Background: Managed withdrawal (detoxification) is a necessary step prior to drug-free treatment. It may also represent the end point of long-term opioid replacement treatment such as methadone maintenance. The availability of managed withdrawal is essential to an effective treatment system.
Objectives: To assess the effectiveness of interventions involving the short-term use of buprenorphine to manage the acute phase of opioid withdrawal.
Search strategy: Multiple electronic databases were searched using a strategy designed to retrieve references broadly addressing the management of opioid withdrawal. Reference lists of retrieved studies, reviews and conference abstracts were handsearched.
Selection criteria: Randomised or quasi-randomised controlled clinical trials or prospective controlled cohort studies that compared different buprenorphine regimes, or that compared buprenorphine with another form of treatment (or placebo) to modify the signs and symptoms of withdrawal in participants who were primarily opioid dependent.
Data collection and analysis: Potentially relevant studies were assessed for inclusion by one reviewer. Inclusion decisions were confirmed by consultation between reviewers. One reviewer undertook data extraction with the process confirmed by consultation between all three reviewers.
Main results: Six studies (5 RCTs and 1 controlled prospective study), involving 357 participants, met the criteria for inclusion in the review. Four studies compared buprenorphine with clonidine. All found withdrawal to be less severe in the buprenorphine treatment group. In three of these studies all participants were withdrawing from heroin. Participants in one study were withdrawing from methadone (10mg/day). Aches, restlessness, yawning, mydriasis, tremor, insomnia, nausea and mild anxiety were reported as being experienced by some participants. Rates of completion of withdrawal ranged from 65% to 100%. None of the studies included in the review reported adverse effects. However a single-group study which therefore did not meet the inclusion criteria, reported the occurrence in some participants of headaches, sedation, nausea, constipation, anxiety, dizziness and itchiness, particularly in the first 2-3 days of treatment. In one of the six studies, and in two studies that did not meet the inclusion criteria, treatment was provided on an outpatient basis.
Reviewer's conclusions: Buprenorphine has potential as a medication to ameliorate the signs and symptoms of withdrawal from heroin, and possibly methadone, but many aspects of treatment protocol and relative effectiveness need to be investigated further.