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  Methadone review article raises more questions than it answers!

Posted: February 01, 2005 12:25

The effectiveness of community maintenance with methadone or buprenorphine for treating opiate dependence. Simoens S, Matheson C, Bond C, Inkster K, Ludbrook A. British Journal of General Practice 2005 55:139-146



Dear Colleagues,

It is always gratifying to see dependency subjects covered in mainstream journals. This should raise awareness of effective opioid maintenance and other therapies for addictions amongst front line health workers. However, this 'Review Article' would be more likely to turn interested GPs, nurses or pharmacists away from being involved in addiction treatments.

The authors quote comparative research which consistently shows buprenorphine to be slightly but significantly inferior to methadone in most outcome measures. Yet their contradictory conclusion states: ". the evidence suggests that . buprenorphine may even be more effective than methadone, depending on dose".

While comparisons between methadone and buprenorphine are worth addressing, these authors seem to expect the literature to determine which is 'best'. Few would spend time arguing the general 'superiority' of one antibiotic over another. In doing so they miss the point that neither is used altogether appropriately in the UK (or most other countries). A review article might be expected to address better ways of matching patient to treatment, yet this is largely ignored here despite some useful recent research on the subject, including those with HIV, pregnancy, fast metabolism, etc.

They write further: "There was some evidence that primary care could be an effective setting [for opioid maintenance treatment] but such evidence was sparse". This academic peccadillo also applies to insulin, warfarin or most other pharmacotherapies. Although most research is performed in clinics, few would doubt its extension to community practice. It seems that these authors lack confidence in the Cochrane contributors on the subjects. The lingering doubts expressed by the authors might deny treatment to most of the patient population while we wait for yet more research!

One of the most important messages of this review paper, UK treatment standards, is almost buried towards the end. Exemplifying understatement (and some clumsy English) we are told: "With respect to community maintenance with methadone . higher doses of methadone are more effective. This is important because surveys of current prescribing practices of GPs in the UK suggest that methadone may still be underdosed." [In fact the mean dose in the UK is less than 40mg daily. While this is a good starting level it is only half the 'plateau' dose needed for optimum results.]

Thus the authors (all but one from Aberdeen) avoid properly addressing the scandal of methadone treatment in the UK which continues unaddressed to this day. Dependent citizens may thus drop out of inadequate treatment, relapse to heroin use, overdose or contract viral infections while the medical profession gets a bad name for gross mismanagement of opioid dependency. A similar state of affairs for diabetics, hypertensives or arthritis patients could make an election issue centring on the NHS.

After apparently searching the literature for negative items, our current authors also state: 'higher doses of methadone may increase craving for heroin and decrease subjective wellbeing'. This is based on one very small study which has never been replicated (Curran et al, Addiction 1999 94:665). The findings conflict with 2000 years of recorded experience where additional opioids are generally associated with reduced cravings and increased feelings of well being in the acute situation. The Addiction editor wrote to me that there may indeed have been a statistical error in this study but he declined to allow any correspondence on the matter, leaving its rather outlandish sentiments uncontested in the literature. One assumes that these 'Review Article' authors would have read the reference carefully before quoting its title. John Strang wrote recently that methadone may yet have a 'sting in the tail' without further explanation.

After 40 years of clinical experience methadone is no longer "on trial". The question is why people still express lingering yet unfounded doubts about its safety and effectiveness when used according to established practice guidelines. It appears that buprenorphine is in the same category giving patients and doctors choice at last.

comments by Andrew Byrne ..

 

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