title: Primary care management of opioid use disorders: Abstinence, methadone, or buprenorphine-naloxone?
abstract: OBJECTIVE
  To advise physicians on which treatment options to recommend for specific patient populations: abstinence-based treatment, buprenorphine-naloxone maintenance, or methadone maintenance.
  
  
  METHODS
  PubMed was searched and literature was reviewed on the effectiveness, safety, and side effect profiles of abstinence-based treatment, buprenorphine-naloxone treatment, and methadone treatment. Both observational and interventional studies were included.
  
  
  RESULTS
  Both methadone and buprenorphine-naloxone are substantially more effective than abstinence-based treatment. Methadone has higher treatment retention rates than buprenorphine-naloxone does, while buprenorphine-naloxone has a lower risk of overdose. For all patient groups, physicians should recommend methadone or buprenorphine-naloxone treatment over abstinence-based treatment (level I evidence). Methadone is preferred over buprenorphine-naloxone for patients at higher risk of treatment dropout, such as injection opioid users (level I evidence). Youth and pregnant women who inject opioids should also receive methadone first (level III evidence). If buprenorphine-naloxone is prescribed first, the patient should be promptly switched to methadone if withdrawal symptoms, cravings, or opioid use persist despite an optimal buprenorphine-naloxone dose (level II evidence). Buprenorphine-naloxone is recommended for socially stable prescription oral opioid users, particularly if their work or family commitments make it difficult for them to attend the pharmacy daily, if they have a medical or psychiatric condition requiring regular primary care (level IV evidence), or if their jobs require higher levels of cognitive functioning or psychomotor performance (level III evidence). Buprenorphine-naloxone is also recommended for patients at high risk of methadone toxicity, such as the elderly, those taking high doses of benzodiazepines or other sedating drugs, heavy drinkers, those with a lower level of opioid tolerance, and those at high risk of prolonged QT interval (level III evidence).
  
  
  CONCLUSIONS
  Individual patient characteristics and preferences should be taken into consideration when choosing a first-line opioid agonist treatment. For patients at high risk of dropout (such as adolescents and socially unstable patients), treatment retention should take precedence over other clinical considerations. For patients with high risk of toxicity (such as patients with heavy alcohol or benzodiazepine use), safety would likely be the first consideration. However, the most important factor to consider is that opioid agonist treatment is far more effective than abstinence-based treatment.
authors.affiliation: Associate Professor in the Department of Family and Community Medicine at the University of Toronto in Ontario and a member of the St Joseph's Urban Family Health Team in Toronto. anita.srivastava@utoronto.ca.
authors.forename: Anita
authors.initials: A
authors.lastname: Srivastava
authors.affiliation: Associate Professor in the Department of Family and Community Medicine at the University of Toronto and Medical Director of the Substance Use Service at Women's College Hospital in Toronto.
authors.forename: Meldon
authors.initials: M
authors.lastname: Kahan
authors.affiliation: Staff physician in the Department of Family and Community Medicine at St Michael's Hospital in Toronto.
authors.forename: Maya
authors.initials: M
authors.lastname: Nader
mesh_terms: D000367:Age Factors; D000069479:Buprenorphine, Naloxone Drug Combination / Q000009:adverse effects / Q000627:therapeutic use*; D019317:Evidence-Based Medicine; D005260:Female; D006304:Health Status; D006801:Humans; D008691:Methadone / Q000009:adverse effects / Q000627:therapeutic use*; D009292:Narcotic Antagonists / Q000009:adverse effects / Q000627:therapeutic use*; D009293:Opioid-Related Disorders / Q000188:drug therapy* / Q000628:therapy; D057240:Patient Preference; D011320:Primary Health Care / Q000379:methods*; D012307:Risk Factors; D040242:Risk Reduction Behavior; D012931:Social Environment; D055815:Young Adult
chemical_list: D000069479:Buprenorphine, Naloxone Drug Combination; D009292:Narcotic Antagonists; D008691:Methadone