Opioid Addiction and Abuse in Primary Care Practice: A Comparison of Methadone and Buprenorphine as Treatment Options

doi:10.1016/S0027-9684(15)30175-9

Journal of the National Medical Association

Volume 104, Issues 7–8, July–August 2012, Pages 342-350

https://doi.org/10.1016/S0027-9684(15)30175-9 Get rights and content

Opioid abuse and addiction have increased in frequency in the United States over the past 20 years. In 2009, an estimated 5.3 million persons used opioid medications nonmedically within the past month, 200 000 used heroin, and approximately 9.6% of African Americans used an illicit drug. Racial and ethnic minorities experience disparities in availability and access to mental health care, including substance use disorders.

Primary care practitioners are often called upon to differentiate between appropriate, medically indicated opioid use in pain management vs inappropriate abuse or addiction. Racial and ethnic minority populations tend to favor primary care treatment settings over specialty mental health settings. Recent therapeutic advances allow patients requiring specialized treatment for opioid abuse and addiction to be managed in primary care settings. The Drug Addiction Treatment Act of 2000 enables qualified physicians with readily available short-term training to treat opioid-dependent patients with buprenorphine in an office-based setting, potentially making primary care physicians active partners in the diagnosis and treatment of opioid use disorders.

Methadone and buprenorphine are effective opioid replacement agents for maintenance and/or detoxification of opioid-addicted individuals. However, restrictive federal regulations and stigmatization of opioid addiction and treatment have limited the availability of methadone. The opioid partial agonist-antagonist buprenorphine/naloxone combination has proven an effective alternative. This article reviews the literature on differences between buprenorphine and methadone regarding availability, efficacy, safety, sideeffects, and dosing, identifying resources for enhancing the effectiveness of medication-assisted recovery through coordination with behavioral/psychological counseling, embedded in the context of recovery-oriented systems of care.

References (72)

D. Broz et al.
Racial and ethnic changes in heroin injection in the United States: implications for the HIV/AIDS epidemic
Drug Alcohol Depend
(2008)
S.E. Back et al.
Gender and prescription opioids: Findings from the National Survey on Drug Use and Health
Addict Behav
(2010)
L.T. Wu et al.
Subtypes of nonmedical opioid users: Results from the national epidemiologic survey on alcohol and related conditions
Drug Alcohol Depend
(2010)
D.L. Haller et al.
Characteristics of pain patients with opioid-use disorder
Psychosomatics
(2010)
R.N. Jamison et al.
Substance misuse treatment for high-risk chronic pain patients on opioid therapy: A randomized trial
Pain
(2010)
J.H. Jaffe et al.
From morphine clinics to buprenorphine: regulating opioid agonist treatment of addiction in the United States
Drug Alcohol Depend
(2003)
S. Fanello et al.
Addictive behavior after starting buprenorphine maintenance treatment
Presse medicale
(2006)
J.R. Bell et al.
Comparing overdose mortality associated with methadone and buprenorphine treatment
Drug Alcohol Depend
(2009)
J. Kakko et al.
Buprenorphine and methadone treatment of opiate dependence during pregnancy: comparison of fetal growth and neonatal outcomes in two consecutive case series
Drug Alcohol Depend
(2008)
H. Alho et al.
Abuse liability of buprenorphine- naloxone tablets in untreated IV drug users
Drug Alcohol Depend
(2007)

N.L. Sohler et al.

Home-versus office-based buprenorphine inductions for opioid-dependent patients

J Subst Abuse Treat

(2010)

R.D. Weiss et al.

A multi-site, two-phase, prescription Opioid Addiction Treatment Study (pOATS): Rationale, design, and methodology

Contemp Clin Trials

(2010)

J.C. Veilleux et al.

A review of opioid dependence treatment: pharmacological and psychosocial interventions to treat opioid addiction

Clin Psychol Rev

(2010)

I. Maremmani et al.

Substance use and quality of life over 12 months among buprenorphine maintenance-treated and metha- done maintenance-treated heroin-addicted patients

J Subst Abuse Treat

(2007)

D. Satcher

Mental Health: Culture, Race, and Ethnicity—A Supplement to Mental Health: A Report of the Surgeon General

(2001)

M. Lillie-Blanton et al.

probing the meaning of racial/ethnic group comparisons in crack cocaine smoking

JAMA.

(1993)

S.A. Strassels

Economic burden of prescription opioid misuse and abuse

JManag Care Pharm

(2009)

C. Ruetsch

Empirical view of opioid dependence

J Manag Care Pharm.

(2010)

M.L. Hatzenbuehler et al.

Racial/ethnic disparities in service utilization for individuals with co-occurring mental health and substance use disorders in the general population

J Clin Psychiafr

(2008)

A.R. Elwy et al.

Race-ethnicity and diagnosis as predictors of outpatient service use among treatment initiators

Psychiafr Serv

(2008)

L.R. Snowden

pingitore D. Frequency and scope of mental health service delivery to African Americans in primary care

Menf Health Serv Res

(2002)

M.J. Krantz et al.

Treating opioid dependence: growing implications for primary care

Arch Intern Med

(2004)

S. Magura

What more do we need to know about medication-assisted treatment for prescription opioid abusers?

Addiction

(2009)

H.K. Knudsen et al.

Racial and ethnic composition as a correlate of medication availability within addiction treatment organizations

Socio Focus.

(2009)

Mental Health Services Administration. Results from the 2004 National Survey on Drug Use and Health: National Findings....

D. De Angelis et al.

Estimating long-term trends in the incidence and prevalence of opiate use/injecting drug use and the number of former users: back-calculation methods and opiate overdose deaths

Am J Epidemiol

(2004)

M.F. Fleming et al.

Reported Lifetime Aberrant Drug Taking Behaviors Are Predictive of Current Substance Use and Mental Health Problems in Primary Care Patients

Pain Med

(2008)

M.C. Canfield et al.

Prescription Opioid Use Among Patients Seeking Treatment for Opioid Dependence

J Addict Med

(2010)

C. Porucznik et al.

Adult use of prescription opioid pain medications-Utah, 2008

MMWR Morb Mortal Wkly Rep.

(2010)

C. Boyd et al.

Non-medical use of prescription analgesics: a three-year national longitudinal study

J Addict Dis

(2009)

R. Cai et al.

Emergency Department Visits Involving Nonmedical Use of Selected Prescription Drugs in the United States, 20042008

J Pain Palliat Care Pharmacother

(2010)

T.F. Babor et al.

Screening, Brief Intervention, and Referral to Treatment (SBIRT): toward a public health approach to the management of substance abuse

Subst Abuse

(2007)

S.P. Barrett et al.

What constitutes prescription drug misuse? Problems and pitfalls of current conceptualizations

Curr Drug Abuse Rev

(2008)

R. Heltsley et al.

Urine Drug Testing of Chronic Pain Patients. II. Prevalence Patterns of Prescription Opiates and Metabolites

J Anal Toxicol

(2010)

H. Smith et al.

Chronic opioid therapy issues associated with opioid abuse potential

J Opioid Manag

(2009)

Mayo Clinic. Prescription drug abuse....

Cited by (59)

Who receives heroin-assisted treatment? A comparison of patients receiving opioid maintenance treatment in Denmark
2024, Drug and Alcohol Dependence
Since 2010, heroin-assisted treatment (HAT) has been one of the treatment options available to people with opioid use disorder (OUD) in Denmark. This study aimed to characterize HAT patients at treatment start and compare their individual characteristics to those of patients entering traditional opioid maintenance treatment (OMT) with methadone or buprenorphine during the same period.
Patients who initiated HAT or OMT with methadone or buprenorphine in Denmark from 2010 to 2018 were included (n=6798). Multiple national registers were linked to compare treatment groups in terms of socio-demographic variables, previous OUD treatment episodes, hospital-based care, and criminal conviction history.
Nearly all HAT patients had a history of methadone treatment (91%) and half had residential treatment experience (48%). In the year previous to admission, HAT patients recorded the highest percentages of non-fatal overdoses (12%) and chronic hepatitis C diagnoses (16%), and the lowest percentages of psychiatric disorders (11%) compared to traditional OMT patients. Criminal convictions were also common: 39% of the HAT group had committed a property crime and 18% a drug-related crime the year before HAT entry. During the study period, an overall reduction in OMT enrollments for each year was recorded. The HAT proportion to the total remained fairly stable (4%−10%), while the buprenorphine proportion increased.
In Denmark, OMT patients exhibited numerous vulnerabilities at treatment start, and among the patient groups, HAT patients were the most burdened. HAT seems to reach the target group and adhere to formulated eligibility criteria.
Access to methadone clinics and opioid overdose deaths in Georgia: A geospatial analysis
2022, Drug and Alcohol Dependence
As a result of the opioid epidemic, the demand for treatment options for opioid use disorder (OUD) such as methadone has increased. Methadone can only be administered in methadone clinics. Though numerous methadone clinics are located across the state of Georgia, access to methadone treatment may still be a concern for certain areas of the state. In this study, we examine the relationship between access to methadone clinics and opioid overdose death rates at the county level and compare access to treatment through Federally Qualified Health Centers (FQHCs) if methadone provision was to expand in Georgia.
We utilize location data for methadone clinics and FQHCs, and opioid overdose death rates at the county level from 2019 for the study analysis. The analysis was carried out using a geographical information system (GIS) mapping and a descriptive analysis.
The results show that there is no methadone clinic accessible to individuals within a 15-minute drive time for 4 out of the 5 counties with the highest opioid overdose death rates in Georgia, though FQHCs are accessible within a 15-minute drive time to more than 67% of the population in each of these counties. Additionally, 7 out of the 9 counties with the highest opioid overdose death rates have no methadone clinic accessible within a 15-minute drive time, though all those counties have easier access to FQHCs.
If methadone distribution was to expand to FQHCs, more counties and a larger area of Georgia would have greater access to methadone treatment.
A bifurcated opioid treatment system and widening insidious disparities
2022, Addictive Behaviors
Co-occurrence of preconception maternal childhood adversity and opioid use during pregnancy: Implications for offspring brain development
2021, Neurotoxicology and Teratology
Understanding of the effects of in utero opioid exposure on neurodevelopment is a priority given the recent dramatic increase in opioid use among pregnant individuals. However, opioid abuse does not occur in isolation—pregnant individuals abusing opioids often have a significant history of adverse experiences in childhood, among other co-occurring factors. Understanding the specific pathways in which these frequently co-occurring factors may interact and cumulatively influence offspring brain development in utero represents a priority for future research in this area. We highlight maternal history of childhood adversity (CA) as one such co-occurring factor that is more prevalent among individuals using opioids during pregnancy and which is increasingly shown to affect offspring neurodevelopment through mechanisms beginning in utero. Despite the high incidence of CA history in pregnant individuals using opioids, we understand very little about the effects of comorbid prenatal opioid exposure and maternal CA history on fetal brain development. Here, we first provide an overview of current knowledge regarding effects of opioid exposure and maternal CA on offspring neurodevelopment that may occur during gestation. We then outline potential mechanistic pathways through which these factors might have interactive and cumulative influences on offspring neurodevelopment as a foundation for future research in this area.
Effects of access barriers and medication acceptability on buprenorphine-naloxone treatment utilization over 2 years: Results from a multisite randomized trial of adults with opioid use disorder
2019, Journal of Substance Abuse Treatment
Citation Excerpt :
In contrast, buprenorphine is a Schedule III partial agonist approved for use in the U.S. in 2002 and available in general health care settings. In addition to buprenorphine's greater ease of access, its abuse potential is lower than methadone, and it has a higher margin of safety (Bonhomme, Shim, Gooden, Tyus, & Rust, 2012; Gryczynski et al., 2013; Whelan & Remski, 2012). Despite the advantages of buprenorphine, individuals remain engaged in buprenorphine treatment for less time than those who receive methadone (Burns et al., 2015; Hser et al., 2016; Proctor, Copeland, Kopak, Herschman, & Polukhina, 2014).
Nationwide efforts seek to address the opioid epidemic by increasing access to medications for opioid use disorder (OUD), particularly with buprenorphine. A poorly understood challenge is that among individuals with OUD who do receive buprenorphine, many do not adhere to the pharmacotherapy long enough to achieve sustained benefits. We aimed to identify factors associated with buprenorphine treatment utilization over time.
We used random-intercept modeling to identify factors associated with buprenorphine treatment utilization over 2 years after first follow-up by 789 individuals with OUD who had participated in a multi-site randomized clinical trial of buprenorphine compared to methadone. Key predictors were participants' reports of buprenorphine treatment accessibility and acceptability (assessed at first follow-up) and their interaction effects, controlling for baseline randomization status, sociodemographics, and other covariates.
Approximately 9.3–11.2% of participants utilized buprenorphine treatment over the 2 years of follow-up. Interaction effects indicated that individuals who perceived buprenorphine to be both accessible and acceptable were most likely to use buprenorphine during follow-up, controlling for other factors. In contrast, individuals who perceived buprenorphine to be unacceptable were least likely to use buprenorphine, regardless the level of perceived access to the medication. Buprenorphine treatment utilization was also negatively associated with Hispanic ethnicity, West coast context, and cumulative months receiving methadone treatment and incarceration during follow-up.
To engage more individuals with OUD in long-term treatment with buprenorphine, interventions should target buprenorphine treatment acceptability, in addition to increasing buprenorphine access, and tailor efforts to meet the needs of vulnerable populations.
The START Follow-up Study on ClinicalTrials.gov (NCT01592461).
Urine is superior to oral fluid for detecting buprenorphine compliance in patients undergoing treatment for opioid addiction
2019, Drug and Alcohol Dependence
Buprenorphine (BUP) is commonly used in opioid agonist medication-assisted treatment (OA-MAT). Oral fluid (OF) is an attractive option for compliance monitoring during OA-MAT as collections are observed and evidence suggests that OF is less likely to be adulterated than urine (UR). However, the clinical and analytical performance of each matrix for monitoring BUP compliance has not been well studied.
We collected 260 paired OF and UR specimens. Concentrations of buprenorphine (BUP) and norbuprenorphine (NBUP) were measured by liquid chromatography-tandem mass spectrometry (LC–MS/MS) in each matrix. The glucuronide metabolites and naloxone concentrations were also measured in UR by LC–MS/MS. Medications were reviewed and UR creatinine concentrations were determined.
147/260 specimens (57%) were positive for BUP and/or metabolites in one or both matrices. BUP and/or metabolites were more likely to be detected in UR (p < 0.001). 1 OF specimen and 12 UR specimens were considered adulterated/substituted. The majority of patients prescribed BUP were positive for BUP in UR (97%) as opposed to OF (78%). The detection of undisclosed use approximately doubled in UR.
UR is the preferred matrix for detecting both buprenorphine compliance and undisclosed use. Clinicians should consider the ease of collection, risk of adulteration and detection of illicit drug use when deciding on an appropriate matrix. If OF testing is clinically necessary, UR should be measured in conjunction with OF at least periodically to avoid false negative BUP results.

View all citing articles on Scopus

: Funding/Support: Partial funding for this review came from the Addiction Technology Transfer Center grant 5UD1TI013589-09.

View full text

Original CommunicationsOpioid Addiction and Abuse in Primary Care Practice: A Comparison of Methadone and Buprenorphine as Treatment Options

Drug Alcohol Depend

Addict Behav

Drug Alcohol Depend

Psychosomatics

Pain

Drug Alcohol Depend

Drug Alcohol Depend

Drug Alcohol Depend

Drug Alcohol Depend

J Subst Abuse Treat

Contemp Clin Trials

Clin Psychol Rev

J Subst Abuse Treat

Mental Health: Culture, Race, and Ethnicity—A Supplement to Mental Health: A Report of the Surgeon General

probing the meaning of racial/ethnic group comparisons in crack cocaine smoking

JAMA.

Economic burden of prescription opioid misuse and abuse

JManag Care Pharm

Empirical view of opioid dependence

J Manag Care Pharm.

Racial/ethnic disparities in service utilization for individuals with co-occurring mental health and substance use disorders in the general population

J Clin Psychiafr

Race-ethnicity and diagnosis as predictors of outpatient service use among treatment initiators

Psychiafr Serv

pingitore D. Frequency and scope of mental health service delivery to African Americans in primary care

Menf Health Serv Res

Treating opioid dependence: growing implications for primary care

Arch Intern Med

What more do we need to know about medication-assisted treatment for prescription opioid abusers?

Addiction

Racial and ethnic composition as a correlate of medication availability within addiction treatment organizations

Socio Focus.

Estimating long-term trends in the incidence and prevalence of opiate use/injecting drug use and the number of former users: back-calculation methods and opiate overdose deaths

Am J Epidemiol

Reported Lifetime Aberrant Drug Taking Behaviors Are Predictive of Current Substance Use and Mental Health Problems in Primary Care Patients

Pain Med

Prescription Opioid Use Among Patients Seeking Treatment for Opioid Dependence

J Addict Med

Adult use of prescription opioid pain medications-Utah, 2008

MMWR Morb Mortal Wkly Rep.

Non-medical use of prescription analgesics: a three-year national longitudinal study

J Addict Dis

Emergency Department Visits Involving Nonmedical Use of Selected Prescription Drugs in the United States, 20042008

J Pain Palliat Care Pharmacother

Screening, Brief Intervention, and Referral to Treatment (SBIRT): toward a public health approach to the management of substance abuse

Subst Abuse

What constitutes prescription drug misuse? Problems and pitfalls of current conceptualizations

Curr Drug Abuse Rev

Urine Drug Testing of Chronic Pain Patients. II. Prevalence Patterns of Prescription Opiates and Metabolites

J Anal Toxicol

Chronic opioid therapy issues associated with opioid abuse potential

J Opioid Manag

Original Communications
Opioid Addiction and Abuse in Primary Care Practice: A Comparison of Methadone and Buprenorphine as Treatment Options