Document Detail

A stepped care strategy using buprenorphine and methadone versus conventional methadone maintenance in heroin dependence: a randomized controlled trial.
MedLine Citation:
PMID:  17475739     Owner:  NLM     Status:  MEDLINE    
OBJECTIVE: Both methadone and buprenorphine are effective therapy for heroin dependence. Efficacy is best documented for methadone maintenance therapy, but safety concerns limit its use. Buprenorphine offers lower overdose risk and improved access, but efficacy may be lower. The authors compared adaptive, buprenorphine-based stepped care to optimal methadone maintenance treatment. METHOD: This randomized controlled trial was undertaken 2004-2006. It consisted of a 24-day uniform double-blind induction phase followed by single-blind flexible dosing based on structured clinical criteria, for a total of 6 months. Ninety-six self-referred subjects with heroin dependence were randomly assigned to methadone or to stepped treatment initiated with buprenorphine/naloxone and escalated to methadone if needed. All subjects received intensive behavioral treatment. Primary outcome was retention in treatment. Secondary outcomes were completer analyses of problem severity (Addiction Severity Index) and proportion of urine samples free of illicit drugs. RESULTS: Overall, 6-month retention was 78%. Stepped treatment and methadone maintenance therapy outcomes were virtually identical. Among completers of stepped therapy, 46% remained on buprenorphine/naloxone. Proportion of urine samples free of illicit opiates increased over time and ultimately reached approximately 80% in both arms. Problem severity decreased significantly and uniformly in both arms. CONCLUSIONS: A stepped treatment of heroin dependence as described here appears equally efficacious compared to optimally delivered methadone maintenance therapy. Together with prior data on the advantageous safety of buprenorphine, this suggests that broad implementation of strategies using buprenorphine as first-line treatment should be considered.
Johan Kakko; Leif Grönbladh; Kerstin Dybrandt Svanborg; Joachim von Wachenfeldt; Christian Rück; Bob Rawlings; Lars-Håkan Nilsson; Markus Heilig
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Publication Detail:
Type:  Comparative Study; Journal Article; Randomized Controlled Trial; Research Support, Non-U.S. Gov't    
Journal Detail:
Title:  The American journal of psychiatry     Volume:  164     ISSN:  0002-953X     ISO Abbreviation:  Am J Psychiatry     Publication Date:  2007 May 
Date Detail:
Created Date:  2007-05-03     Completed Date:  2007-06-18     Revised Date:  2007-12-07    
Medline Journal Info:
Nlm Unique ID:  0370512     Medline TA:  Am J Psychiatry     Country:  United States    
Other Details:
Languages:  eng     Pagination:  797-803     Citation Subset:  AIM; IM    
Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden.
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MeSH Terms
Behavior Therapy
Buprenorphine / administration & dosage,  therapeutic use*
Combined Modality Therapy
Double-Blind Method
Drug Administration Schedule
Drug Combinations
Drug Therapy, Combination
Heroin / urine
Heroin Dependence / rehabilitation*
Longitudinal Studies
Methadone / therapeutic use*
Naloxone / administration & dosage,  therapeutic use*
Patient Compliance
Patient Dropouts
Severity of Illness Index
Single-Blind Method
Substance Abuse Detection
Treatment Outcome
Reg. No./Substance:
0/Drug Combinations; 465-65-6/Naloxone; 52485-79-7/Buprenorphine; 561-27-3/Heroin; 76-99-3/Methadone
Comment In:
Am J Psychiatry. 2007 May;164(5):702-4   [PMID:  17475725 ]
Am J Psychiatry. 2007 Nov;164(11):1757; author reply 1757-8   [PMID:  17974942 ]

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

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