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We demonstrated the recent clinical enthusiasm for buprenorphine in the UK (de Wet, Reed & Bearn 2005) and agree with Drs Alvarez and González-Saiz (2005), that, given its favourable clinical profile, this is to be expected. We do not intend to suppress this enthusiasm or deter the introduction of buprenorphine to countries where it is not yet generally available. Indeed, the increasingly widespread use of buprenorphine testifies to its value on the part of both patients and clinicians, but in the broader context of service provision, it is important that this does not race ahead of clear prescribing policies, underpinned by pharmocoeconomic considerations.

We agree with the respondents that since buprenorphine is more expensive than methadone, the pharmocoeconomic aspects of prescribing need rigorous investigation. Whilst the studies they cite provide preliminary evidence of equipoise between buprenorphine and methadone, as they point out, these do not adequately take into account the broader effects on quality of life and user satisfaction, as well as other important adverse effects such as overdose. Future pharmacoeconomic studies should also address clinical concerns that, in the context of limited budgets, clinicians are forced to walk a tightrope in balancing quality and quantity in terms of service provision. More expensive treatment runs the risk of reducing the number of individuals for whom treatment is available. We completely agree with the authors that these difficult decisions can only be made in the context of well-designed pharmacoeconomic studies which take multiple factors into account.

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