Buprenorphine for the management of opioid withdrawal.
BACKGROUND
Managed withdrawal is a necessary step prior to drug-free treatment. It may also represent the end point of maintenance treatment.


OBJECTIVE
To assess the effectiveness of interventions involving the use of buprenorphine to manage opioid withdrawal, for withdrawal signs and symptoms, completion of withdrawal and adverse effects.


METHODS
We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, including the Cochrane Drugs and Alcohol Group trials register, Issue 3, 2005), MEDLINE (January 1966 to August 2005), EMBASE (January 1985 to August 2005), PsycINFO (1967 to August 2005), CINAHL(1982 to July 2005) and reference lists of articles.


METHODS
Experimental interventions involved the use of buprenorphine to modify the signs and symptoms of withdrawal in participants who were primarily opioid dependent. Comparison interventions involved reducing doses of methadone, alpha2 adrenergic agonists, symptomatic medications or placebo, or different buprenorphine-based regimes.


METHODS
One reviewer assessed studies for inclusion and methodological quality, and undertook data extraction. Inclusion decisions and the overall process was confirmed by consultation between all three reviewers.


RESULTS
Eighteen studies (14 randomised controlled trials), involving 1356 participants, were included. Ten studies compared buprenorphine with clonidine; four compared buprenorphine with methadone; one compared buprenorphine with oxazepam; three compared different rates of buprenorphine dose reduction; two compared different starting doses of buprenorphine. (Two studies included more than one comparison.)Relative to clonidine, buprenorphine is more effective in ameliorating the symptoms of withdrawal, patients treated with buprenorphine stay in treatment for longer, particularly in an outpatient setting (SMD 0.82, 95% CI 0.57 to 1.06, P < 0.001), and are more likely to complete withdrawal treatment (RR 1.73, 95% CI 1.21 to 2.47, P = 0.003). At the same time there is no significant difference in the incidence of adverse effects, but drop-out due to adverse effects may be more likely with clonidine. Severity of withdrawal is similar for withdrawal managed with buprenorphine and withdrawal managed with methadone, but withdrawal symptoms may resolve more quickly with buprenorphine. There is a trend towards completion of withdrawal treatment being more likely with buprenorphine relative to methadone (RR 1.30, 95% CI 0.97 to 1.73, P = 0.08).


CONCLUSIONS
Buprenorphine is more effective than clonidine for the management of opioid withdrawal. There appears to be no significant difference between buprenorphine and methadone in terms of completion of treatment, but withdrawal symptoms may resolve more quickly with buprenorphine.
Gowing
L
L
University of Adelaide, Department of Clinical and Experimental Pharmacology, DASC Evidence-Bsed Practice Unit, Adelaide, AUSTRALIA, 5005. linda.gowing@adelaide.edu.au
Ali
R
R
White
J
J
D000208:Acute Disease; D002047:Buprenorphine / Q000627:therapeutic use*; D003000:Clonidine / Q000627:therapeutic use; D006801:Humans; D009292:Narcotic Antagonists / Q000627:therapeutic use*; D009293:Opioid-Related Disorders / Q000150:complications / Q000188:drug therapy*; D016032:Randomized Controlled Trials as Topic; D013375:Substance Withdrawal Syndrome / Q000188:drug therapy*
D009292:Narcotic Antagonists; D002047:Buprenorphine; D003000:Clonidine