Opioid Addiction Meds Effective but Buprenorphine a Better Bet?

Megan Brooks

February 20, 2014

Both buprenorphine maintenance treatment (BMT) and methadone maintenance treatment (MMT) are associated with improved outcomes for individuals with opioid use disorders, according to results of 2 separate literature reviews.

MMT should be a covered service available to all individuals, and BMT should be considered for inclusion as a covered benefit, the reviewers conclude.

Both reviews were published in the February issue of Psychiatric Services as companion articles. They are part of the "Assessing the Evidence Base Series," commissioned by the Substance Abuse and Mental Health Services Administration (SAMHSA) through a contract with Truven Health Analytics of Cambridge, Massachusetts.

The MMT efficacy review included 7 randomized controlled trials, 2 retrospective quasiexperimental studies, and 15 reviews or meta-analyses that examined multiple studies.

The evidence for the effectiveness of MMT for opioid use disorder is "high," report Catherine Anne Fullerton, MD, MPH, of Truven Health, and colleagues. The evidence "clearly" shows that MMT has a positive impact on retention in treatment and decreasing illicit opioid use, they say.

"Methadone maintenance doses above 60 mg confer greater efficacy in retention and suppression of illicit opioid use; however, there is limited evidence that doses above 100 mg provide additional benefits. No evidence has emerged to delineate the duration of MMT beyond an indefinite period," the authors write.

The evidence is less clear but suggestive that MMT has a positive impact on mortality, illicit nonopioid drug use, drug-related HIV risk behaviors, and criminal activity. The evidence suggests that MMT has little impact on sex-related HIV risk behaviors, they report.

Adverse events with MMT have been reported; these include respiratory depression and cardiac arrhythmias in the presence of rapid titrations or other risk factors. There is "no clear evidence" of an added benefit to structured psychotherapy in addition to the psychosocial support normally offered at methadone treatment centers, the researchers note.

MMT also improves pregnancy-related outcomes by reducing illicit drug use and increasing treatment retention, the evidence indicates. However, newborn infants of mothers treated with methadone during pregnancy may be born with neonatal abstinence syndrome (NAS), regardless of the methadone dose used by the mothers.

"Because of MMT's relative efficacy, efforts should be made to increase access to MMT for all individuals who struggle with opioid use disorders," the researchers write.

"Directors of state mental health and substance abuse agencies and community health organizations should look for methods to increase access to MMT, and purchasers of health care services should cover appropriately monitored MMT," they add.

BMT a Better Bet?

Dr. Fullerton and colleagues also found strong evidence supporting the effectiveness of BMT in their review of 16 randomized controlled trials and 7 reviews or meta-analyses.

The data show a "high level" of evidence that BMT helps people stay in treatment and decrease their use of illicit opioids, the authors say. When the medication is dosed adequately, both BMT and MMT cause similar reductions in illicit opioid use, they report, but BMT is associated with less risk for adverse events, and results suggest better treatment retention with MMT.

Research regarding the impact of BMT on nonopioid illicit drug use is less conclusive but suggests positive trends, they note.

As with MMT, BMT is associated with improved maternal and fetal outcomes in pregnancy, compared with no medication-assisted treatment. Rates of NAS appear similar for mothers treated with BMT and MMT during pregnancy, but symptoms are less severe for infants whose mothers were treated with BMT, the researchers report.

Adding any type of psychosocial regimen to BMT has not been shown to improve outcomes, but the heterogeneity of interventions across trials limits the ability to make strong conclusions, the authors note.

"As with MMT, there is growing evidence that higher doses of buprenorphine (16 - 32 mg) are more efficacious than lower doses; however, because of the pharmacology of buprenorphine, doses above 32 mg do not provide additional efficacy," they report.

"Given the poor success rates of abstinence-based treatments for opioid use disorders and the limited access to and more restrictive safety profile of MMT, BMT is an important treatment for opioid dependence," the researchers conclude.

"Administrators of substance use treatment programs, community health centers, and managed care organizations and other purchasers of healthcare services, such as Medicare, Medicaid, and commercial insurance carriers, should give careful consideration to BMT as a covered benefit," they advise.

Psychiatr Serv. 2014;65:146-157, 158-170. Full article, Full article

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