
for an individual patient. Both medications are opioids themselves and carry a high risk for
abuse.
Implications for Practice
Based on the above studies, I would recommend either buprenorphine or methadone for
the treatment of opioid withdrawal and management. Buprenorphine-licensed physicians are the
only providers who can prescribe and manage buprenorphine treatment. Referral to a pain
management provider is vital to success of opioid withdrawal. Both of these medications must be
monitored closely with frequent follow up and urine drug screening.
CAT Project – Addiction treatment with buprenorphine
DeFoe
References
Gowing, L. (2009). Buprenorphine for the management of opioid withdrawal. Cochrane
Database Of Systematic Reviews, (3), doi:10.1002/14651858.CD002025.pub4
Mattick, R. (2014). Buprenorphine maintenance versus placebo or methadone maintenance for
opioid dependence. Cochrane Database Of Systematic Reviews, (2),
doi:10.1002/14651858.CD002207.pub4
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