Statement of the American Society of Addiction Medicine Consensus Panel on the Use of Buprenorphine in Office-Based Treatment of Opioid Addiction

Abstract

Therapeutic outcomes for patients who self-select office-based treatment with buprenorphine are essentially comparable to those seen in patients treated with methadone programs. There are few absolute contraindications to the use of buprenorphine, although the experience and skill levels of treating physicians can vary considerably, as can access to the resources needed to treat comorbid medical or psychiatric conditions--all of which affect outcomes. It is important to conduct a targeted assessment of every patient to confirm that the provider has resources available to meet the patient's needs. Patients should be assessed for a broad array of biopsychosocial needs in addition to opioid use and addiction, and should be treated, referred, or both for help in meeting all their care needs, including medical care, psychiatric care, and social assistance. Current literature demonstrates promising efficacy of buprenorphine, though further research will continue to demonstrate its effectiveness for special populations, such as adolescents, pregnant women, and other vulnerable populations. Since the time of this review, several new studies have provided new data to continue to improve our understanding of the safety and efficacy of buprenorphine for special patient populations.

Effects of a Higher-bioavailability Buprenorphine/Naloxone Sublingual Tablet Versus Buprenorphine/Naloxone Film for the Treatment of Opioid Dependence During Induction and Stabilization: A Multicenter, Randomized Trial

“…These findings were consistent when assessed by treatment retention and by reductions in withdrawal symptoms and opioid cravings. Opioid withdrawal symptoms and craving were nearly eliminated by the end of the stabilization period with the use of the higher-bioavailability BNX sublingual tablet or BNX film, consistent with treatment goals during the early phases of medication-assisted treatment 18 and with previously reported findings during induction with BNX film. 6 Together, treatment retention and the reduction of clinical symptoms are important factors in the stabilization of patients and in the prevention of illicit opioid use.…”

Management of opioid use disorders: a national clinical practice guideline

“…• Health Canada exemption is not required to prescribe buprenorphine-naloxone in most provinces and territories (Appendix 1) • Lower risk of overdose due to partial agonist properties and ceiling effect for respiratory depression (in the absence of benzodiazepines or alcohol) 19,24,25 • Lower risk of public safety harms if diverted 26,27 • Milder adverse effect profile 22,23 • Easier to transition from buprenorphine-naloxone to methadone if treatment is unsuccessful 22,23 • Shorter time to achieve therapeutic dose (1-3 d) [28][29][30] • Lower risk of toxicity and drug-drug interactions 31 • Milder withdrawal symptoms when discontinuing treatment; may be a better option for individuals with lower-intensity opioid dependence (e.g., oral opioid dependence, infrequent or no injection use, short history of opioid use disorder), and individuals planning to taper off opioid agonist treatment in a relatively short period 22,23 • Optimal for rural and remote locations where access to care is limited, methadone prescribers are lacking, or daily witnessed ingestion at a pharmacy is not feasible • More flexible dosing schedules (e.g., alternate-day dosing, earlier provision of 1-to 2-week take-home prescriptions, and unobserved home inductions) support patient autonomy and can reduce costs [32][33][34][35] • Easier to adjust and retitrate following missed doses, owing to its partial agonist properties…”

“…• Health Canada exemption is required to prescribe methadone in all provinces and territories • Higher risk of overdose 19,24,25,36 • More often prescribed as witnessed doses; prescription of take-home doses typically use slow graduated schedule (e.g., increase of 1 takehome dose per week about every 4 weeks), which can be inconvenient or not feasible for some patients • More severe adverse effect profile (e.g., somnolence, erectile dysfunction, cognitive blunting) 22,23 • Longer time to achieve therapeutic dose (several weeks) 36 • Can be more challenging to transition from methadone to buprenorphine-naloxone if treatment is unsuccessful 22,23 • Higher risk of public safety harms if diverted 26,27 • Higher potential for adverse drug-drug interactions (e.g., antibiotics, antidepressants, antiretrovirals) 31 • Associated with QTc prolongation and increased risk of cardiac arrhythmia in patients prescribed higher doses, with pre-existing risk factors or taking other medication(s) that prolong QTc interval 22,23 • Can be more expensive if prescribed as daily witnessed doses, mainly owing to fees associated with dispensing and witnessed ingestion 34,35 • Potentially lower treatment retention, particularly in higherintensity opioid use disorder with low-dose buprenorphinenaloxone 18 • May cause precipitated withdrawal if appropriate dose-induction protocols are not followed 30 • Suppression of withdrawal symptoms may be inadequate for individuals with high opioid tolerance 22,23 • Reversing effects of overdose can be challenging because of the pharmacology of buprenorphine (i.e., high affinity for opioid receptors and long half-life) 31 • Patients require education on how to take sublingual doses correctly (i.e., hold under tongue until dissolved -up to 10 minutes; do not drink or smoke, and minimize swallowing) • Nonadherence to treatment may require frequent reinductions Note: QTc = corrected QT.…”

Methadone Medical Maintenance: An Early 21st-Century Perspective

“…4,[44][45][46] Buprenorphine is a partial opioid agonist with adequate bioavailability when given sublingually. With sublingual administration, it has a long elimination half-life (37 hr), 4,45 making it useful as a maintenance medication.…”