Slow release oral morphine versus methadone for the treatment of opioid use disorder

Abstract

ObjectiveTo assess the efficacy of slow release oral morphine (SROM) as a treatment for opioid use disorder (OUD).DesignSystematic review and meta-analysis of randomised controlled trials (RCTs).Data sourcesThree electronic databases were searched through 1 May 2018: the Cochrane Central Register of Controlled Trials, MEDLINE and EMBASE. We also searched the following electronic registers for ongoing trials: ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, Current Controlled Trials and the EU Clinical Trials Register.Eligibility criteria for selecting studiesWe included RCTs of all durations, assessing the effect of SROM on measures of treatment retention, heroin use and craving in adults who met the diagnostic criteria for OUD.Data extraction and synthesisTwo independent reviewers extracted data and assessed risk of bias. Data were pooled using the random-effects model and expressed as risk ratios (RRs) or mean differences with 95% CIs. Heterogeneity was assessed (χ2 statistic) and quantified (I2 statistic) and a sensitivity analysis was undertaken to assess the impact of particular high-risk trials.ResultsAmong 1315 records screened and four studies reviewed, four unique randomised trials met the inclusion criteria (n=471), and compared SROM with methadone. In the meta-analysis, we observed no significant differences between SROM and methadone in improving treatment retention (RR=0.98; 95%CI: 0.94 to 1.02, p=0.34) and heroin use (RR=0.96; 95% CI: 0.61 to 1.52, p=0.86). Craving data was not amenable to meta-analysis. Available data implied no differences in adverse events, heroin, cocaine or benzodiazepine use.ConclusionsMeta-analysis of existing randomised trials suggests SROM may be generally equal to methadone in retaining patients in treatment and reducing heroin use while potentially resulting in less craving. The methodological quality of the included RCTs was low-to-moderate.

The effectiveness of substance use interventions for homeless and vulnerably housed persons: A systematic review of systematic reviews on supervised consumption facilities, managed alcohol programs, and pharmacological agents for opioid use disorder

“…Of note, methadone maintenance therapy use was negatively associated with homelessness in a separate observational study (odds ratio 0.29, 95% CI 0.17-0.49) [72]. One review reported that difference in dropouts was not statistically significant between participants in slow release morphine vs methadone (risk ratio 0.98; 95% CI: 0.94-1.02, p = 0.34) [63]. The relative superiority of one pharmacological agent over another on retention outcomes remains unclear.…”

“…Because of the high risk of bias and variability in several aspects of studies examining the risk of HIV infection, combined totals were not calculated [44]. Methadone was associated with more adverse events compared to buprenorphine, including sedation [50,60], but not compared to slow release oral morphine (81% SROM vs 79% methadone, p = 0.62 [no further data reported]) [63]. Buprenorphine patients had a significantly lower prevalence of fatigue (15.5% vs 25.1%; risk ratio 0.62; 95% CI 0.41-0.95; GRADE certainty of evidence [as reported in [64]: moderate) but no difference in insomnia (risk ratio1.12 95%CI 0.78-1.62) compared to methadone patients [64].…”

Clinical guideline for homeless and vulnerably housed people, and people with lived homelessness experience

“…103 Adverse events were reported for all agents. 100,109,119,122 Treatment with methadone and buprenorphine was associated with reduced illicit opioid use (standardized mean difference -1.17, 95% CI -1.85 to -0.49). 109 Availability of buprenorphine treatment expanded access to treatment for patients unlikely to enrol in methadone clinics and facilitated earlier access for recent initiates to opioid use.…”

Lignes directrices de pratique clinique pour les personnes sans-abri, logées précairement, ou ayant connu l’itinérance

“…Le degré de certitude des données probantes a été jugé faible parce que plusieurs essais présentaient un risque élevé de biais de détection et d'exécution. Des événements indésirables ont été signalés avec tous les agents 100,109,119,122 . Le traitement à la méthadone et à la buprénorphine a été associé à une baisse de l'utilisation illicite des opioïdes (différence moyenne normalisée -1,17, IC de 95 %, -1,85 à -0,49) 109 .…”