Opioid agonist treatment for patients with dependence on prescription opioids: Clinical evidence synopsis

May 2017
Nielsen, S., Larance, B. & Lintzeris, N. (2017) Opioid Agonist Treatment for Patients with Dependence on Prescription Opioids: Clinical Evidence Synopsis. JAMA 317(9):967-968. doi: 10.1001/jama.2017.0001

Dependence on prescription opioids has led to a significant increase in opioid overdose and deaths in the US and Australia. There is, therefore, an urgent need for best possible clinical evidence to guide treatment for people dependent on prescription opioids. The authors conducted a Cochrane review of current clinical evidence on the use of opioid agonist treatment for patients dependent on prescription opioids. The purpose of the review was to determine whether different opioid agonist treatments, methadone or buprenorphine, were associated with differences in effectiveness, and also to compare the effectiveness of long-term maintenance treatment and opioid taper (withdrawal) or psychological treatments alone.

Six studies were identified – the majority of them conducted in the US. The review found that long-term maintenance treatment is associated with reduced prescription opioid use and better adherence to medication and psychological therapies, compared with opioid taper or psychological treatments alone. It also concluded that there was no difference in effectiveness of methadone or buprenorphine and both were equally suitable choices for long term maintenance treatment. However, the authors noted that the evidence base was poor to moderate, sample size was small and no trial included a double blind component. They recommended that future studies should include a pain measure to further understand the link between chronic pain and opioid treatment. An updated search conducted in August 2016 did not find any other trials suitable for inclusion.

The conclusions were consistent with current US guidelines (The US Centre for Substance Abuse Treatment guidelines) and A Guideline for the Clinical Management of Opioid Addiction, which both suggest that long-term maintenance treatment is preferable to withdrawal treatment or psychological treatment alone. The American Society of Addiction Medicine Guidelines concluded that long term maintenance therapy was superior to withdrawl or psychological treatment alone. Buprenorphine and methadone were equally suitable choices for long term treatment.  See JAMA opioid microsite (http://sites.jamanetwork.com/opioids/) for further clinical information such as differences between methadone and buprenorphine induction.

Evidence profile
Number of studies: 6 randomised clinical trials
Study years: Conducted 2002-2014; published 2003-2015
Number of participants: 607
Gender: Men 77%; Women 33%
Race/ethnicity: 86% white (reported in 3 studies)
Age: Mean (range) 32 years (17-60 years; reported in 3 studies)
Setting: Outpatient; 1 study recruited from Emergency Departments
Countries: United States and Iran