Buprenorphine (often prescribed in a combined formulation with naloxone, under the brand name “Suboxone”) has received much attention as an evidence-based medication-assisted treatment for individuals with opioid use disorder. However, some questions remain about its effectiveness at lower doses.
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Buprenorphine (Suboxone) is effective in reducing opioid use short term relative to placebo particularly at higher doses. To illustrate, studies have shown overall that, relative to placebo, the average buprenorphine patient would be using opioids far less often (at about the 16th percentile in the placebo group in terms of opioid use).
This benefit is true when patients are followed up longer term as well. This particular study took a closer look at the earliest days of buprenorphine treatment, also called the “induction” period. This is the time when doctors initially start an individual on a medication. Clinical research on this induction period, like in the current investigation, can help practitioners understand whether there are clinical decisions during these early critical days that impact how individuals fare later on while taking buprenorphine to help prevent illicit opioid use.
This study analyzed data from a large trial of buprenorphine (Suboxone) compared to methadone, to evaluate their safety when used in real-world settings (see here for more information on this trial, and a comparison of the two medications over several years). The researchers examined just the 740 who were randomized to the buprenorphine group in that trial, all of whom had opioid dependence based on criteria from the diagnostic and statistical manual of mental disorders, 4th edition (DSM-IV).
On average, the sample was 37 years old, and used opioids 27 of 30 days before they entered the study. Most were male (90%) and White (95%).
Dosing Guide:
The groups were then compared on treatment drop-out, opioid use, and adverse events as outlined above over the 6 months during which they were enrolled in the study. These analyses comparing groups also controlled statistically for several variables at once that were related to the groups, and that one might think would also be related to these treatment outcomes.
This helped to increase the likelihood that any advantage or disadvantage found for one of the groups was caused by their different initial buprenorphine (Suboxone) dosing pattern. These included both demographic characteristics (e.g., gender) and clinical variables, including whether or not they injected opioids.
Jacobs and colleagues found that how someone is initially started and stabilized on buprenorphine (Suboxone) in a real-world treatment setting is related to treatment outcomes, but only in some respects.
Generally, there are few differences in how individuals fare in Suboxone treatment based purely on their dose. One exception is that those on higher doses (e.g., 16mg or more) are more likely to remain in treatment during the 1st month.
In comparing groups of individuals receiving different doses of buprenorphine, individuals on higher doses (e.g., 16 or more mg) during the first month of the 6-month treatment were less likely to drop out of treatment.
However, someone’s buprenorphine (Suboxone) dose was not related to drop-out during the last month of treatment. Someone’s buprenorphine dose was generally unrelated to how often they used illicit opioids during the study. One exception was that individuals stably on a moderate dose (8-24mg) used illicit opioids on fewer days during the last month than those stably on a low dose, although this difference was not large (about 1 day of opioid use in a month).
Buprenorphine use was generally unrelated to negative health outcomes from the medication itself. In fact, those on a higher dose may be at lower risk for medication-related adverse events during the initial month.
Not surprisingly, individuals who took longer to achieve a stable dose, defined as the highest dose a patient took for greater than 1 month, had more opioid use days during the last month of treatment. These individuals may be more complicated from a clinical perspective, contributing both to the difficulty establishing a stable dose, and to their poorer outcomes. How quickly they achieved this stable dose, on the other hand, was unrelated to treatment drop-out or adverse events.
The study examined differences in outcomes based on dosing patterns of individuals with opioid use disorder in medication-assisted treatment with buprenorphine (Suboxone).
Clinically it may be worth starting individuals at a higher dose, & maintaining that dose or lowering it over time if indicated. This practice could help initially engage patients in Suboxone treatment which prior studies suggest increases someone’s likelihood of opioid abstinence over time.
In fact, while there is general consensus that buprenorphine treatment is one clinical strategy to reduce relapse and overdose risk among those with opioid use disorder, a combined review of several studies (meta-analysis) suggests buprenorphine may only be more effective at reducing opioid use than placebo at these higher doses (see here).
A randomized trial to test whether low buprenorphine doses are as effective as placebo may help determine their overall utility.
Jacobs, P., Ang, A., Hillhouse, M. P., Saxon, A. J., Nielsen, S., Wakim, P. G., … & Blaine, J. D. (2015). Treatment outcomes in opioid dependent patients with different buprenorphine/naloxone induction dosing patterns and trajectories. The American Journal on Addictions, 24(7), 667-675.
l
Buprenorphine (Suboxone) is effective in reducing opioid use short term relative to placebo particularly at higher doses. To illustrate, studies have shown overall that, relative to placebo, the average buprenorphine patient would be using opioids far less often (at about the 16th percentile in the placebo group in terms of opioid use).
This benefit is true when patients are followed up longer term as well. This particular study took a closer look at the earliest days of buprenorphine treatment, also called the “induction” period. This is the time when doctors initially start an individual on a medication. Clinical research on this induction period, like in the current investigation, can help practitioners understand whether there are clinical decisions during these early critical days that impact how individuals fare later on while taking buprenorphine to help prevent illicit opioid use.
This study analyzed data from a large trial of buprenorphine (Suboxone) compared to methadone, to evaluate their safety when used in real-world settings (see here for more information on this trial, and a comparison of the two medications over several years). The researchers examined just the 740 who were randomized to the buprenorphine group in that trial, all of whom had opioid dependence based on criteria from the diagnostic and statistical manual of mental disorders, 4th edition (DSM-IV).
On average, the sample was 37 years old, and used opioids 27 of 30 days before they entered the study. Most were male (90%) and White (95%).
Dosing Guide:
The groups were then compared on treatment drop-out, opioid use, and adverse events as outlined above over the 6 months during which they were enrolled in the study. These analyses comparing groups also controlled statistically for several variables at once that were related to the groups, and that one might think would also be related to these treatment outcomes.
This helped to increase the likelihood that any advantage or disadvantage found for one of the groups was caused by their different initial buprenorphine (Suboxone) dosing pattern. These included both demographic characteristics (e.g., gender) and clinical variables, including whether or not they injected opioids.
Jacobs and colleagues found that how someone is initially started and stabilized on buprenorphine (Suboxone) in a real-world treatment setting is related to treatment outcomes, but only in some respects.
Generally, there are few differences in how individuals fare in Suboxone treatment based purely on their dose. One exception is that those on higher doses (e.g., 16mg or more) are more likely to remain in treatment during the 1st month.
In comparing groups of individuals receiving different doses of buprenorphine, individuals on higher doses (e.g., 16 or more mg) during the first month of the 6-month treatment were less likely to drop out of treatment.
However, someone’s buprenorphine (Suboxone) dose was not related to drop-out during the last month of treatment. Someone’s buprenorphine dose was generally unrelated to how often they used illicit opioids during the study. One exception was that individuals stably on a moderate dose (8-24mg) used illicit opioids on fewer days during the last month than those stably on a low dose, although this difference was not large (about 1 day of opioid use in a month).
Buprenorphine use was generally unrelated to negative health outcomes from the medication itself. In fact, those on a higher dose may be at lower risk for medication-related adverse events during the initial month.
Not surprisingly, individuals who took longer to achieve a stable dose, defined as the highest dose a patient took for greater than 1 month, had more opioid use days during the last month of treatment. These individuals may be more complicated from a clinical perspective, contributing both to the difficulty establishing a stable dose, and to their poorer outcomes. How quickly they achieved this stable dose, on the other hand, was unrelated to treatment drop-out or adverse events.
The study examined differences in outcomes based on dosing patterns of individuals with opioid use disorder in medication-assisted treatment with buprenorphine (Suboxone).
Clinically it may be worth starting individuals at a higher dose, & maintaining that dose or lowering it over time if indicated. This practice could help initially engage patients in Suboxone treatment which prior studies suggest increases someone’s likelihood of opioid abstinence over time.
In fact, while there is general consensus that buprenorphine treatment is one clinical strategy to reduce relapse and overdose risk among those with opioid use disorder, a combined review of several studies (meta-analysis) suggests buprenorphine may only be more effective at reducing opioid use than placebo at these higher doses (see here).
A randomized trial to test whether low buprenorphine doses are as effective as placebo may help determine their overall utility.
Jacobs, P., Ang, A., Hillhouse, M. P., Saxon, A. J., Nielsen, S., Wakim, P. G., … & Blaine, J. D. (2015). Treatment outcomes in opioid dependent patients with different buprenorphine/naloxone induction dosing patterns and trajectories. The American Journal on Addictions, 24(7), 667-675.
l
Buprenorphine (Suboxone) is effective in reducing opioid use short term relative to placebo particularly at higher doses. To illustrate, studies have shown overall that, relative to placebo, the average buprenorphine patient would be using opioids far less often (at about the 16th percentile in the placebo group in terms of opioid use).
This benefit is true when patients are followed up longer term as well. This particular study took a closer look at the earliest days of buprenorphine treatment, also called the “induction” period. This is the time when doctors initially start an individual on a medication. Clinical research on this induction period, like in the current investigation, can help practitioners understand whether there are clinical decisions during these early critical days that impact how individuals fare later on while taking buprenorphine to help prevent illicit opioid use.
This study analyzed data from a large trial of buprenorphine (Suboxone) compared to methadone, to evaluate their safety when used in real-world settings (see here for more information on this trial, and a comparison of the two medications over several years). The researchers examined just the 740 who were randomized to the buprenorphine group in that trial, all of whom had opioid dependence based on criteria from the diagnostic and statistical manual of mental disorders, 4th edition (DSM-IV).
On average, the sample was 37 years old, and used opioids 27 of 30 days before they entered the study. Most were male (90%) and White (95%).
Dosing Guide:
The groups were then compared on treatment drop-out, opioid use, and adverse events as outlined above over the 6 months during which they were enrolled in the study. These analyses comparing groups also controlled statistically for several variables at once that were related to the groups, and that one might think would also be related to these treatment outcomes.
This helped to increase the likelihood that any advantage or disadvantage found for one of the groups was caused by their different initial buprenorphine (Suboxone) dosing pattern. These included both demographic characteristics (e.g., gender) and clinical variables, including whether or not they injected opioids.
Jacobs and colleagues found that how someone is initially started and stabilized on buprenorphine (Suboxone) in a real-world treatment setting is related to treatment outcomes, but only in some respects.
Generally, there are few differences in how individuals fare in Suboxone treatment based purely on their dose. One exception is that those on higher doses (e.g., 16mg or more) are more likely to remain in treatment during the 1st month.
In comparing groups of individuals receiving different doses of buprenorphine, individuals on higher doses (e.g., 16 or more mg) during the first month of the 6-month treatment were less likely to drop out of treatment.
However, someone’s buprenorphine (Suboxone) dose was not related to drop-out during the last month of treatment. Someone’s buprenorphine dose was generally unrelated to how often they used illicit opioids during the study. One exception was that individuals stably on a moderate dose (8-24mg) used illicit opioids on fewer days during the last month than those stably on a low dose, although this difference was not large (about 1 day of opioid use in a month).
Buprenorphine use was generally unrelated to negative health outcomes from the medication itself. In fact, those on a higher dose may be at lower risk for medication-related adverse events during the initial month.
Not surprisingly, individuals who took longer to achieve a stable dose, defined as the highest dose a patient took for greater than 1 month, had more opioid use days during the last month of treatment. These individuals may be more complicated from a clinical perspective, contributing both to the difficulty establishing a stable dose, and to their poorer outcomes. How quickly they achieved this stable dose, on the other hand, was unrelated to treatment drop-out or adverse events.
The study examined differences in outcomes based on dosing patterns of individuals with opioid use disorder in medication-assisted treatment with buprenorphine (Suboxone).
Clinically it may be worth starting individuals at a higher dose, & maintaining that dose or lowering it over time if indicated. This practice could help initially engage patients in Suboxone treatment which prior studies suggest increases someone’s likelihood of opioid abstinence over time.
In fact, while there is general consensus that buprenorphine treatment is one clinical strategy to reduce relapse and overdose risk among those with opioid use disorder, a combined review of several studies (meta-analysis) suggests buprenorphine may only be more effective at reducing opioid use than placebo at these higher doses (see here).
A randomized trial to test whether low buprenorphine doses are as effective as placebo may help determine their overall utility.
Jacobs, P., Ang, A., Hillhouse, M. P., Saxon, A. J., Nielsen, S., Wakim, P. G., … & Blaine, J. D. (2015). Treatment outcomes in opioid dependent patients with different buprenorphine/naloxone induction dosing patterns and trajectories. The American Journal on Addictions, 24(7), 667-675.
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