Table 3 International guideline assessment of the evidence for substitute opioid therapy in treatment of opioid dependence (assessment of recommendations based on effect reported in literature)
Title of guideline | Evidence provided | Eligibility criteria used across trials (including criteria from trials within meta-analyses used as evidence) | Grading of evidence by guideline panel | Reported net effect of intervention | Recommendation | Guideline provided caution about populations the intervention was assessed in | Cautions | Discussion of opioid substitution treatment use for subpopulations (psychiatric patients, patients on psychotropic medication, patients with concurrent poly-substance use problems) |
|---|---|---|---|---|---|---|---|---|
Clinical practice guideline for management of substance use disorders (SUD) [13] (Methadone and buprenorphine for reduction in illicit opioid use) | Inclusion of patients >18 with DSM-IV diagnosis of opioid dependence Exclusion of patients with psychiatric disorders, concurrent substance use disorders, and those being prescribed psychotropic medications | Good | Substantiala | A strong recommendation | No | Note that buprenorphine is preferred to methadone in pregnant women | Yes, methadone was more effective than buprenorphine for patients with concurrent cocaine dependence | |
Clinical practice guideline for management of substance use disorders (SUD) [13] (Methadone and buprenorphine for patient retention) | [75] | Inclusion of patients >18 with DSM-IV diagnosis of opioid dependence Exclusion of patients with psychiatric disorders, concurrent substance use disorders, and those being prescribed psychotropic medications. | Good | Substantiala | A strong recommendation | No | None | No |
Clinical practice guideline for management of substance use disorders (SUD) [13] Naltrexone for reduction in illicit opioid use and treatment retention) | Inclusion of patients >18 with DSM-IV diagnosis of opioid dependence Exclusion of patients with psychiatric disorders, concurrent substance use disorders, and those being prescribed psychotropic medications | Poor to fair | Small to moderate | No recommendation for or against the routine provision of the intervention is made. At least fair evidence was found that the intervention can improve health outcomes, but concludes that the balance of benefits and harms is too close to justify a general recommendation. | No | Suggested for use in highly motivated patients | Yes, recommends naltrexone within highly motivated patients | |
Buprenorphine/naloxone treatment for opioid dependence clinical practice guidelines[14] | Inclusion of patients with daily drug injection behavior, ≥18 and a DSM-IV diagnosis of opioid dependence Exclusion of patients prescribed psychotropic medications, and patients with serious physical conditions or concurrent drug/alcohol dependence | Good | Not reported | A strong recommendation | No | A list of contraindications is provided (e.g., pregnancy, allergy, severe liver dysfunction, acute severe respiratory illness. No mention of psychiatric illness or concurrent substance use problems. | Yes, require no concurrent substance use problems prior to buprenorphine induction as well as required full management of psychiatric symptoms | |
Methadone maintenance treatment program standards and clinical guidelines [12] | Inclusion of patients ≥18 with DSM-IV diagnosis of opioid dependence 18 and 50 years, history of intravenous opioid dependence, no chronic medical illnesses, absence of a major mental illness, a negative pregnancy test for women, and at least 3 months since the patient’s last treatment at the clinic | Not graded | Not reported | There are guideline suggestions provided but no “rank” of recommendation | No | Note about treatment pregnant women and patients under 18 | No | |
Methadone and buprenorphine for the management of opioid dependence [52] | [82] | Inclusion of patients ≥18 with DSM-IV diagnosis of opioid dependence Exclusion of patients with psychiatric disorders, comorbid substance use, patients on psychotropic medications | Reported as good quality evidence | Not reported | No direct recommendations made | Yes, discussed the populations the interventions were tested in and explicit detailing of trial design characteristics | None | Yes |
Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence [53] | Inclusion of patients age ≥18 meeting DSM-IV criteria for opioid dependence with six prior treatment episodes at the facility running the randomized trial, or a single prior methadone treatment, and urine screen positive for opioids. | Moderate for substance use behavior and high for treatment retention (for both methadone and buprenorphine) | Small to moderate (for both opioid use and retention) | Strong | Yes, also a guidance is provided for managing specific subpopulations (women, patients with psychiatric comorbidity, patients with chronic pain) | Note agonist therapy is suggested most effective, methadone is preferred to buprenorphine. In pregnant women less safety evidence is available, use methadone in such cases. | Yes | |
Exclusion of patients with psychiatric or chronic physical comorbidities or being prescribed psychotropic medication, acute medical condition, and pregnant women |