Opioid Agonist for the Opioid-Dependent Person: Where's the Data?

Peter M. Yellowlees, MBBS, MD


July 29, 2016

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This is the Medscape Psychiatry Minute. I'm Dr Peter Yellowlees. There are increasing public concerns regarding pharmaceutical opioid overdose and dependence. People dependent on pharmaceutical opioids appear to differ in important ways from people who use heroin, yet most opioid agonist treatment research has been conducted in people who use heroin, and we don't have strong evidence describing the effects of maintenance agonist pharmacotherapy, typically methadone or buprenorphine, for the treatment of pharmaceutical opioid dependence. A team of investigators[1] from the University of New South Wales, Australia, has used standard Cochrane methodologic review procedures to help [better understand opioid agonist treatment]. They were able to identify only six randomized controlled trials of 607 participants that included comparisons of various combinations of full opiate agonist maintenance, placebo, detoxification only, or psychological treatment. The authors concluded that there was low to moderate quality evidence supporting the use of maintenance agonist pharmacotherapy for pharmaceutical opioid dependence, and that methadone and buprenorphine appeared equally effective, while maintenance treatment with buprenorphine appeared more effective than detoxification or psychological treatments.

So where does this leave us? First, as physicians, we need to recognize our own role as part of the cause of the increased number of prescribed opioid addicts who present to us. Second, we need to take a harm-minimization approach rather than insisting on complete sobriety, and that involves acknowledging that many of them will require maintenance agonist pharmacotherapy with methadone or buprenorphine along with appropriate psychological support and counseling. Thank you for listening to this Medscape Psychiatry Minute. Do enjoy your practice.


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