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Suboxone versus Methadone for the Treatment of Opioid Dependence: A Review of the Clinical and Cost-effectiveness

Rapid Response Report: Summary with Critical Appraisal

Addiction to opioids causes major medical, social, and economic problems to both the individual and society. Opioid dependence is defined as a strong desire to use the substance, difficulty in controlling its use, the presence of a physiological withdrawal state, tolerance of the use of the drug, neglect of alternative pleasures and interests and persistent use of the drug, despite harm to oneself and others. It is a complex disease involving physiological, psychological, genetic, behavioral and environmental factors. In Canada, it is estimated that there were more than 80,000 regular illegal opioid users in 2003. The number of illegal drug-related overdose deaths in Canada was 958 in 2002. Opioid dependence is related to the abuse of not only illegal opioid drugs (e.g. heroin), but also some of the most commonly prescription drugs, such as codeine-containing Tylenol, hydromorphone, oxycodone, morphine and others.

Treatment of opioid dependence includes three approaches: stabilization, detoxification and maintenance. Stabilization is usually achieved by opioid substitution treatments to ensure that the drug use becomes independent of mental state (such as craving and mood) and independent of circumstances (such as finance and physical location). The next stage is detoxification that is to withdraw from opioids. The final step is maintenance to prevent relapse. Detoxification refers to the process by which the effects of opioid drugs are eliminated in a safe and effective manner, such that withdrawal symptoms are minimized. Appropriate use of the detoxification agents plays a crucial role in increasing the successful detoxification rate, while minimizing the side effects and withdrawal symptoms. Methadone (μ-opioid receptor agonist) or buprenorphine (μ-opioid receptor agonist and κ-opioid receptor antagonist) are recommended first-line treatments in opioid detoxification. Naloxone is an opioid antagonist without agonist properties. In opioid-dependent patients, naloxone precipitates withdrawal.

Suboxone (buprenorphine/naloxone) was approved by Health Canada in 2007 for substitution treatment in opioid drug dependence in adults. It is a fixed combination of buprenorphine (a partial μ-opioid receptor agonist) with naloxone (an opioid antagonist) in a 4:1 ratio. The addition of naloxone to buprenorphine is expected to decrease the intravenous abuse of buprenorphine, because when taken sublingually, absorption of naloxone is minimal, however it can rapidly precipitate opioid withdrawal when injected. Suboxone is recommended for the treatment of opioid dependence for patients in whom methadone is contraindicated (such as patients at high risk of, or with QT prolongation, or hypersensitivity to methadone).

The purpose of this review is to provide evidence on the comparative clinical effectiveness and cost-effectiveness of use of Suboxone compared with methadone, for the treatment of patients with opioid dependence. Subgroups such as children and pregnant women may also have access to opioids thus, the clinical benefits and risks of Suboxone for these patients will be examined as well, when evidence is available.

Disclaimer: The Rapid Response Service is an information service for those involved in planning and providing health care in Canada. Rapid responses are based on a limited literature search and are not comprehensive, systematic reviews. The intent is to provide a list of sources of the best evidence on the topic that CADTH could identify using all reasonable efforts within the time allowed. Rapid responses should be considered along with other types of information and health care considerations. The information included in this response is not intended to replace professional medical advice, nor should it be construed as a recommendation for or against the use of a particular health technology. Readers are also cautioned that a lack of good quality evidence does not necessarily mean a lack of effectiveness particularly in the case of new and emerging health technologies, for which little information can be found, but which may in future prove to be effective. While CADTH has taken care in the preparation of the report to ensure that its contents are accurate, complete and up to date, CADTH does not make any guarantee to that effect. CADTH is not liable for any loss or damages resulting from use of the information in the report.

Links: This report may contain links to other information available on the websites of third parties on the Internet. CADTH does not have control over the content of such sites. Use of third party sites is governed by the owners’ own terms and conditions.

Copyright © 2013 Canadian Agency for Drugs and Technologies in Health.

Copyright: This report contains CADTH copyright material and may contain material in which a third party owns copyright. This report may be used for the purposes of research or private study only. It may not be copied, posted on a web site, redistributed by email or stored on an electronic system without the prior written permission of CADTH or applicable copyright owner.

Except where otherwise noted, this work is distributed under the terms of a Creative Commons Attribution-NonCommercial- NoDerivatives 4.0 International licence (CC BY-NC-ND), a copy of which is available at http://creativecommons.org/licenses/by-nc-nd/4.0/

Bookshelf ID: NBK195153PMID: 24716256

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