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Practice Profile

Buprenorphine Maintenance Treatment

Evidence Ratings for Outcomes:

Effective - One Meta-Analysis Drugs & Substance Abuse - Heroin/opioids
Effective - One Meta-Analysis Drugs & Substance Abuse - Treatment Retention
No Effects - One Meta-Analysis Drugs & Substance Abuse - Benzodiazepines

Practice Description

Practice Goals
Buprenorphine maintenance treatment (BMT) is a medication-assisted treatment for individuals with opioid dependence. The goals of BMT are to alleviate withdrawal symptoms, suppress opiate effects and cravings, and decrease the risk of overdose as a result of the illicit use of opioids.

Practice Components
Opioids, such as heroin or morphine, cause a release of excess dopamine in the body. Users become dependent on the drug because they need opiates to continuously occupy the opioid receptor in the brain. Similar to methadone, buprenorphine works by occupying this receptor and blocking the high that usually comes from illicit opioid drug use. While methadone causes a stronger agonist effect because it is a full agonist, buprenorphine exerts a weaker agonist effect at opioid receptor sites because it is a partial agonist.

The effects of buprenorphine increase as the dosage of the drug is increased; however, at moderate doses, the effects reach a plateau and no longer continue to grow (known as the ceiling effect). Because there is no ceiling to the level of effects that methadone can induce, illicit drug use can lead to fatal overdoses. Thus, buprenorphine can be used as a viable pharmacological alternative to methadone because it carries a lower risk of abuse, overdose, and side effects than do full opioid agonists.

Another benefit to BMT is the dosing schedule. Although the effects of buprenorphine are not as strong as methadone, they last longer. While methadone requires daily dosing, buprenorphine can be taken once every 2 days. This can be an advantage because opioid-addicted patients may not be able to adhere to treatment that requires daily dosage and visits to the clinics.

In addition, buprenorphine can be dispensed in office-based settings. Although methadone can only be dispensed from federally licensed opioid treatment programs, buprenorphine can be administered by physicians in their offices.

There are generally three stages of BMT: induction, stabilization, and maintenance. During the induction phase, patients are medically monitored during the beginning of the buprenorphine therapy. The stabilization phase begins once patients have greatly reduced or stopped their opioid abuse. During this phase, they no longer have cravings and experience few or no side effects. The dosage may also be adjusted during this phase. The maintenance phase begins once patients are on a steady dose of buprenorphine. The length of time that patients continue to receive BMT varies by individual and may be indefinite (SAMHSA 2019).

In addition to medication, BMT can include providing patients with comprehensive rehabilitation services, such as group therapy, individual therapy, medical services, and referrals to community-based agencies.

Meta-Analysis Outcomes

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Effective - One Meta-Analysis Drugs & Substance Abuse - Heroin/opioids
Examining the results from three studies, Mattick and colleagues (2014) found that participants who received high-dose buprenorphine maintenance treatment (BMT) were less likely to test positive for heroin use (as measured by morphine- positive urinalysis), compared with control group participants who received placebos (SMD = -1.17). This difference was statistically significant.
Effective - One Meta-Analysis Drugs & Substance Abuse - Treatment Retention
Examining the results from five studies, Mattick and colleagues (2014) found there was greater retention in treatment for participants in the high-dose BMT group, compared with control group participants who received placebos (RR = 1.82). This difference was statistically significant.
No Effects - One Meta-Analysis Drugs & Substance Abuse - Benzodiazepines
Based on the results from two studies, Mattick and colleagues (2014) found there was no statistically significant effect on use of benzodiazepines (as measured by positive urinalysis).
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Meta-Analysis Methodology

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Meta-Analysis Snapshot
 Literature Coverage DatesNumber of StudiesNumber of Study Participants
Meta-Analysis 11998 - 201051001

Meta-Analysis 1
Mattick and colleagues (2014) conducted a meta-analysis to evaluate buprenorphine maintenance, compared with placebo medication and methadone maintenance, in the management of opioid dependence. The meta-analysis included only randomized controlled trials (RCTs) that looked at BMT versus placebo medication or BMT versus methadone maintenance (for this CrimeSolutions.gov review, the focus was on the comparisons between BMT and placebo medications).

To find eligible studies, databases were searched through January 2013, including Cochrane Drugs and Alcohol Review Group Specialised Register, MEDLINE, EMBASE, PsycLIT, and other databases. Published and non-published RCTs were also sought from identified study authors. A total of 31 RCTs were identified for inclusion in the review. Dose ranges for buprenorphine were classified as follows: between 2mg and 6mg were classified as low dose; between 7mg and 15mg were classified as medium dose; and 16mg or more were considered high dose (for this CrimeSolutions.gov review, the focus was on the comparisons between high-dose BMT and placebo medications).

Of the 31 included studies, 5 RCTs specifically looked at high-dose BMT versus placebo control groups; these studies encompassed 1,001 participants. Three of the studies were conducted in the United States, one was conducted in Sweden, and one was conducted in Norway. The average age of participants ranged from 29 to 38 years. The majority of participants across the studies were male, and all participants had DSM-IV opioid dependence diagnoses. There was no information provided on participants’ race/ethnicity. The participants were given high doses of buprenorphine for treatment. The time in treatment ranged from 4 weeks to 12 months.

The outcomes of interest were illicit drug use, including opioids and other substances (measured as positive urinalysis results) and retention in treatment. A risk ratio (RR) and the 95-percent confidence interval were calculated for a dichotomous outcome (such as retention), while a standardized mean difference (SMD) was calculated for a continuous outcome (such as the positive urinalysis results). A random-effects model was used to analyze the data.
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Cost

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There is no cost information available for this practice.
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Implementation Information

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Buprenorphine maintenance treatment is a federally monitored and regulated medical treatment. Therefore, when used in the treatment of opioid addiction, buprenorphine can only be dispensed by federally licensed opioid treatment programs (OTPs). OTPs must be certified by the Substance Abuse and Mental Health Services Administration (SAMHSA) and registered with the Drug Enforcement Agency (DEA). For more information, please see SAMHSA’s website on Certification of OTPs: https://www.samhsa.gov/medication-assisted-treatment/opioid-treatment-programs
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Other Information

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While the results from the meta-analysis by Mattick and colleagues (2014) showed that participants who received high-dose buprenorphine maintenance treatment (BMT) (defined as 16mg or more) were less likely to test positive for heroin/opioid use, compared with the control group participants who received placebos, the authors found no statistically significant differences between the BMT and control groups when looking at low- and medium-dose BMT (defined as 15mg or less).

Mattick and colleagues (2014) also compared BMT with methadone maintenance treatment (MMT) on several factors. They found that there was greater retention in treatment for individuals given flexible does of MMT, compared with individuals given flexible doses of BMT. However, there were no statistically significant differences between MMT and BMT on heroin/opioid use (as measured by self-reports and morphine-positive urine) or use of cocaine and benzodiazepine (as measured by positive urine). This suggests that while MMT is more effective in retaining people in treatment, MMT and BMT are equally effective at reducing illicit drug use.
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Evidence-Base (Meta-Analyses Reviewed)

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These sources were used in the development of the practice profile:

Meta-Analysis 1
Mattick, Richard P., Courtney Breen, Jo Kimber, and Marina Davoli. 2014. “Buprenorphine Maintenance Versus Placebo or Methadone Maintenance for Opioid Dependence.” Cochrane Database of Systematic Review (2):CD002207.
https://www.cochrane.org/CD002207/ADDICTN_buprenorphine-maintenance-versus-placebo-or-methadone-maintenance-for-opioid-dependence
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Additional References

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These sources were used in the development of the practice profile:

Fudala, Paul J., T. Peter Bridge, Susan Herbert, William O. Williford, C. Nora Chiang, Karen Jones, Joseph Collins, Dennis Raisch, Paul Casadonte, R. Jeffrey Goldsmith, Walter Ling, Usha Malkerneker, Laura McNicholas, John Renner, Susan Stine, and Donald Tusel. 2003. “Office-Based Treatment of Opiate Addiction with a Sublingual-Tablet Formulation of Buprenorphine and Naloxone.” New England Journal of Medicine 349(10):949–56.

Kakko, J., K.D. Svanborg, M.J. Kreek, and M. Heilig. 2003. “1-Year Retention and Social Function After Buprenorphine-Assisted Relapse Prevention Treatment for Heroin Dependence in Sweden: A Randomised, Placebo-Controlled Trial.” Lancet 361(9358):662–68.

Katz, Elizabeth C., Robert P. Schwartz, Stuart King, David A. Highfield, Kevin E. O’Grady, Timothy Billings, Devang Gandhi, Eric Weintraub, David Glovinsky, Wardell Barksdale, and Barry S. Brown. 2009. “Brief Versus Extended Buprenorphine Detoxification in a Community Treatment Program: Engagement and Short-Term Outcomes.” American Journal of Drug and Alcohol Abuse 35:63–67.

Kinlock, Timothy W., Michael S. Gordon, Robert S. Schwartz, and Terrence T. Fitzgerald. 2010. “Developing and Implementing a New Prison-Based Buprenorphine Treatment Program.” Journal of Offender Rehabilitation 49:91–109.

Krook, Aud L., Odd Brørs, Jannicke Dahlberg, Kirsten Grouff, P. Magnus, E. Røysamb, and Helge Waal. 2002. “A Placebo-Controlled Study of High Dose Buprenorphine in Opiate Dependents Waiting for Medication-Assisted Rehabilitation in Oslo, Norway.” Addiction 97:533–42.

Krook, A.L., O. Brørs, J. Dahlberg, K. Grouff, P. Magnus, E. Røysamb, and H. Waal. 2002. “A Placebo-Controlled Study of High Dose Buprenorphine in Opiate Dependents Waiting for Medication-Assisted Rehabilitation in Oslo, Norway.” Addiction 97(5):533–42.

Ling, W., C. Charuvastra, J.F. Collins, S. Batki, L.S. Brown Jr., P. Kintaudi … D. Segal. 1998. “Buprenorphine Maintenance Treatment of Opiate Dependence: A Multicenter, Randomised Clinical Trial.” Addiction 93(4):475–86.

Ling, W., P. Casadonte, G. Beglow, K.M. Kampman, A. Patkar, G.L. Bailey… K.L. Beebe. 2010. “Buprenorphine Implants for Treatment of Opioid Dependence: A Randomized Controlled Trial.” JAMA 304(14):1576–1583.

Lintzeris, Nicholas, Alison Ritter, Mary Panjari, Nicholas Clark, Jozica Kutin, and Gabriele Bammer. 2004. “Implementing Buprenorphine Treatment in Community Settings in Australia: Experiences from the Buprenorphine Implementation Trial.” The American Journal on Addictions 13:S29–S41.

(SAMHSA) Substance Abuse and Mental Health Services Administration. 2019. “Buprenorphine.” Rockville, Md.: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration.
https://www.samhsa.gov/medication-assisted-treatment/treatment/buprenorphine

Washington State Institute for Public Policy. 2018. Buprenorphine (or Buprenorphine/Naloxone) Maintenance Treatment for Opioid Use Disorder. Olympia, Wash.: Washington State Institute for Public Policy.
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Practice Snapshot

Age: 32 - 38

Gender: Both

Targeted Population: Alcohol and Other Drug (AOD) Offenders

Settings: Inpatient/Outpatient, Other Community Setting

Practice Type: Alcohol and Drug Therapy/Treatment, Residential Treatment Center

Unit of Analysis: Persons