Avoid Buprenorphine Detox for Prescription Opioid Addiction

Liam Davenport

October 23, 2014

Buprenorphine detoxification, or tapering, should be avoided in patients with prescription opioid dependence, who benefit from ongoing maintenance treatment, new research shows.

Investigators at Yale University School of Medicine, in New Haven, Connecticut, found that patients whose buprenorphine therapy was tapered were more likely to test positive for illicit opioid use than patients receiving maintenance therapy, and they were less likely to be abstinent.

"Buprenorphine taper should be used sparingly, if at all, in primary care treatment of patients dependent on prescription opioids," the researchers, led by David Fiellin, MD, professor of medicine, investigative medicine, and public health, write.

The study was published online October 20 in JAMA Internal Medicine.

Prescription Opioid Epidemic

For the study, 113 patients with prescription opioid dependence were randomly assigned to receive the partial opioid agonist either as taper or ongoing maintenance therapy. The taper was begun after a 6-week induction and stabilization phase, with the initial dose of 15.0 mg/d reduced by 2 mg every 3 days for 3 weeks.

Patients in the taper group were provided medications for opioid withdrawal. Those who achieved at least 7 days of opioid abstinence after their last buprenorphine dose were offered oral naltrexone (multiple brands) plus ongoing clinical care and counseling. Patients receiving buprenorphine maintenance therapy also received ongoing clinical care and counseling.

The proportion of urine samples testing negative for opioids during the 14-week trial was lower in the taper group than in the maintenance group, at a mean percentage of 35.2% vs 53.2%. Patients in the taper group also reported more days of illicit opioid use following the taper than patients in the maintenance group, at a mean of 1.27 days vs 0.47 days.

The maximum consecutive weeks of opioid abstinence was lower for taper patients than for those receiving maintenance therapy, at a mean of 2.70 weeks and 5.20 weeks, respectively. Taper patients were also less likely to complete the trial, at 11% vs 66% in the maintenance group (P< .001). Moreover, 16 taper patients reinitiated buprenorphine therapy after a relapse.

These findings underscore the difficulties of treating prescription opioid dependence, which is a growing problem.

"In the US, there has been an increase in the number of individuals addicted initially and, in some cases, exclusively to prescription opioids, and some of these individuals exclusively use prescription opioids that maintain their dependence," Dr Fiellin told Medscape Medical News.

Great Debate

Dr Fiellin explained that the majority of individuals who become dependent on prescription opioids have sought them out as a recreational drug.

"A small proportion of these individuals are those who may have initiated their opioid use because of an acute or perhaps chronic pain complaint...for instance, a broken bone or a kidney stone, or some kind of trauma. They initiate opioid use because of pain but continue their opioid use because of the euphoria that they derive from that."

"But I have to say that, certainly in the United States, the majority of the prescription opioid‒dependent individuals are folks who have started in their young adulthood through experimentation and develop a full-fledged addiction because of that experimentation."

With the advent of buprenorphine as an office-based treatment, there has been a great deal of debate over how best to deploy it.

"The literature clearly supports the superiority of methadone maintenance over methadone taper for heroin-dependent patients," said Dr Fiellin.

"However, given that many of the prescription opioid‒dependent patients tended to be younger and have greater levels of social stability, and given that buprenorphine has a less severe withdrawal profile than methadone, many practitioners were enthusiastic about providing primarily detoxification or taper strategies for prescription opioid‒dependent patients, believing that the literature and the evidence base that existed for methadone for heroin-dependent patients perhaps did not transfer to prescription opioid‒dependent patients receiving treatment with buprenorphine," he added.

Two Camps

Commenting on the study for Medscape Medical News, Frances Levin, MD, Kennedy Leavy Professor of Clinical Psychiatry, Columbia University Medical Center, and chair of the American Psychiatric Association's Council on Addiction Psychiatry, supported the findings.

"I think [the study] makes a very good point...that remaining on agonist treatment such as buprenorphine is less likely to lose people from treatment, as the retention rate was higher, as well as the likelihood of remaining abstinent."

The current findings suggest that tapering is not sufficient to achieve long-lasting abstinence, even if it has not closed the debate entirely.

"I think what this study shows is that, at least in the short run, 6 weeks of stabilization before the taper [is] probably not enough," said Dr Levin.

"The question of whether people have to be on buprenorphine for years is the same thing people have struggled with for methadone. There's a camp that says you are on methadone for life, and then there're other people who will argue somebody who's got all their psychosocial [and] other areas of their life stable could be tapered," she added.

"But that's a discussion that often goes back and forth. Common sense is that patients probably need to be stabilized for a longer period of time before you even contemplate tapering someone off."

Nevertheless, the desire to detoxify or taper opioid addiction treatment is attractive to patients.

"I think there's a desire for almost a surgical cure for addiction, partly on the part of society but very much so on the part of patients and their families," said Dr Fiellin.

"The disease process and the extent to which it impacts and destroys their lives is such that the desire is to quickly and once and for all take care of it and have it behind them. Unfortunately, I think that type of viewpoint isn't consistent with what we know about the neurobiology and the changes in the brain that take place through the process of developing addiction."

"This is a chronic and relapsing medical condition not unlike others ― both psychiatric conditions, such as depression, but also medical conditions, such as high blood pressure and diabetes ― whereby the condition can be managed with combined medication and lifestyle changes. But it is not possible to effect a rapid cure over a short period of time."

Room for Improvement

Tapering therapy is also attractive to physicians, because it allows them to treat more patients ― new patients can be prescribed buprenorphine as the previous patients are taken off the partial opioid agonist. However, as Dr Levin pointed out: "The old patients will start not doing so well, so you are back where you started."

Given the difficulties in achieving abstinence, one question that the study results pose is whether novel treatments are required for prescription opioid addiction, or whether the available therapies simply need to be deployed more effectively.

"I think it's clear that there is room for improvement, despite the treatments that we do have, and there are active efforts under way to develop both new medications and new and more effective counseling strategies to engage and retain patients in opiate agonist treatment," said Dr Fiellin.

"Nonetheless, I think we do need to be cautious to employ the treatments that we have in the most effective manner, and I think our study demonstrates that maintenance treatment is more effective than detoxification or tapering treatment for prescription opioid dependence."

This study was supported by grants from the National Institute on Drug Abuse (NIDA). Reckitt-Benckiser Pharmaceuticals provided buprenorphine through the NIDA. Dr Fiellin has received honoraria for serving on expert advisory boards to monitor for diversion, misuse, and abuse of buprenorphine for Pinney Associates and ParagonRx; and he has received honoraria from the American Society of Addiction Medicine to serve as the medical director of the Physician Clinical Support Systems for Buprenorphine and Primary Care and from the American Academy of Addiction Psychiatry to serve as a consultant to the Physician Clinical Support Systems for Buprenorphine and Opioids.

JAMA Intern Med. Published online October 20, 2014. Abstract

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