The study by Ling and colleagues (Ling et al. 2005), in this issue of Addiction, shows conclusively the value of buprenorphine as a detoxification agent in comparison to the non-opioid clonidine and that its superiority over clonidine remains despite the addition of naloxone to reduce abuse potential. There was no randomization between inpatient and outpatient treatment, but inpatient buprenorphine/naloxone (bup-nx) achieved more than twice the success rate of the outpatient bup-nx. It is interesting to note that outpatient retention was about the same as that for bup-nx inpatients. The study was stopped early by the Data and Safety Monitoring Board because the results were so clear that further randomization was not justified. No post detoxification follow up is reported so the reader does not know how many patients were transferred to a long-term relapse prevention treatment such as naltrexone or therapeutic community after the detoxification. One suspects that very few received any lasting benefit and this begs the question: why detoxify?

In the United States of America, it is politically correct to embrace the value of drug free treatment, but for opiates I am aware of no program that has reported results indicating that the drug free state endures for any significant length of time. One practical benefit is that with repeated evidence of relapse, the patient can more easily qualify for methadone maintenance. Of course, each relapse carries significant health risks including infection, injury and legal problems.

This study also demonstrates the effort that must be expended to achieve an opiate free state no matter how transient. The ‘treatment as usual’ method using outpatient clonidine resulted in a 95% failure to achieve the desired opiate-free urine. One wonders how any clinician could continue a treatment where almost all the patients fail. Clonidine is approved by the FDA for the treatment of hypertension, but it is widely used for opiate detoxification because it does reduce some of the signs of opiate withdrawal. It has limiting side-effects especially hypotension with fainting, but its great advantage is that it is a non-opiate thus freeing the community treatment program from the licensing and oversight required by the opiate class. While the legal impediments to buprenorphine prescription are different from those of methadone, they are still formidable in the US and it remains to be seen whether this useful treatment will be employed to the extent that it has been in other countries. Currently buprenorphine prescription requires special training and licensing. Also, each physician or group of physicians is limited to 30 patients on this medication.

A randomized trial should not have been necessary to alert clinicians to the fact that going directly to maintenance without the ritual of attempted clonidine detoxification makes more sense. Even if detoxification failure is a requirement for methadone maintenance, is it ethical to expose a patient to the risks of continuing heroin use when immediate methadone slots are available?

Of course, the real value of this multi-clinic trial is that it achieved the goal of providing experience with buprenorphine to clinicians in community treatment programs and it demonstrated that buprenorphine is clearly superior to clonidine for detoxification. One hopes that this experience will make them more inclined to use buprenorphine/naloxone as one option for the long-term maintenance of opiate addicted patients. As the authors indicate in their discussion, addiction is a chronic relapsing disorder and short-term treatment is not likely to have any lasting impact.


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  2. References
  • Ling, W., Amass, L., Shoptaw, S., Annon, J. J., Hillhouse, M., Babcock, D. et al.(2005) A multi-center randomized trial of buprenorphine-naloxone versus clonidine for opioid detoxification: findings from the National Institute on Drug Abuse Clinical Trails Network. Addiction, 100, 10901100.