Home > Medicine choices in opioid substitution treatment. Recommendations for prescribing methadone and buprenorphine to people in treatment for opioid dependence in England.

United Kingdom. Department of Health & Social Care. (2024) Medicine choices in opioid substitution treatment. Recommendations for prescribing methadone and buprenorphine to people in treatment for opioid dependence in England. London: Department of Health & Social Care.

External website: https://www.gov.uk/government/publications/medicin...


Opioid substitution treatment (OST) is proven to reduce harm to people who are dependent on opioids. In 2007, the National Institute for Health and Care Excellence (NICE) technology appraisal Methadone and buprenorphine for the management of opioid dependence (TA114) made the following recommendations:

  • Methadone and buprenorphine (given as a tablet or a liquid) are recommended as treatment options for people who are opioid dependent.
  • A decision about which is the better treatment should be made on an individual basis, in consultation with the person, taking into account the possible benefits and risks of each treatment for that particular person. If both drugs are likely to have the same benefits and risks, methadone should be given as the first choice.
  • Different people will need different doses of methadone or buprenorphine. People should take methadone or buprenorphine daily in the presence of their doctor, nurse or community pharmacist for at least the first 3 months of treatment and until they are able to continue their treatment correctly without supervision.
  • Treatment with methadone or buprenorphine should be given as part of a support programme to help the person manage their opioid dependence.

In 2017, Drug misuse and dependence: UK guidelines on clinical management (the Orange Book) developed these recommendations further and in more depth, as well as taking into account changes in clinical practice since 2007. It also referenced the NICE clinical guideline Drug misuse in over 16s: opioid detoxification (CG52).

Since these guidance documents were published, there have been 3 main changes which meant that an update was necessary:

  • our knowledge base (research evidence, data and clinical experience) has grown, and so has the availability of different buprenorphine formulations
  • we have more evidence that engagement with OST is associated with reduced mortality across a range of conditions
    the arrival of potent illicit synthetic opioids in the UK has reinforced the importance of engaging and retaining greater numbers of opioid dependent people in treatment

These changes led to the Department of Health and Social Care (DHSC) convening a clinical expert group to consider the evidence and clinical experience to advise DHSC on recommendations for England to supplement the Orange Book. This guidance on the choice between, and use of, methadone and buprenorphine in OST is the first output of that work. We will update it in 2025 to include guidance on the use of buprenorphine long-acting injection in treatment.

NICE has confirmed that except for the recommendations on the duration of supervised consumption, this guidance does not significantly differ from its TA114 and CG52. Since these documents were published, clinical practice and guidance has already established greater flexibility than was recommended in 2007...

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