Recommendations for buprenorphine and methadone therapy in opioid use disorder: a European consensus

ABSTRACT

Introduction: Management of patients with opioid use disorder (OUD) commonly includes opioid agonist therapy (OAT) as a part of an integrated treatment plan. These interventions are associated with proven benefits to the individual and society.

Areas covered: The use of methadone and buprenorphine within an integrated treatment plan in the management of patients with OUD: this work provides consensus recommendation on pharmacotherapy in OUD to assist clinicians with practical decision making in this field.

Expert opinion: Pharmacotherapy is recommended as part of an integrated OUD treatment approach with psychosocial interventions, with the goal of reducing risks of illicit opioid use, overdose mortality, infection with HIV or HCV, improving health, psychological and social outcomes. Access to OAT should be prioritised in the treatment of OUD. Treatment choices in OUD pharmacotherapy should be based on the needs of the individual and characteristics of medications. Recommendations for choices of OAT are based on clinical efficacy, safety, patient preference, side effects, pharmacological interactions, quality of life, dose titration potential and outcomes (control craving, ongoing opioids consumption or other drugs, and potentially psychiatric comorbidities). Special groups, pregnant women, prisoners, patients with mental health problems have specific needs which must be addressed with expert input.

KEYWORDS:

• Buprenorphine
• methadone
• opioid agonist therapy
• opioid use disorder

Article highlights

• Opioid use disorder (OUD) is characterised by repeated use of opioids with harmful consequences that may require long-term treatment. Opioid agonist therapy (OAT) is an important part of care with proven benefits to patients and society.

• Access to quality OAT for OUD should be prioritized. Patients should receive an individualised treatment approach with choices and ongoing management, including dose titration, based on their specific needs and progress.

• Buprenorphine treatment is recommended as an important option based on safety profile (low overdose risk).

• Buprenorphine/Naloxone is recommended in settings with increased risk of misuse/diversion.

• Methadone is an option with extensive clinical experience in patients who may continue to use other opioids, for those with pain and/or benefiting from sedative effects; there is an important risk of overdose with methadone therapy.

• Groups including pregnant women, prisoners and patients with mental health problems require special consideration, which must be addressed with expert input.

This box summarizes key points contained in the article.

Acknowledgments

The authors are grateful for the advanced contribution of Dr Li Li and Dr Tara Lumley in preparing this analysis and other editorial work.

Declaration of interest

M Dematteis has given expert advice to Indivior, Lundbeck, Merck-Serono and D&A Pharma, and was co-investigator for an Ethypharm study. M Auriacombe does not have direct conflicts of interest but acknowledges that through the University of Bordeaux he manages funds from or gives expert advice to the following companies: Indivior, Gilead, Mundipharma, D&A Pharma, Lundbeck, Ethypharm. R Littlewood works in advisory roles for companies providing medicines for addiction. F Alam has provided consultancy to Martindale, Indivior & Mundipharma. C Leonardi is consultant for Indivior, Molteni, Gilead, Merck-MSD, Mundipharma. I Maremmani served as consultant for Indivior, Molteni, Gilead, Merck-MSD, Mundipharma, D&A Pharma, Lundbeck, Angelini, and CT Sanremo. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed. Peer reviewers on this manuscript have received an honorarium from Expert Opinion on Pharmacotherapy for their review work. A reviewer on this manuscript has disclosed that they have received research funding from Reckittbenckiser, and have received consultancy fees from Martindale Pharma and Indivior. They have also received honorarium for presentations they have performed on behalf of Indivior. A second peer reviewer has disclosed that they have received untied education grants from both Indivior and Mundipharma for post-surveillance research projects. All other peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

Expert meeting attendance and support services for this work were supported by a grant from Indivior. Indivior did not influence the meeting discussion, nor the content of this review.