The effectiveness of community maintenance with methadone or buprenorphine for treating opiate dependence.

BACKGROUND: Opiate dependence is a major health and social issue in many countries. A mainstay of therapy has been methadone maintenance treatment, but other treatments, particularly buprenorphine, are increasingly being considered.

AIM: To conduct a systematic review to synthesise and critically appraise the evidence on the effectiveness of community maintenance programmes with methadone or buprenorphine in treating opiate dependence.

METHOD: A systematic review of databases, journals and the grey literature was carried out from 1990-2002. Inclusion criteria were: community-based, randomised controlled trials of methadone and/or buprenorphine for opiate dependence involving subjects who were aged 18 years old or over.

RESULTS: Trials were set in a range of countries, employed a variety of comparators, and suffered from a number of biases. The evidence indicated that higher doses of methadone and buprenorphine are associated with better treatment outcomes. Low-dose methadone (20 mg per day) is less effective than buprenorphine (2-8 mg per day). Higher doses of methadone (>50-65 mg per day) are slightly more effective than buprenorphine (2-8 mg per day). There was some evidence that primary care could be an effective setting to provide this treatment, but such evidence was sparse.

CONCLUSION: The literature supports the effectiveness of substitute prescribing with methadone or buprenorphine in treating opiate dependence. Evidence is also emerging that the provision of methadone or buprenorphine by primary care physicians is feasible and may be effective.