Buprenorphine: Then and Now

Then…

In 2002, buprenorphine, and buprenorphine with naloxone (suboxone), became the first medications to be approved under a new federal law permitting long-term opioid treatment in settings other than opioid treatment clinics. In early randomized clinical trials, the evidence for buprenorphine’s efficacy was empirically established, indicating its positive impact on illicit opioid dependence and treatment retention. These data became a “green light” so to speak, compelling more physicians to get on the buprenorphine bandwagon.

Now…

Compared to methadone, the recent evidence on buprenorphine with naloxone reveals a different picture. Although counseling is a required part of office-based buprenorphine treatment of opioid use disorders, the definition of what constitutes “counseling” is ambiguous and controversial.

In a review article by Carroll and Weiss (2017), the authors reviewed the literature on the role, nature and intensity of behavioral interventions in office-based buprenorphine treatment. They reviewed questions regarding the subtype of patients who are not retained, research methodology, the role of the physician and the efficacy of various counseling approaches.

The conclusions were mixed regarding “high quality” medical management. Specifically, the parameters of what constituted quality were not defined. The same held true for counseling. The recommendations included a less intensive, “stepped care” treatment model starting with less intensive counseling that could be increased for patients who struggle early in treatment. Again, what constitutes “struggle” is not defined, and therefore useless for clinicians.

While it is true that the statistical efficacy of buprenorphine is waning when compared to methadone. For example, in randomly assigned cases a study of 1,267 individuals who were prescribed either buprenorphine or methadone for treatment of opioid use disorder. At 6 months, the retention rate for the patients given buprenorphine was 46%. In contrast, a 5-year study showed less drug use, more retention and less drop outs for methadone. Yet, individuals taking methadone as part of a continuous care treatment model differ dramatically than individuals who seek out a buprenorphine prescriber for office based “treatment”, which consists of monthly visits for refills and drug testing. Methadone maintenance programs, which have been in existence since the late 1960s, require patients to come to the clinic daily to purchase a one-day supply of methadone. Failure to comply results in the rapid onset of withdrawal symptoms, which for methadone, are more severe and protracted than withdrawal from heroin.

Why Does this Matter?

Buprenorphine versus methadone is the wrong question. The severity of the disease, the patient’s motivation for treatment, and the patient’s social support are the determinants of the type, intensity and duration of treatment, and the best predictors of outcome. Coming to a clinic to receive a prescription and a 20-minute chat with a counselor is insufficient for most addicted persons. Why would we think otherwise?

There is no pill or silver bullet for SUDs. Reiterating the Institute of Behavioral Health’s recommendations, patient-centered treatment, of adequate duration and intensity is always necessary. MATs are at best, adjunctive modalities within the framework of a comprehensive, multimodal treatment approach, with social and 12-step support. Lastly, treatment for SUD is a highly relational process consisting of building social support with one’s counselor and friendships with others in recovery.