Our expert says:
I would have prefered that one of the exerts on the forum that is medically trained respond to your question... but time is running out, so I will try to respond as best I can to your question.... I will use the term buprenorphine in my response to you (Subutex is what buprenorphine is marked as in SA).
Alternative pharmacotherapies, such as buprenorphine, have been proposed to be more effective than methadone, and also cause less limiting hypotensive side effects and adverse events for the heroin user.
Buprenorphine exerts sufficient opioid effects to prevent or alleviate opioid withdrawal symptoms, but produces a milder, less euphoric and less sedating effect than high doses of heroin or methadone.
Buprenorphine has unusual properties in that it is a partial opioid agonist and a partial opioid antagonist; thus, there is a lower risk of overdose and an easier withdrawal process than methadone.
Buprenorphine is also a safer substitute drug as it does not depress the central nervous system as severely as methadone; thus, death from buprenorphine alone is extremely rare.
Auriacombe’s (2001) study in France noted that the death rate per patient treated with methadone was 0.0007 compared with 0.0002 for buprenorphine.
When put into context, these results show that if all of the patients receiving substitute prescriptions were on methadone then the death rate would have been 288 whereas if they had all been on buprenorphine the death rate would have been 46.
Buprenorphine also has a longer half-life than methadone so, potentially, dosing could be given three times a week as opposed to daily with methadone.
Thrice weekly dosing reduces the costs of maintaining a heroin dependent person, as well as reduce the disruption caused to the life of the heroin dependent individual.
Daily dosing of buprenorphine seems to combine effectiveness with patient convenience, and may carry some cost savings for the patient and the health system by reducing the frequency of attending for dosing and increasing the capacity of the treatment service.
Research has established that buprenorphine blocks the effects of exogenous opioid administration, suppresses heroin self-administration and reduces the severity of withdrawing from opioids.
The use of buprenorphine for medical withdrawal from opioids can serve to initiate and engage patients into continuing addiction treatment due to its shorter term medical withdrawal in comparison to longer term treatments such as methadone programmes.
Furthermore, buprenorphine is reputed to be well accepted by pregnant women, and is associated with a low incidence of neonatal abstinence syndrome.
There have been numerous studies comparing the effectiveness of buprenorphine against methadone.
However, the results are varied and in many cases inconclusive. Johnson (1992). compared doses of 8mgs of buprenorphine against 20mgs and 60mgs of methadone.
It was reported that 8mgs of buprenorphine was superior to 20mgs of methadone and equal to 60mgs of methadone with regard to retention in treatment.
Subjects in the buprenorphine and high dose methadone groups were noted to have similar numbers of opioid negative urine samples, and both were superior to low dose methadone.
However, studies using higher doses of methadone (80mgs) have reported that methadone is superior to buprenorphine (8mgs).
A number of randomised clinical trials have reported that buprenorphine and methadone are equally effective in the treatment of opioid dependent patients.
Ahmadi (2003) reported that the retention rate in treatment of patients on 8mgs of buprenorphine was 68.3% which was superior to the retention rate for patients on 30mgs of methadone which was 61%.
However, an equivalent number of studies have reported inferior results for buprenorphine with regard to retention in treatment and opioid negative urinalysis.
Eder and colleagues (1998) noted that subjects on buprenorphine provided a greater proportion of negative urine samples.
However, retention in the buprenorphine group was significantly lower than that of the methadone group.
Interestingly, it was noted that buprenorphine was clearly more effective in the more motivated individuals in the study.
The inferiority of buprenorphine reported in the aforementioned studies has been attributed to the dose of buprenorphine being too low, or a too slow induction onto low doses of buprenorphine.
Meta-analyses studies have reported that there was relative equality in buprenorphine and methadone efficacy, although the participants on methadone were less likely to have opioid positive urine samples.
It was also noted that those participants who had had past experiences with methadone were more likely to be drug free on the buprenorphine treatment .
So to try and answer your question in short - out of my experience in the field, opioid dependents are normally given approximately 8mg burprenorphine to commence with - this is then gradually tapered off. For those of buprenorphine maintenance - the dosage can vary - depending on how the individual is coping - I know many who maintain on 1 or 2mg for a year or so.
So what I would imagine, anything more than 8 mg is more risky - but I would advise that a medical practitioner assess the concerned individual and give a medical opinion.
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