Buprenorphine for the management of opioid withdrawal

 

Abstract

Background

Managed withdrawal is a necessary step prior to drug-free treatment or as the end point of substitution treatment.

Objectives

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.

Search methods

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2008), MEDLINE (January 1966 to July 2008), EMBASE (January 1985 to 2008 Week 31), PsycINFO (1967 to 7 August 2008) and reference lists of articles.

Selection criteria

Randomised controlled trials of interventions involving 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.

Data collection and analysis

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

Main results

Twenty-two studies involving 1736 participants were included. The major comparisons were with methadone (5 studies) and clonidine or lofexidine (12 studies). Five studies compared different rates of buprenorphine dose reduction.

Severity of withdrawal is similar for withdrawal managed with buprenorphine and withdrawal managed with methadone, but withdrawal symptoms may resolve more quickly with buprenorphine. It appears that completion of withdrawal treatment may be more likely with buprenorphine relative to methadone (RR 1.18; 95% CI 0.93 to 1.49, P = 0.18) but more studies are required to confirm this.

Relative to clonidine or lofexidine, buprenorphine is more effective in ameliorating the symptoms of withdrawal, patients treated with buprenorphine stay in treatment for longer (SMD 0.92, 95% CI 0.57 to 1.27, P < 0.001), and are more likely to complete withdrawal treatment (RR 1.64; 95% CI 1.31 to 2.06, P < 0.001). 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.

Authors' conclusions

Buprenorphine is more effective than clonidine or lofexidine for the management of opioid withdrawal. Buprenorphine may offer some advantages over methadone, at least in inpatient settings, in terms of quicker resolution of withdrawal symptoms and possibly slightly higher rates of completion of withdrawal.

 

Plain language summary

Buprenorphine is more effective than clonidine or lofexidine, and may have advantages over methadone, for the management of opioid withdrawal.

Dependence on opioid drugs (heroin, methadone) is a major health and social issue in many societies. Managed withdrawal from opioid dependence is an essential first step for drug-free treatment. This review of trials found that the drug buprenorphine is more effective than clonidine or lofexidine in reducing the signs and symptoms of opioid withdrawal, retaining patients in withdrawal treatment, and supporting the completion of treatment. There is no significant difference in the incidence of adverse effects, but patients treated with buprenorphine may be less likely to drop-out due to adverse effects than is the case with clonidine or lofexidine. There is limited evidence comparing buprenorphine with methadone, but it appears that completion of withdrawal may be more likely with buprenorphine and withdrawal symptoms may resolve more quickly with buprenorphine.

 

摘要

背景

Buprenorphine對鴉片類戒斷的治療效果

處理戒斷對於病人免於藥物成癮是個必要步驟. 它也代表著病人藥物持續治療的最終成效

目標

評估使用 buprenorphine 對鴉片類戒斷的治療效果.例如戒斷的徵象或是症狀, 戒斷的完成或副作用

搜尋策略

我們搜尋了 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)以及各篇論文後的索引表列

選擇標準

臨床隨機試驗去尋找有鴉片依賴症的病人, 使用 buprenorphine 對戒斷症狀的影響. 其他比較的方式包括 methadone, alpha2 adrenergic agonist, 症狀治療藥物或安慰劑, 或使用不同劑量的 buprenophine 來評估

資料收集與分析

一位分析資料者來評估選進資料與方法學的品質, 與資料的擷取.決定選進這篇研究與整個步驟的所有過程則由負責分析資料者來討論與決定

主要結論

總共包括22篇研究,1736個受試者.5篇文獻比較 buprenorphine 跟methadone,12篇比較 buprenorphine 跟clonidine或lofexidine,5篇比較不同buprenorphine劑量減少的速度.戒斷症候群的嚴重性用 buprenorphine 與 methadone 相似,但減輕戒斷症狀buprenorphine作用會比較快,意味著buprenorphine 完成戒斷的可能性較 methadone 大(RR 1.18; 95% CI 0.93 to 1.49, P = 0.18),但須更多研究證實. 相較於clonidine或lofexidine, buprenorphine 對減輕戒斷的症狀更為有效. 用 buprenorphine 持續治療的病人維持較久(SMD 0.92, 95% CI 0.57 to 1.27, P < 0.001),因此更能完整的完成戒斷治療(RR 1.64; 95% CI 1.31 to 2.06, P < 0.001). 同時在副作用發生上沒有顯著的差異, 但因副作用而中斷治療,較可能是 clonidine 造成的.

作者結論

Buprenorphine對鴉片戒斷症候群治療的效果比Clonidine或lofexidine好.至少對於住院病患而言, Buprenorphine 與 Methadone 對治療戒斷來說,似乎沒有差異.但用Bupreorphine治療,戒斷症候群可能消失的比較快且完成戒斷的可能性較高

翻譯人

本摘要由高雄榮民總醫院葉宣德翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

嗎啡類藥物(海洛英, methadone)的依賴性,對很多社會來說,是很重要的健康與社會課題.治療戒斷症候群對嗎啡依賴的病人是很重要的第一步,這文章顯示Buprenorphine對鴉片戒斷症候群治療的效果比Clonidine或lofexidine好,尤其在減輕戒斷症狀的程度與治療持續性,同時在副作用發生上沒有顯著的差異, Buprenorphine 比 Clonidine 好, 與 methadone 相似.這文章顯示 Buprenorphine 對減輕嗎啡戒斷症狀與症候的程度,比 Clonidine 好. 能讓病人持續戒斷治療, 更能完成治療. 對於戒斷的副作用沒有顯著差別.但用Buprenorphine, 相對於Clonidine或lofexidine,病人較不會因副作用中途放棄治療.對於 Buprenorphine 與Methadone 的比較, 證據比較少, 但似乎Buprenorphine較能持續完成治療且戒斷症候群可能消失的比較快