A study published online May 12, 2014 in Substance Abuse compared demographic characteristics and treatment outcomes of 252 patients enrolling in a methadone maintenance treatment (MMT) program with those of 252 buprenorphine patients starting treatment in an internal medicine practice affiliated with a medical school.
The authors planned the study as “a real-life comparison,” where opioid-dependent patients chose their type of treatment from two possibilities available at the same time, on the same medical campus, Johns Hopkins Bayview Medical Center in Baltimore.
Program Characteristics
MMT program. MMT patients received individual counseling, and selected patients could be required to attend weekly counseling groups as well. Staff collected urine samples for drug testing on a random schedule, one to four times each month, under observation. The average methadone dose was 80 mg/day.
Buprenorphine practice. Certified primary care physicians had discretion in dosing titration, patient monitoring plan, frequency of patient visits, and treatment discontinuation. Follow-up visits typically lasted 15 minutes and covered brief supportive interventions and primary care health issues. Once stabilized, patients visited the practice monthly—more often if illicit substance use continued. Attendance at self-help groups was encouraged. Staff did not collect urine samples under observation, but did check urine temperature to make sure the sample was fresh. The average buprenorphine dose was 16 mg/day.
Program Selection
Factors involved in choosing methadone vs. buprenorphine included patient preferences, provider decisions, and availability.
Data Collection and Analysis
Each month for one year, staff classified patients as “opioid-positive” or “opioid-negative,” based on provider assessment and urine drug testing. The “opioid-positive” category included any positive drug screen, patient report of opioid use, or lack of a urine collection, if the most recent test result was positive.
Criteria for Success
Investigators chose two patient criteria for successful treatment:
- Scoring at least six opioid-negative months
- Remaining in treatment after one year
Patient Characteristics
Buprenorphine patients were more likely than methadone patients to:
- Be male
- Be employed
- Be HIV-infected (14.3% vs. 7.9%), despite reporting less exposure to injection-drug use
- Abuse prescription opioids
They were less likely to abuse benzodiazepines.
Outcomes
Looking at the predetermined criteria for successful treatment response—at least six opioid-negative months and remaining in treatment after one year—the results were as follows: methadone patients, 137 (54.4%); buprenorphine patients, 104 (41.3%). The difference was statistically significant.
Successful patients had several characteristics in common. They were more likely to
- be receiving MMT
- have been on opioid agonist treatment before starting either program
- Less likely to have faced recent criminal charges, or to have used heroin
Withdrawal from treatment. Methadone patients were significantly less likely to discontinue treatment during the first month (2.4% vs. 17.1%), but rates of discontinuation in later months were similar.
Reasons for discontinuation of therapy varied, as shown below.
| Reason | Methadone Patients (n) | Buprenorphine Patients (n) |
| Patient decision (dropout) | 67 | 70 |
| Provider decision | 5 | 10 |
| Transfer to another program | 24 | 11a |
| Planned medication taper | 0 | 8a |
| Lost health insuranceb | 0 | 10a |
| Deceased | 0 | 2 |
aThe difference is statistically significant.
bInsurance was required for buprenorphine patients.
The authors commented on the more difficult induction period with buprenorphine, referring to the opioid withdrawal symptoms that can occur during initial treatment with a partial opioid agonist. They said that the higher dropout rate in the first month accounted almost entirely for the difference in treatment retention, and added that the relative ease of access to buprenorphine may have “attracted less motivated patients.”
Conclusions
The authors found that the study “provides additional evidence that office-based buprenorphine and methadone maintenance programs serve different populations of opioid-dependent patients.”
Given the preselected criteria for success—at least six opioid-negative months, and remaining in treatment after one year—methadone therapy was found to be the only factor significantly associated with a successful treatment response. Both treatments were effective, but methadone patients had modestly better outcomes.
Reference
Fingerhood MI, King VL, Brooner RK, Rastegar DA. A comparison of characteristics and outcomes of opioid-dependent patients initiating office-based buprenorphine or methadone maintenance treatment [E pub ahead of print May 12, 2014]. Subst Abuse. 35:122-126. doi: 10.1080/08897077.2013.81928.
http://www.ncbi.nlm.nih.gov/pubmed/24821346