Effect of buprenorphine dose on treatment outcome. Fareed A., Vayalapalli S., Casarella J. et al. Journal of Addictive Diseases: 2012, 31(1), p. 8–18.

How much buprenorphine does it take to keep patients in treatment and suppress illicit use of heroin or other opiate-type drugs? This review concludes that on average higher is better than lower, but that individualising dose and a preparedness to go high if needed are the keys to effective treatment.

Summary
As an alternative primarily to methadone, buprenorphine has many qualities which make it an effective treatment for opioid dependence. There is less of a build up of tolerance to the drug, it is safer in overdose, and it may help relieve negative mood. Induction is easy, even for physicians with limited experience with opioid maintenance treatment. Several studies have found buprenorphine a safe and effective medication for primary care-based treatment.

Most of the initial studies of buprenorphine reported that lower doses (8mg or less per day) were not as effective as higher doses (8–16mg) in suppressing illicit opiate use and retaining patients in treatment. Such findings led to studies of yet higher doses which have found 16–32mg safe and more effective than lower doses in reducing illicit use and craving for opioids.

Doses greater than 24 to 32mg per day do not directly increase the risk of overdose death due to respiratory depression but may increase risk when other depressant drugs are taken at the same time. The aim is to achieve the best treatment outcome without jeopardising safety.

As a contribution to this objective, the featured review looked for studies which would enable a comparison between retention and substance use outcomes among patients prescribed less than 16mg per day versus those prescribed 16mg or more. The search was restricted to randomised controlled trials of buprenorphine maintenance treatment, the results of which were published in English-language articles between 1960 and 2010. Fifty such articles were found of which the results reported in 21 could be included in a synthesis of the findings. These studies were divided in to those which prescribed 16mg or more of buprenorphine per day versus those which prescribed less than 16mg per day.