Methadone may provide a more durable treatment option for opioid addiction

Key takeaways:

• Methadone linked to a lower risk for opioid use disorder treatment discontinuation vs. buprenorphine and naloxone.
• Both treatment options associated with low mortality risk.

Individuals receiving methadone for opioid use disorder had a lower risk for discontinuing treatment compared with the combination of buprenorphine and naloxone, study results published in JAMA showed.

However, the findings revealed low mortality risk when receiving either treatment option.

According to Bohdan Nosyk, PhD, a professor in the faculty of health sciences at Simon Fraser University in Canada, and colleagues, international guidelines on the treatment of opioid use disorder (OUD) “remain discordant” due to limited evidence on the comparative effectiveness between methadone and buprenorphine with naloxone.

Treatment options for OUD also remain underutilized, with prior research showing that only one in five adults with the condition receive medication.

In the analysis, the researchers compared the treatments’ effects on risks for treatment discontinuation and mortality among a cohort of adults who received treatment between Jan. 1, 2010, and March 17, 2020.

Researchers constructed the study cohort from patient data taken from linked health administrative databases in Canada. They presented results of both a treatment initiator analysis and a per-protocol analysis.

The initiator analysis included all patients who started treatment , whereas in the per-protocol analysis the researchers compared the two treatments at optimal doses.

Overall, the analysis included 30,891 individuals — 39% of whom received buprenorphine and naloxone — in the initiator analysis and 25,614 in the per-protocol analysis.

In the initiator analysis, users of buprenorphine and naloxone had a higher risk for treatment discontinuation at 24 months vs. users of methadone (88.8% vs 81.5%; adjusted HR = 1.58; 95% CI, 1.53-1.63).

Nosyk and colleagues added that there was little change in the estimates of treatment discontinuation between buprenorphine and naloxone users and methadone users when they were evaluated in the per-protocol analysis (42.1% vs. 30.7%; aHR = 1.67; 95% CI, 1.58-1.76).

The differences in the risks for mortality between buprenorphine and naloxone users and methadone users was “ambiguous” among first-time users (aHR = 0.57; 95% CI, 0.24-1.35) and prevalent users (aHR = 0.97; 95% CI, 0.54-1.73), the researchers noted.

They added that the results remained consistent across subgroups and sensitivity analyses.

Noysk and colleagues explained that the data add to the growing body of evidence that supports methadone for the sustained treatment of OUD.

However, strategies to improve retention, “potentially including engagement of peer

support workers, require dedicated focus to ensure the benefits of these lifesaving medications are fully realized,” they wrote.

There were several study limitations. For example, the estimates of mortality were imprecise because of low event rates, whereas the analysis may have been affected by uncontrolled confounding, Nosyk and colleagues pointed out.

They concluded that “clinical guidelines for all aspects of the treatment of people with OUDs require reconsideration to reduce the risk of discontinuation of treatment” as the use of synthetic opioids continues to grow.