Is Supervised Dosing Necessary in Opioid Substitution?

Peter M. Yellowlees, MBBS, MD


July 17, 2017

This is the Medscape Psychiatry Minute. I'm Dr Peter Yellowlees.

Opioid dependence is a massive clinical and public health problem worldwide, and opioid substitution treatment such as methadone and buprenorphine is the usual guideline-recommended first-line medication treatment. We know that some patients divert the substitutes if their administration is unsupervised, but we do not know whether supervised administration leads to overall better clinical outcomes. Now a team of investigators[1] from Lazio, Italy, have undertaken a Cochrane methodology systematic review to study the effectiveness of opioid substitution treatment with supervised dosing, compared with dispensing of medication for off-site consumption. While six studies involving 7999 participants met the inclusion criteria, unfortunately the authors found that there remains uncertainty about the effects of supervised dosing compared with unsupervised medication due to the very low quality of the evidence in these studies.

So, what should we do about these results, given the opioid epidemic in the USA and the appalling lack of knowledge that we have about this very basic question with major clinical and economic consequences? Should we supervise the taking of opioid substitutes or not? Obviously, more research comparing supervised and take-home medication strategies is urgently needed to support decisions on the relative effectiveness of these strategies, as are studies assessing the risk for diversion and safety outcomes when using supervised opioid substitution treatment to manage patients with opioid dependence. The need for this research is urgent, as is the translation of the results into clinical practice.

Thank you for listening to this Medscape Psychiatry Minute. Do enjoy your practice.


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