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A Systematic Review of the Effectiveness of Buprenorphine for Opioid
Use Disorder Compared to Other Treatments: Implications for Research
and Practice
Tara Mariolis1, Jordon Bosse2, Stephen Martin2,3, Amanda Wilson2 and Lisa Chiodo2,4
1 Department of Nursing, Fitchburg State University, 160 Pearl Street, Fitchburg, MA 01420, USA
2CleanSlate Centers Research and Education Foundation, Inc., 1 Roundhouse Plaza, Northampton, MA 01060, USA
3Department of Family Medicine and Community Health, University of Massachusetts Medical School, MA, USA
4University of Massachusetts Amherst, College of Nursing, 651 N Pleasant St, Amherst, MA 01003 USA
*Corresponding author: Tara Mariolis, Department of Nursing, Fitchburg State University, 361 Long Hill Road,160 Pearl Street, Fitchburg, MA 01420, USA, Tel:
+15087335134; E-mail: tmariolis@acad.umass.edu
Received date: January 21, 2019; Accepted date: March 22, 2019; Published date: April 08, 2019
Copyright: © 2019 Mariolis T, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution and reproduction in any medium, provided the original author and source are credited.
Abstract
Background: Prior systematic reviews have compared the relative effectiveness of buprenorphine (BUP),
methadone (MET) and other medications and treatments for opioid use disorder (OUD). The results suggest BUP is
highly effective for reducing illicit opioid use and retaining people in treatment. The current review extends these
prior reviews by synthesizing research, which compares BUP and buprenorphine and naloxone (BUP/NX) to several
treatments in addition to MET on several primary and secondary outcomes.
Method: Literature searches were conducted using nine databases. Articles were limited to quantitative reports of
studies conducted with adult human subjects in an outpatient, non-residential treatment settings in the United
States, in peer-reviewed journals between January 1, 2001 and May 31, 2017, and written in English. Search
strategies returned 1,981 articles, an additional eight articles were added through hand searching. Ninety-nine
articles met inclusion criteria. After reading abstracts, 48 articles were excluded from the review. After reading the
remaining 59 articles, another 36 were excluded. A total of 18 studies were included in the final analyses.
Results: MET was found to be superior to buprenorphine (BUP) in helping patients adhere to and remain in
treatment, while BUP was superior to MET for achieving abstinence from opioids. BUP was found to be superior to
behavioral treatment alone, extended release naltrexone (XR-NTX), an absence of any treatment, and placebo.
Given the range of study designs and quality, populations, and outcomes examined, a meta-analysis was not
feasible. The heterogeneity of included studies, however, permitted close examination of both the benefits and
barriers of medication treatment for OUD in a range of patient populations and clinical settings, as well as the
identification of gaps in both the research and treatment of OUD across a body of available literature.
Conclusion: Buprenorphine (BUP) is an effective treatment option for achieving abstinence from opioids, and
with emerging treatment guidelines, may be easier to access than other forms of treatment. The review underscores
much of the available research utilized protocols that are inconsistent with current clinical practice guidelines.
Further, flaws in research designs make it difficult for providers to determine the best medication treatment in order
to improve outcomes. Future research is necessary to determine the effectiveness of BUP when administered
according to the most current protocols.
Keywords: Systematic review; Buprenorphine; Methadone;
Treatment; Research; Practice
Introduction
Over ve million individuals in the United States (US) have opioid
use disorder (OUD), a chronic illness with devastating consequences
for individuals, their families, and society [1]. Of the 63,000 US drug
overdose deaths in 2016, 42,000 were attributable to opioids [2,3].
OUD has also escalated the spread of infectious diseases due to high-
risk behaviors such as sharing injection materials. For example,
hepatitis C increased from 2004 to 2014 (400% among 18-29 year-olds
and 325% among 30 to 39 year-olds) and hepatitis B also increased
(20,000 new cases in the US among persons who inject drugs) [4].
Additionally, the rates of HIV, endocarditis, and abscesses have also
increased among persons who inject drugs [5]. e economic burden
of prescription opioid abuse and fatal overdoses among Americans was
an estimated $78.5 billion in 2013; due primarily to healthcare
expenditures (38%), non-fatal and fatal lost productivity costs (53%),
criminal justice costs (10%) and substance treatment (4%) [6].
Treatment options for opioid use disorder (OUD) include
medications and psychologically based approaches, used either alone
or in combination with other strategies [7,8]. ree medications,
which have FDA approval, are used to treat OUD: buprenorphine
(BUP) alone and combined with naloxone (BUP/NX), methadone
(MET), and naltrexone (NTX) [8-14]. Many substance abuse treatment
providers recommend that psychologically based approaches such as
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ISSN: 2155-6105
Journal of Addiction Research &
Therapy Mariolis et al., J Addict Res Ther 2019, 10:2
DOI: 10.4172/2155-6105.1000379
Review Article Open Access
J Addict Res er, an open access journal
ISSN:2155-6105
Volume 10 • Issue 2 • 1000379
*
individual, group, and family counseling, self-support groups and
residential care be used in combination with medication for the
treatment of OUD [12-14]. Opioid antagonists such as NTX prevent
opioids from binding at the receptors, while opioid agonists (BUP and
MET) act on opioid receptors and have been deemed to be safer and to
reduce harmful behaviors associated with addiction when used as
prescribed [12,13]. Finally, research ndings suggest that all these
medications are eective for improving engagement and adherence to
treatment, reducing illicit drug use, improving brain function, and
overall health [14].
Prior systematic review has compared the relative eectiveness of
BUP compared to other medications and treatments for helping
patients abstain from opioids and remain in treatment. Ling et al. [15]
compared BUP versus counseling on abstinence from illicit opioids,
and Mattick et al. [16] compared the eectiveness of BUP versus MET
maintenance and placebo on treatment retention and illicit opioid use.
Similarly, Timko et al. [17] compared BUP versus MET, an absence of
medication treatment, counseling and placebo on retention in
treatment. All three reviews conrmed that BUP in high doses is
highly eective for OUD reducing illicit opioid use, and retaining
people in treatment.
e current review extends these prior reviews by synthesizing
research, which compares BUP and BUP/NX to several treatments in
addition to MET. ese include levo-alpha acetyl methadol (LAAM),
extended-release naltrexone (XR-NTX)}, behavioral approaches (BA),
placebo, BUP as a maintenance therapy versus detoxication, and an
absence of treatment. Additionally, a wide range of primary outcomes
(abstinence from illicit opioids and other substances, treatment
adherence, retention, and duration) and secondary outcomes
(withdrawal symptoms, treatment safety, high-risk sex and needle-
sharing practices, criminality, employment, treatment cost, and
utilization), are evaluated.
Given the range of study designs and quality, populations, and
outcomes included, a meta-analysis was not feasible. e heterogeneity
of included studies, and lack of emphasis on specic level of evidence,
permitted an examination of both the benets and barriers of MT in a
range of patient populations and clinical settings, as well as the
identication of gaps in present research on OUD across a body of
available literature.
Method
Literature search
Strategy: Literature searches were conducted using nine databases,
which included Cochrane Clinical Trials, Cumulative Index of Nursing
and Allied Health Literature (CINAHL) Complete, Ovid, ProQuest,
PsycArticles, Psych Info, PubMed, PubMed Central, and Web of
Science. Additional articles were identied from reference lists of
included studies.
A typical search string in each of the databases was:
((eect* OR ecac* OR treat* OR interven*) AND (opiate OR
opioid OR heroin) AND (depend* OR addict* OR abuse OR use
disorder) AND (buprenor* OR suboxone) NOT pregnan* NOT pain)
NOT cancer) NOT smok*) NOT (cocai* OR crack OR stimulant)).
Eligibility criteria: Articles were limited to quantitative reports of
research studies conducted with adult human subjects in an outpatient,
non-residential treatment setting in the United States, published in
peer-reviewed publications between January 1, 2001 and May 31, 2017,
and written in English. Given the aim of examining treatment rather
than tapering or “detox” with buprenorphine (BUP), only studies that
administered BUP for four weeks or longer were included. Studies
comparing short (detox) versus longer (maintenance) courses of BUP
were only included if there were long-term outcomes with which to
compare the eects of BUP versus another treatment.
Exclusion criteria: Articles were excluded if samples were comprised
primarily of minors, pregnant women, subjects who were incarcerated
or recently incarcerated, had severe co-occurring mental illness (e.g.,
schizophrenia), or who treated for a disorder other than opioid use
disorder (OUD) as the primary outcome of the study. Articles were
also excluded if the focus was on provider knowledge or attitudes
about medication assisted treatment (MAT) or patients with substance
use disorder (SUD) or on patient characteristics (e.g., gender) or
attitudes as the primary predictor of treatment success. Articles that
were editorial or commentary or focused on scale development,
medication pharmacokinetics, or educational interventions to improve
patient or provider knowledge or attitudes about MAT were also
excluded. e protocol was not formally registered. Study selection.
Two authors (TM and JB) conducted the literatures searches and
independently coded articles for inclusion or exclusion. A third author,
(LC) compared the codes for inclusion and exclusion and retained all
items that were agreed upon by the rst two authors. In the event of a
disagreement, the item was reviewed (LC) and a determination made
as to whether the item met inclusion criteria and decided whether it
met inclusion criteria. A fourth author (AW) resolved dierences as to
whether to exclude studies from the nal inclusion list. Once the initial
list was agreed upon and data extraction began, any decision about
whether a study should be excluded was determined by consensus.
Data collection: Two authors independently assessed the quality of
the studies (high, good, or poor/major aws) utilizing the Johns
Hopkins Nursing Evidence-Based Practice Rating Scale [18]. Another
individual (AC) compared the quality ratings, and discrepancies were
discussed until consensus was reached. Another author (AW) made
two nal determinations. Data on the population, methods, treatment
protocol, operationalization of concepts (e.g. treatment success), and
study results were extracted by three of the authors (TM, JB, AC).
Data extraction: Data were extracted from each of the included
studies based upon a priori criteria determined by four of the authors
(TM, JB, LC, and AW). Study authors were also contacted for
additional information or clarication.
Variables: Data items included funding source, study type and
duration, population, sample, methods, design, analysis, outcomes,
strengths, limitations, and risk of bias. Study type and duration
included: length of study, length of follow-up period, and years in
which the data were collected. Sample description data included
sample size, mean age, gender, race, and whether signicant
dierences exist between study groups on demographic information.
Study methods data extracted included recruitment, study settings,
measures and measure reliability, type of laboratory test used to detect
substances, whether urine samples were observed, and type of
buprenorphine (BUP) and comparison treatment. Study protocol
considerations included whether individual, group counseling, and 12-
Step program meetings were required; the use of adjunctive treatment
for breakthrough symptoms; individualization of treatment;
comparison treatments; and treatment medication information (mean
dose, frequency of administration, number of weeks received, taper
start, length, and taper duration).
Citation: Mariolis T, Bosse J, Martin S, Wilson A, Chiodo L (2019) A Systematic Review of the Effectiveness of Buprenorphine for Opioid Use
Disorder Compared to Other Treatments: Implications for Research and Practice. J Addict Res Ther 10: 379. doi:
10.4172/2155-6105.1000379
Page 2 of 14
J Addict Res er, an open access journal
ISSN:2155-6105
Volume 10 • Issue 2 • 1000379
Data were extracted on outcomes related to abstinence from opiates
and other substances, relapse with opiates and other substance;
treatment length; adherence; retention; Human Immunodeciency
Virus (HIV) and hepatitis C virus (HCV) risk behaviors; medication
safety and side eects; cravings for substances and symptom
management; use and cost of substance abuse treatment; use and cost
of other health services; physical and mental health; quality of life; and
functional outcomes such as employment and legal involvement. Study
analysis data included handling of missing lab samples and other data
and year of US dollar value utilized in reports, where applicable. When
specically noted by study authors, operationalization of variables such
as treatment compliance, treatment retention, and treatment success
were recorded, as was US dollar value of any nancial analyses.
Data analyses: Data were evaluated descriptively as not enough
studies comparing the same treatments and outcomes were identied
that would allow for a formal meta-analysis.
Results
Study selection
e search strategies returned 1,981 articles, and an additional eight
articles were added through hand searching of references. A total of 18
studies were included in the nal analyses. Inter-rater agreement on
whether studies met inclusion criteria was 92.4%. Figure 1 shows the
literature ow for the articles in this study.
Figure 1: Literature ow diagram.
As demonstrated in Figure 1, approximately 99% of the articles
identied in our searches were excluded. Nearly a quarter of the
studies that could have been included ultimately had to be excluded
because it was not possible to determine the eect of compared to
another treatment on the outcomes of interest. ese included: the
outcome of being in treatment considered being in any treatment
compared to no treatment at all [19-22]; the study compared
buprenorphine (BUP) to BUP plus other treatments, such as an
additional medication [23], or dierent types of counseling [15,24,25];
dierent lengths of BUP taper as the treatment groups [26-30]; and not
reporting BUP data [31,32]. A detailed list of all studies excluded is
provided in Table 1.
N%
Included 18 0.9
Not a research study (e.g., policy, educational) 291 14.6
Animal studies/studies not focused on OUD 30 1.5
Qualitative studies 44 2.2
No comparison to buprenorphine 384 19.3
Detox only 48 2.4
Predicting attitudes about addiction/MAT 45 2.3
Predicting patient/provider characteristics 144 7.2
Primary population comorbid major disorder 2 0.1
Primary population is incarcerated/recently released 53 2.7
Primary population is pregnant women 21 1.1
Primary population is youth 31 1.6
Focus is pharmacokinetics of medications 142 7.1
Scale/instrument development 9 0.5
Educational Interventions for providers 19 1.0
Duplicate study 189 9.5
Not conducted in US 519 26.0
Total 1989
Table 1: Description of excluded studies.
Study quality
e majority of the included studies were rated as having “good”
quality (n=12). One study was rated as high quality, and ve studies
were rated to be of poor quality or had major aws.
Study characteristics
Study sample sizes for experimental studies ranged from 152 to 287.
Samples from analyses of medical record data or insurance claims were
larger and ranged from 56 to 56,278 patients (Table 1 highlights study
characteristics). Samples included subjects that were predominantly
white, male, and in their mid-30 s. Figures 2-4 show the race, sex, and
mean age of each study group. Studies frequently (n=11) reported
signicant dierences between study groups on major characteristics
(race, ethnicity, insurance status, use history, etc.) [Table 2].
N%
Funding source
Government (e.g., NIH)a6 33.3
Multiple (including pharmaceutical) 4 22.3
Multiple (no pharmaceutical) 2 11.1
Pharmaceutical Industry 2 11.1
Private/Internal 2 11.1
Citation: Mariolis T, Bosse J, Martin S, Wilson A, Chiodo L (2019) A Systematic Review of the Effectiveness of Buprenorphine for Opioid Use
Disorder Compared to Other Treatments: Implications for Research and Practice. J Addict Res Ther 10: 379. doi:
10.4172/2155-6105.1000379
Page 3 of 14
J Addict Res er, an open access journal
ISSN:2155-6105
Volume 10 • Issue 2 • 1000379
None 2 11.1
Study type
Effectiveness 8 44.4
Efficacy 5 27.8
Cost Effectiveness 3 16.7
Safety 2 11.1
Data source
Randomized Controlled Trial 6 33.3
Medical Record/Charts 6 33.3
Secondary Analysis 6 33.3
Number of comparison treatments
Compared to 1 med/treatment 8 44.4
Compared to 2 meds/treatments 6 33.3
Compared to 3 meds/treatments 4 22.3
Comparison treatments/groupsb
Methadone (any) 9 50.0
Location (office/clinic) 1 11.1
Specific doses 3 16.6
Naltrexone (incl. XR-NTX) 1 11.1
LAAM 2 22.3
Placebo 2 22.3
BUP detox 2 22.3
BUP/NX (sublingual) 2 22.3
Naltrexone (XR-NTX) 1 11.1
No treatment 1 11.1
Behavioral only treatment 1 11.1
Patients without OUD 1 11.1
Study protocols
Included urine drug screen (UDS) 11 61.1
Required counseling (any) 61.1
Reduced frequency visits over time 11 16.7
Different treatment protocols between groups 27.8
Handling of missing UDS data
Treated as positive 5 27.8
Not reported 6 33.3
Table 2: Study characteristics.
Figure 2: Reported race of study group participants.
Figure 3: Reported sex of study groups.
Figure 4: Reported age of study group participants.
Data sources and study locations
Six studies used retrospective chart review of data from primary or
secondary sources, and six studies conducted secondary analyses from
insurance, episode treatment, WHO and FDA data. Six additional
studies presented primary or secondary data from experimental
designs, most of which were from randomized controlled trials
([RCTs] n=6). Two of the included studies [33,34], evaluated dierent
Citation: Mariolis T, Bosse J, Martin S, Wilson A, Chiodo L (2019) A Systematic Review of the Effectiveness of Buprenorphine for Opioid Use
Disorder Compared to Other Treatments: Implications for Research and Practice. J Addict Res Ther 10: 379. doi:
10.4172/2155-6105.1000379
Page 4 of 14
J Addict Res er, an open access journal
ISSN:2155-6105
Volume 10 • Issue 2 • 1000379
outcomes on the same sample. Lott et al. [35] conducted a secondary
analysis of a study by Johnson et al. [36] which did not include patients
who were on low-dose methadone and then ‘rescued’ with higher
doses in their analyses.
Data were primarily from one or more outpatient addiction
treatment settings including methadone clinics (n=6) or oce-based
methadone programs (n=1), youth specic treatment programs (n=2),
or intensive outpatient program ([IOP] n=1). Data were also collected
from primary care (n=3), federally licensed opioid treatment programs
(n=1), state-subsidized treatment programs (n=1), FDA reports (n=1),
and the Veteran’s Health Administration ([VHA] n=1).
Study protocols
More than half of the studies (n=11) include urine drug screen
(UDS) results as at least one of their measures (Table 3). Some reported
using random drug screens (n=6) and some used observed urine drug
screens (n=6). Five studies reported temperature of urine when
subjects were not observed providing samples.
Differences in treatment protocols
Random drug screens used 6
Both/all groups 4
Comparison group Only 2
Observed drug screens used 6
Both/All groups 3
Comparison group Only 3
Required group counseling 5
Both/All groups 3
Comparison group only 2
Required individual counseling 9
Both/All groups 7
Comparison group only 2
Required 12-step attendance 1
Comparison group only 1
Reasons for study withdrawal
Missing counseling 3
Missing meds/appts 2
Missing UDS 2
Provider discretion 1
Table 3: Dierences in treatment protocols.
Counseling
Half of the studies (n=9) required individual counseling of at least
some study participants, fewer (n=5) required group counseling for at
least some study participants. In one study, participants’ medication
was withheld until participants attended counseling [37]. In three
studies, participants who struggled with continued opioid use received
additional counseling [33,34,38]. One study required subjects who
received MET to attend a 12-Step program as part of the treatment
protocol [34]. Participants in one study that received medication also
received psychosocial treatment; it is unclear if the psychosocial
treatment was required [39].
Medication dosing
e majority of the studies required frequent visits to the study site
to obtain treatment. Kamien et al. [37] required all participants to
attend seven days a week. Two studies required daily attendance except
for Sundays and holidays [40,41], and another required attendance ve
to seven days a week [38]. Participants in an adult intensive outpatient
program (IOP) attended sessions for three hours a day, four days a
week [42]. In another study following daily visits for medication
induction, participants had to come to the site Monday, Wednesday,
and Friday [35,36]. Adolescent IOP patients could earn up to one
week’s supply of medication as they progressed in treatment [43].
ree of the retrospective chart reviews reported patients who received
BUP were seen weekly and MET patients were seen daily or near daily
[33,44,45]. Five studies reported dierent protocols for dierent study
groups, generally with less strict requirements, (e.g., no counseling, less
frequent visits to receive medication, fewer urine drug screens) for
subjects receiving buprenorphine.
Study outcomes
Study outcomes were grouped into primary and secondary
outcomes. Treatment adherence, retention, abstinence from
substances, and medication safety were considered primary outcomes.
e most common study outcome was relapse with opiates (n=12) or
other substances (n=9). Studies also evaluated length of time in
treatment (n=7), treatment adherence (n=6) continuing treatment
aer the study ended (n=3), and medication safety (n=2). Secondary
outcomes considered included: cost of substance abuse treatment
(n=3), all medical treatment (n=3), crime and arrests (n=3), HIV and
Hepatitis C risk reduction (n=2), symptom management (n=2),
employment (n=1), cost of mental health treatment (n=1) and
treatment utilization (n=1).
Risk of bias with within studies: Six of the studies received some or
all of their funding from the pharmaceutical industry [38-40,46-48];
and another study that did not receive pharmaceutical funding
included authors who were aliated with a pharmaceutical company
[37]. Response bias is present in two studies [38,41], which relied only
on self-reported data for some or all of the outcomes (including recent
use of substances, criminality, etc.). Self-selection bias is present in
three studies [33,43,49], as they allowed clients to choose their own
treatment.
In the sections that follows, the results are presented based on the
treatment that buprenorphine is being compared to: MET, levo-alpha
acetyl methadol (LAAM), naltrexone (NTX), and other treatments
(e.g., counseling only, placebo). A summary of these ndings is
presented in Table 4.
Citation: Mariolis T, Bosse J, Martin S, Wilson A, Chiodo L (2019) A Systematic Review of the Effectiveness of Buprenorphine for Opioid Use
Disorder Compared to Other Treatments: Implications for Research and Practice. J Addict Res Ther 10: 379. doi:
10.4172/2155-6105.1000379
Page 5 of 14
J Addict Res er, an open access journal
ISSN:2155-6105
Volume 10 • Issue 2 • 1000379
First
author
(year)
Study design Primary outcome Secondary outcomes Protocol
Problems/
Bias
Overall
finding
Sample Setting Req Fund TX
Adh
ere
TX
Retent
TX
Length
Abstain
from
Opiates
Abstain
from other
Safety HIV/HC
V risk
TX
Cost/
Util
N Treatment
groups
Buprenorphinea vs. Other treatments
BUP/NX vs. MET
Johnson
(2000)
S
220 BUP (55) Outpatien
t TX
Y G NS NS BOTH BOTH - NS - - Small/
unmatched
samples;
generalizabi
lity
Both
MET
dose (55)
MET
¯dose
(55)
Lott (2006) 137 BUP (47) Secondar
y analysis
- - - NS NS - NS - Small
samples;
generalizabi
lity
NS
MET (51)
Kamien
(2008)
268 BUP
(140)
Outpatien
t TX
Y G NS NS NS BUP NS - - - Potential
conflict of
interest
bias;
unequal
sample
sizes;
generalizabi
lity
BUP
MET
(128)
Barnett
(2009)
8,
673
Only
BUP
(482)
Secondar
y analysis
of VA
EMR
G - - BUP - - BUP - BUP Generalizab
ility
BUP
Only
MET
(8191)
Jones
(2009)
78 BUP
OBT (34)
Office &
Clinic
Y - NS - - NS - - MET Small and
unmatched
samples;
generalizabi
lity
NS
Primary
MET
OBT (21)
MET
clinic
(23)
MET
Secondar
y
Fingerhoo
d (2014) 504 BUP
OBT
(252)
Office &
Clinic
Y MET MET MET MET - - - - Unmatched
samples;
generalizabi
lity
MET
MET
clinic
(252)
(MET)
Hser
(2014)
1267 BUP
(738)
Secondar
y analysis
N MET MET MET BUP - - - - Generalizab
ility;
inadequate
treatment
protocol info
Both
MET
(529)
Proctor
(2014)
BUP
(102)
Retrospec
tive
review;
NR I - MET MET NS NS - - - Inadequate
treatment
protocol info
MET
Citation: Mariolis T, Bosse J, Martin S, Wilson A, Chiodo L (2019) A Systematic Review of the Effectiveness of Buprenorphine for Opioid Use
Disorder Compared to Other Treatments: Implications for Research and Practice. J Addict Res Ther 10: 379. doi:
10.4172/2155-6105.1000379
Page 6 of 14
J Addict Res er, an open access journal
ISSN:2155-6105
Volume 10 • Issue 2 • 1000379
b
Couns.
MET
(2,738)
Outpatient
TX
Woody
(2014) 731 BUP
(340)
Secondary
analysis
NR G - MET - BOTH MET - BOTH - Generalizab
ility;
inadequate
treatment
protocol info
Both
MET
(391)
Methadone
clinic
Clark
(2015)
43,
175
BUP
(18,866)
Secondary
analysis
NA I - - BOTH - - - - BOTH Generalizab
ility
Both
MET
(24,309)
Medicaid
claims
Rastegar
(2016)
504 BUP
(252)
Retrospec
tive chart
Review
Y
(MET)
N - NS - - - - - - Generalizab
ility
NS
MET
(252)
Office &
clinic
Sessler
(2017)
60,
179
BUP
trans
(22,454)
Secondary
analysis
FDA
database
NA I - - - - - BUP - - Generalizab
ility
BUP
BUP/NX
(11,206)
MET
(26,519)
Johnson
(2000)
220 BUP (55) Outpatient
TX
Y G - NS NS BOTH BOTH NS - - Small/
unmatched
samples;
generalizabi
lity
Both
LAAM
(55)
Lott (2006) 86 BUP (47) Secondary
analysis
Y G - - - NS NS NS Small
samples;
generalizabi
lity
NS
LAAM
(39)
BUP/NX vs. XR-NTX
Crits-
Christoph
(2016)
548 BUP
(394)
Outpatien
t TX
N MI BUP BUP - - - - - - Potential
COI bias;
unequal
sample
sizes
BUP
XR-NTX
(154)
Vo (2016) 56 BUP (43) Communit
y-based
IOP
Y S NS NS - NS NS - - - Small/
unequal
sample
sizes;
generalizabi
lity
NS
XR-NTX
(13)
BUP/NX vs. BA treatment only
Clark
(2015)
50,
086
BUP
(18,866)
Secondar
y analysis
of
medicaid
claims
NA I - - - BUP - - - BUP Generalizab
ility
BUP
BA Only
(31,220)
Buprenorphine vs. No buprenorphine
BUP/NX implant vs Placebo
Ling
(2010)
163 Implant
(108)
Multiple
outpatient
Y I BUP BUP - BUP BUP - - - Unequal
sample
sizes;
BUP
Citation: Mariolis T, Bosse J, Martin S, Wilson A, Chiodo L (2019) A Systematic Review of the Effectiveness of Buprenorphine for Opioid Use
Disorder Compared to Other Treatments: Implications for Research and Practice. J Addict Res Ther 10: 379. doi:
10.4172/2155-6105.1000379
Page 7 of 14
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Volume 10 • Issue 2 • 1000379
Placebo
(55)
generalizabi
lity
Rosenthal
(2013)
168 Implant
(114)
Outpatient
TX
Y M
O*
- BUP - BUP - - - - Unequal
sample
sizes;
generalizabi
lity
BUP
Placebo
(54)
BUP/NX maintenance vs. BUP/NX detox
Caldiero
(2006)
60 Maint
(30)
Retrospec
tive chart
review;
Hospital-
based
IOP
Y M
O
Main
t
Maint Maint NS NS - - - Small
sample;
generalizabi
lity; potential
bias
Maint
Detox
(30)
Woody
(2008)
152 Maint
(74)
Outpatient
TX
(adol)
Y MI Main
t
Maint - Maint NS - - - Generalizab
ility
Maint
Detox
(78)
BUP/NX vs. no treatment
Barnett
(2009)
19,
642
Only
BUP
(482)
Secondary
analysis
of VA
EMR
NA G - - BUP - - BUP - BUP Generalizab
ility
BUP
No TX
(19,160)
Buprenorphine forms & doses compared
BUP/NX vs. BUP
Proctor
(2014)
495 BUP
(393)
BUP/NX
(102)
Retrospec
tive chart
review;
Outpatient
TX
NR I - BUP BUP NS NS - - - Inadequate
treatment
protocol info
BUP
BUP/NX 16 mg/day vs. BUP/NX 8 mg/day
Kamien
(2008)
140 BUP 8/2
(82)
Outpatient
TX
Y G* - - - 16 mg - - - - Potential
conflict of
interest
bias;
unequal
sample
sizes;
generalizabi
lity
16 mg
BUP
16/4 (58)
aExcept where noted, BUP and BUP/NX refer to sublingual forms
bFunding: F: Foundation; G: Government, I: Industry, MI: Multiple, incl. industry, MO: Multiple, No industry, N: None, NR: Not Reported, S: Internal
*Not funded by pharmaceutical industry, but PI or author is affiliated with pharmaceutical industry
Abbreviations: Adhere: Adherence; BUP: Buprenorphine; BUP/NX: Buprenorphine/Naloxone; detox: Short:term treatment with buprenorphine; HCV: Hepatitis C
Virus; HIV: Human Immunodeficiency Virus; I: Implant; IOP: Intensive Outpatient Program, LAAM: Levo Alpha Acetyl Methadol; Maint: Buprenorphine maintenance
treatment; MET: Methadone; NA: Not Applicable; NTX: Naltrexone; NR: Not Reported; NS: Non Significant findings; Retent: Retention; Subs: Substances; Sx:
Symptoms; TX: Treatment; Util: Utilization; XR-NTX: Extended release naltrexone; BOTH-BUP and Comparison treatment
Table 4: Primary and secondary outcomes and favored treatment by comparison treatment.
Methadone
Twelve studies compared the relative eectiveness of buprenorphine
(BUP) versus MET and mainly examined primary outcomes. Of these,
ten studies examined their relative eectiveness on treatment
adherence and retention; seven of the twelve examined their
eectiveness in helping subjects remain abstinent from opioids. Several
studies examined secondary outcomes such as medication safety and
treatment costs. Overall, MET performed better than BUP on both
Citation: Mariolis T, Bosse J, Martin S, Wilson A, Chiodo L (2019) A Systematic Review of the Effectiveness of Buprenorphine for Opioid Use
Disorder Compared to Other Treatments: Implications for Research and Practice. J Addict Res Ther 10: 379. doi:
10.4172/2155-6105.1000379
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J Addict Res er, an open access journal
ISSN:2155-6105
Volume 10 • Issue 2 • 1000379
treatment adherence and retention, while BUP was superior than MET
in assisting subjects to abstain from opioids.
Two studies reported MET outperformed BUP in helping subjects
adhere to treatment [33,40] and four studies that compared treatment
retention also found MET was superior [33,40,41,49]. On the outcome
of treatment length, one study found BUP to perform better [50], while
two studies found the medications comparably eective [36,41], and
three others found that MET outperformed BUP [33,40,49].
One study found MET to be better in preventing subsequent opioid
use [33], two studies reported that BUP was superior to MET [37,40],
and two others found BUP and MET to be comparable [36,41]. BUP
was also found to be superior to MET on the outcome of medication
safety in two studies [48,50], while no studies reported MET to be safer
than BUP. Several studies reported no signicant dierences between
MET and BUP on treatment adherence [36,37], treatment retention
[34,36,37,45], abstinence from opioids [35,49], and abstinence from
other drugs [35,37,45,49].
Medication safety and symptom management: Among patients with
opioid use disorder (OUD) who were treated at the Veterans Health
Administration (VHA) over the course of one year, signicantly fewer
patients on buprenorphine (BUP) died in the study period compared
to patients receiving methadone (MET) or no treatment at all [50].
Another study compared adverse events for BUP and MET reported in
the Food and Drug Administration Database and identied
disproportionately higher rates of broad and narrow cardiac
arrhythmia among patients on MET compared to all forms of BUP
[48]. Johnson et al. [36] compared low- dose BUP (20 mg) and a
variable higher dose (60 mg-100 mg) MET and found subjects who
received either BUP or variable higher dose MET rated the severity of
their symptoms signicantly lower than patients who received low-
dose MET. ey found no signicant dierences in symptom severity
between BUP and high dose MET treatment groups.
Secondary outcomes: In a retrospective chart review comparing
patients enrolled in methadone (MET) maintenance compared to
buprenorphine (BUP), only MET patients reported a signicant
decline in number of criminal cases, including drug charges, at 12 and
24 months of treatment, both treatment groups, however, had
signicantly reduced odds of criminal charges at 12 months [51].
HIV and hepatitis C risk behaviors: Two studies evaluated whether
BUP or MET reduced high-risk behaviors associated with HIV and
Hepatitis C infection. Woody et al. [41] found injection risk behaviors
were signicantly reduced among females in both treatment groups;
however, there was no signicant dierences between groups. Sexual
risk behaviors were comparable and were signicantly reduced among
females in both treatment groups, and for males who received MET.
Such behaviors were increased for males on BUP and reduced in males
on MET [41]. In another study, patients receiving BUP and MET
demonstrated a signicant reduction in injection-related risks over
time compared to baseline (time eect), but there was no signicant
dierence between groups [35].
Treatment Cost and Utilization: Patients in the VHA system with
opioid use disorder (OUD) who were prescribed buprenorphine (BUP)
had signicantly fewer ambulatory care visits aer MAT initiation
compared to patients who received methadone (MET) [50]. e cost of
ambulatory care treatment was signicantly reduced for patients on
either BUP (18%) or MET (11.8%) [50]. Further, making BUP available
through providers in the VHA system did not result in a signicant
increase in visits in the system overall [50]. A study of Medicaid claims
also found that treatment with BUP costs signicantly less than MET
[44]. Additionally, the researchers found that providing either BUP or
MET costs signicantly less than behavioral-only (e.g. counseling)
treatment [44]. In a comparison of the cost of MAT that considered
both medication and location in which it was administered, MET
administered in a clinic was least expensive and BUP was the most
expensive for both providers and patients [45].
Levomethadyl acetate
Of the two studies which compared buprenorphine (BUP) to levo-
alpha acetyl methadol (LAAM), Johnson et al. [36] reported both
medications were comparably eective for sustaining abstinence from
opioids and other drugs, however, they found no signicant dierences
in length of time in treatment, treatment retention and medication
safety [36]. Lott et al. [35] reported no signicant dierences between
the two medications in maintaining abstinence from opioids and other
drugs, and for HIV/HCVI risk behaviors.
Naltrexone
In the two studies that compared buprenorphine (BUP) and
extended release naltrexone (XR-NTX), Crits-Christoph et al. [39]
reported BUP was more eective for treatment adherence and
retention [39], however, Vo et al. [43] reported no signicant
dierences between the two medications for treatment adherence,
treatment retention, and remaining abstinent from opioids and other
drugs. Subjects in the study by Crits-Christoph et al. [39], who received
XR-NTX showed a signicant increase in employment from baseline
compared to BUP patients. Conversely, BUP patients had a signicant
decrease in employment at the end of the study compared to baseline
[39]. Neither group reported signicant changes in arrests or self-help
group attendance over time [39].
Other treatments
Clark et al. [44], found buprenorphine (BUP) superior to counseling
alone in maintaining abstinence from opioids, and for treatment cost
and utilization. In studies that compared BUP and placebo, BUP was
found more eective for maintaining treatment adherence and
treatment retention [46,47], abstinence from opioids [46,47] and
abstinence from other drugs [46]. Barnett [50] found that BUP was
superior to an absence of any treatment for lengthening time in
treatment, medication safety, and treatment cost and utilization. In a
study that compared BUP alone versus BUP combined with naloxone,
the results suggest BUP was more eective for improving treatment
retention and lengthening time in treatment [49], however, no
signicant dierences were found for remaining abstinent from
opioids and other drugs [49].
In two studies, the ndings suggest BUP administered as a
maintenance medication was more eective than detoxication on
several outcomes including treatment adherence [38,42], treatment
retention [38,42], abstinence from opioids [42], and abstinence from
other drugs [38]. In at least one study, no signicant dierences were
noted in abstinence from opioids [42], and both studies found no
signicant dierence between the two methods of delivery for
sustaining abstinence from other drugs [38,42]. In a study that
compared high dosages (16 mg or greater) versus low dosages (8 mg)
of BUP, high dosages was found more eective for maintaining
abstinence from opioids than low dosages [37].
Citation: Mariolis T, Bosse J, Martin S, Wilson A, Chiodo L (2019) A Systematic Review of the Effectiveness of Buprenorphine for Opioid Use
Disorder Compared to Other Treatments: Implications for Research and Practice. J Addict Res Ther 10: 379. doi:
10.4172/2155-6105.1000379
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ISSN:2155-6105
Volume 10 • Issue 2 • 1000379
Predictors of relapse
An analysis of six years of Medicaid claims for patients with opioid
use disorder (OUD) demonstrated that the risk of relapse increased by
4.32 if patients had a co-occurring addiction to alcohol and 2.33 if
patients were addicted to other substances [44]. Rastegar et al. [34]
identied that being in any treatment at six months predicted being in
MAT at twelve months. Longer periods of treatment with MAT (either
MET or BUP) signicantly reduced the risk of relapse [44].
Strengths of reviewed studies
Six of the included studies were RCTs, which in some instances used
blind treatments [35-38,46,47], and six studies were secondary
analyses of data collected in other studies, RCTs or databases
[40,41,44,45,48,50]. Two studies focused on opioid use disorder
(OUD) treatment among young adults [38,43], an age group that is
disproportionately impacted by opioids, particularly prescription drug
misuse [52], and is also underrepresented in research studies. Six
additional studies were retrospective chart reviews of patients in
treatment for opioid use disorder [33,34,39,42,43,49], and improved
the quality of data by conducting rigorous analyses such as using only
cases that had complete demographic information available [49];
matching patients for comparison on age and gender [42]; and
including the rst episode of treatment in their analyses [39]. Among
other studies, additional strategies included triangulating data with
other sources (e.g. billing claims) [44], including patients with OUD
receiving no MAT when evaluating primary outcomes [39], and
including patients without OUD in cost and utilization studies [50].
One design that included searching databases for reports of adverse
events utilized standardized terminology in the queries [48].
Limitations of reviewed studies
Many of the studies had strict exclusion criteria, which limits the
generalizability of the ndings. For example, two studies did not
include subjects with another substance disorder, including nicotine
[38,46]. Ling et al. [46] also excluded participants who had moderate-
severe withdrawal symptoms, which could overestimate the
eectiveness of medications on symptom management. Another
analysis used secondary data from a study that required participants to
be stable on medication for 12 months prior to entering the study [45],
in contrast to most other studies. Rastegar et al. [34] compared
outcomes for patients who received treatment at two dierent
programs. Two other samples that might limit generalizability of the
ndings based on the population studied are a sample in which
25-30% of each group had a history of anti-social personality disorder
[35], and Medicaid patients receiving treatment in Massachusetts [44].
Some studies had small sample sizes and may have lacked statistical
power to identify small eects [37,39,42,43,45]. One study using
medical record data reported a great deal of missing or incomplete
data, making it dicult to interpret results [39]. e measurement of
outcomes was poorly done in some studies. For example, Woody et al.
[38] relied on self-report only at 6, 9, and 12-month follow up from
their study; response bias could be part of the reason they did not nd
signicant dierences between groups. In a few studies, treatment
groups were not mutually exclusive, so patients may have received
more than one type of MAT or other treatment in the time period
being evaluated [44,50]. Key variables were not clearly identied in
some studies such as duration of treatment with medication and
frequency and duration of counseling [39]. Finally, many of the studies
used protocols in which the delivery and requirements of care do not
emulate current best practice models, such as requiring daily or near-
daily dosing of medication with buprenorphine (BUP) [35,40,43].
Others mandated counseling [36-38,42,45,46], and some went so far as
to withhold treatment for missed counseling [37], or withdraw clients
from the study for missing counseling [38,46].
Discussion
e purpose of this review was to determine the eectiveness of
buprenorphine (BUP) compared to other treatments on several
primary and secondary outcomes for treatment of opioid use disorder
(OUD). Overall, methadone (MET) performed better than BUP in
helping subjects adhere to and remain in treatment, while BUP was
found to be superior to MET in helping patients abstain from opioids.
BUP was found to be superior to behavioral treatment alone, extended
release naltrexone (XR-NTX), an absence of any treatment, and
placebo. Given the range of study designs and quality, populations, and
outcomes examined, a meta-analysis was not feasible. e
heterogeneity of included studies, however, permitted close
examination of both the benets and barriers of MT for OUD in a
range of patient populations and clinical settings, as well as the
identication of gaps in both the research and treatment of OUD
across a body of available literature. Following is a discussion of the
results of this analysis.
Treatment cost and service utilization
Jones et al. [45] reported buprenorphine (BUP) and BUP/naloxone
(NX) cost more than other medications, accounting for 77% of the cost
associated with providing medication treatment. Cost of medications,
especially BUP and BUP/NX, to providers and patients may be
overestimated in the included studies as they were conducted before
generic forms of BUP and BUP/NX were available. In addition, other
studies highlighted that even when BUP cost more than the
comparison treatment, the overall cost of providing healthcare to
patients on BUP was signicantly lowered as it reduces the number of
ambulatory care and other visits required [44,50].
Criminal behavior
ough we excluded studies whose primary population was
incarcerated or recently incarcerated individuals, Rastegar et al. [34]
examined the association between treatment and criminal behavior
and identied that methadone (MET) is better at reducing drug-
related arrests [34, 53]. One possible reason for this nding is that
there were signicantly more men than women in the buprenorphine
(BUP) group, and men are more likely to have criminal issues and legal
involvement related to OUD opioid use disorder (OUD) than women
[26,53]. Arrest and formal charges may also be inuenced by other
factors (e.g., racism), and race of participants is not reported. Limited
evidence with populations a history of criminal justice involvement
suggests an increased willingness to use BUP over MET [54] and
reduced rates of recidivism [55].
Unclear study outcomes and methodological challenges
For some of the outcomes of interest (e.g., relapse) results are less
clear. Among the 12 studies that included relapse with opiates as an
outcome, three favored buprenorphine (BUP), two favored the
comparison treatment, four found no dierence between groups, and
three reported signicant reduction in relapse for both BUP and at
least one other comparison treatment. One possible explanation is that
Citation: Mariolis T, Bosse J, Martin S, Wilson A, Chiodo L (2019) A Systematic Review of the Effectiveness of Buprenorphine for Opioid Use
Disorder Compared to Other Treatments: Implications for Research and Practice. J Addict Res Ther 10: 379. doi:
10.4172/2155-6105.1000379
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J Addict Res er, an open access journal
ISSN:2155-6105
Volume 10 • Issue 2 • 1000379
patient characteristics (e.g., use history, insurance status) varied widely
within and between studies, as did study protocols. Similarly, strict
denitions of relapse (e.g., seeking care in ER) [44] and permissive
denitions of who is receiving medication (e.g. a single prescription for
BUP) [33,34] could also inuence results.
Both included and excluded studies had methodological challenges
that make it dicult to answer our initial research question. For
example, some studies excluded participants with co-occurring mental
disorders, but evidence suggests that a high proportion of patients with
OUD also have co-morbid conditions such as depression or are
addicted to multiple substances [52]. It is widely known that co-
occurring substance abuse disorder and other mental illnesses are
known to increase risk of relapse and cost for treatment [44]. Many
studies used protocols that are not consistent with current practice
such as requiring daily or near-daily dosing of medications [40,41],
administering dierent doses on dierent days [35,36], and higher
than usual doses of methadone (MET) [35-37], which could lead to an
overestimate of the eectiveness of comparison treatments (usually
MET). Patients in standard outpatient BUP treatment are generally not
be expected to have observed daily dosing of medication. As such, it
would be understandable that a subject participating in a study
examining treatment with BUP, may elect to seek treatment elsewhere
if they are required to come to a clinic on a daily basis. A deviation
from practice such as this, may explain a high attrition rate in subjects
in receiving BUP, and therefore makes it dicult to assess which of the
two medications would have improved retention rates.
Barriers to treatment
In our practice experience, many patients never return to oce –
based treatment aer being prescribed buprenorphine (BUP). is
may be due in part to requirements for frequent oce visits or random
drug screening which present a signicant burden on patients in early
recovery, making continued drug use easier than participation in care.
Practice models that present signicant barriers to treatment for many
patients were frequently used in the included studies and may have
inuenced the outcomes as well.
Required counseling: In some of the studies that required
counseling, missing counseling was the most common reason for
people being withdrawn from the study [38]. ough counseling is a
common addition to treatment programs, there are few if any studies
to date that demonstrate that counseling is an essential component of
outpatient opioid use disorder (OUD) treatment for all patients. In
fact, the few studies that have examined the eects of types of
counseling combined with BUP have identied few if any additional
benets [15,25,56,57]. Similarly, lower-barrier counseling options (e.g.,
phone-based) have had little impact on treatment outcomes, mostly
due to patients’ lack of interest in participation. In one study, more
than half of the intervention group didn’t complete a single phone-
based counseling session [58]. Based on the lack of evidence in support
of counseling, In fact, the American Society of Addiction Medicine
[59] has recently updated their treatment guidelines to suggest
counseling should not be mandatory; instead, patient care should be
individualized and reassessed oen to determine if any additional
supports beyond medication may be necessary to continue treatment.
Subjects withdrawn from treatment: A signicant concern about
study approaches was the practice of withholding medication [37] or
withdrawing patients from a study for noncompliance, or treatment
‘failure’ [46]. For example, participants whose withdrawal symptoms
were not adequately reduced by treatment with a combination of either
1) buprenorphine (BUP) or placebo implant and 2) supplemental
sublingual BUP were withdrawn from the study conducted by Ling et
al. [46]. While such practices may make sense in a research setting, the
approach of withholding treatment is not consistent with the treatment
of a chronic, relapsing condition. Patients with OUD oen require
years of treatment before they stabilize and may require lifelong
maintenance therapy to avoid relapse. Remaining in treatment and
receiving either BUP or MET signicantly reduces risk of mortality
from overdose [60], suggesting a harm reduction approach is benecial
to patients [61]. Studies included in the review also highlighted
signicant benets of actively receiving any treatment, including
reductions in relapse, HIV and HCV risk behaviors, costs associated
with all treatment (including substance abuse treatment), and number
of arrests, as well as improved compliance, retention and predicted
being in treatment in the future [34-37,44].
Expanding denitions of successful treatment
Initially, we set out to include any outcomes of treatment, with an
interest in quality of life and other markers of recovery[62]. However,
none of the included studies (and few of the studies excluded aer
reading) evaluated addiction treatment success beyond abstinence. A
review focused on functional outcomes in medication assisted
treatment published aer our search was conducted and identied the
existing literature was both sparse and of low or very low quality. ere
have been a growing number of calls for a dierent approach to the
measurement of success in treatment. For example, SAMHSA’s
Recovery Support Strategic Initiative [63] recognized the need for a
new denition of recovery that includes four dimensions: 1) Health
[being healthy physically and emotionally], 2) Home [having a stable
place to live], 3) Purpose [having a purpose in life and the ability to
participate in society], and 4) Community [maintaining relationships].
Similarly, Dupont [64] argues that patient outcomes worth considering
include substance-related illness, injury, accidents, arrests, self-
evaluation of recovery, employment and education status, and overall
physical and mental health. e National Institute of Drug Abuse [65]
recognized that use of opioids while in treatment is common,
suggesting the need to consider opioid use disorder (OUD) treatment
outcomes other than abstinence. Martin et al. [61] remind that shiing
the focus to include other outcomes does not mean we should ignore
intermittent or continued opioid use; instead, it can be seen as an
opportunity to identify patient-centered augmentations to the
treatment plan (e.g. family supervision of BUP administration) to
support recovery
Suggestions for future research
e ndings of the review and limitations of the included studies
provide many questions to be answered in future research. First, given
the urgent need and lack of access to treatment, future research should
examine the eectiveness of the use of buprenorphine (BUP) as a
standalone treatment, as well as the eectiveness of reducing barriers
to treatment protocols presently suggested by current practice
guidelines. Studies should also examine the application of current
treatment models with the aforementioned expanded measures of
treatment “success”. is aligns more closely with the present view that
opioid use disorder (OUD) is chronic illness from which one can
expect to “recover”. Despite periods of relapse, many individuals with
OUD continue to function eectively in many areas and achieve a
good quality of life [13].
Citation: Mariolis T, Bosse J, Martin S, Wilson A, Chiodo L (2019) A Systematic Review of the Effectiveness of Buprenorphine for Opioid Use
Disorder Compared to Other Treatments: Implications for Research and Practice. J Addict Res Ther 10: 379. doi:
10.4172/2155-6105.1000379
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J Addict Res er, an open access journal
ISSN:2155-6105
Volume 10 • Issue 2 • 1000379
It is also important that treatment protocols and outcome measures
be standardized in order to permit direct comparison of treatment
eectiveness [64]. Also, including measures of patient satisfaction with
treatment may help clinicians and researchers further understand what
is and is not eective for patients. Although research ndings suggest
there is a wide range of eective treatments, a principle of opioid abuse
treatment put forth by NIDA [65] suggests that treatment plans should
be individualized, and that no one treatment plan works for everyone.
Studies evaluating the eectiveness of medications should be
adequately powered and include matched samples. Study designs
should account for between-group dierences or other confounding
variables in statistical analyses. Since methadone (MET) and BUP
demonstrate comparable eectiveness on many outcomes, research in
pinpointing characteristics of persons who respond better to one
medication over the other would be highly useful. For instance, we
may learn more about individuals who benet from continuous
monitoring oen required by treatment facilities that dispense MET.
A nal limitation of the current review is that many of the studies
included other medications in their OUD treatment protocols, for
example comfort medications for withdrawal and related symptoms.
ese reports did not provide information regarding the impact of
such medications on outcomes. us, it is not clear the extent to which
these medications might have impacted the results.
Implications for policy and practice
Policy makers, researchers, and clinicians will need to be cautious
and must not be misled by studies with short treatment schedules and
those with many barriers to care. We can begin the paradigm shi in
addiction treatment and research by moving away from the
abbreviation MAT, as ASAM has suggested, and using medication
treatment (MT) instead, which suggests that medication is treatment,
rather than a tool that assists other treatment approaches. As such,
payers should remove additional treatment requirements and limits on
treatment length, so providers and researchers can study the outcomes
of treatment when patients can engage in OUD treatment long-term.
Policy makers, providers, and researchers should work together to
identify a set of standardized outcomes for the evaluation of treatment
for opioid use disorder that allow (OUD) us to understand the benets
of treatment beyond abstinence from opiates and other substances.
Standardized outcomes should be required as common data elements
in clinical practice (via electronic health record) and research studies,
which would facilitate data-sharing and reasonable evaluation of
treatment.
Providers need to be aware of all barriers to successful treatment
that individuals might face including unidentied and untreated co-
occurring substance use disorders or mental illness; given the
increased prevalence of co-morbid conditions and risks to health
should they remain untreated. In addition, a compassionate approach
with an understanding that relapse is an inherent aspect of this chronic
illness, and providing additional support options rather than punishing
patients, could improve retention in treatment and the possibility for
better outcomes.
Conclusion
Buprenorphine (BUP) is an eective treatment option for many
individuals with opioid use disorder (OUD) and with emerging
treatment guidelines, may be easier to access than other forms of
treatment. Previous reviews have found BUP in higher doses is more
highly eective than other medications and counselling for reducing
the use of illicit opioids and as a standalone treatment. e unique
contribution of this review is the synthesis of data from multiple study
types (RCT, secondary data, retrospective chart review, and insurance
claims) that compare dierent formulations of BUP for a wide range of
outcomes. Further, these review highlights that much of the available
literature utilized protocols that are inconsistent with current clinical
practice recommendations and what is understood about the needs of
patients with OUD. In addition, aws in research designs make it
dicult for providers to determine the best MT and ancillary services
to improve outcomes for specic patient populations. us, additional
research that carefully examines the eectiveness of BUP when
administered in accordance with current best practice guidelines and a
set of standardized, patient-centered outcomes is needed to help us
understand the best approach to mitigate the personal and social
consequences of opioid use disorder.
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