Similar Outcomes from Observed and Unobserved Dosing of Buprenorphine-Naloxone

Few studies have compared the effects of observed dosing of opioid maintenance treatment (medication dispensed daily in a clinic) with the effects of unobserved dosing (medication dispensed weekly and taken at home). This Australian study randomized 119 people who used heroin and were seeking maintenance treatment to receive either observed dosing or unobserved dosing of buprenorphinenaloxone for 3 months. All subjects met weekly with a nurse case-manager.

• At 3 months, retention in treatment was similar among the groups (61% of the observed dosing group versus 57% of the unobserved dosing group).

• Reduction in days of heroin use from baseline to 3 months was also similar (reduction of 22 days for the observed dosing group versus 18.5 days for the unobserved dosing group).

• Cost was significantly higher for the observed dosing group ($1858 versus $1445).*

Comments:

This paper has implications for primary care and office-based providers who routinely prescribe buprenorphine- naloxone. An editorialist notes that opioid treatment providers often believe that observed dosing (i.e., “more intensive treatment”) leads to better outcomes. Conversely, this study’s investigators hypothesized that attendance for observed dosing would serve as a deterrent to treatment retention and lead to worse outcomes. The overall findings suggest that neither assertion is universal and that unobserved dosing is, on average, more cost effective.

From a clinical perspective, however, the results beg this question: will certain patients (e.g., those with more severe and disabling disorders) do better in a more structured program and others (e.g., those able to work) benefit from fewer constraints? Ideology aside, the availability of both office-based buprenorphine-naloxone and structured opioid treatment programs remains necessary in order to meet the individual treatment needs of patients with opioid dependence.

Peter D. Friedmann, MD, MPH

Reference:

Bell J, Shanahan M, Mutch C, et al. A randomized trial of effectiveness and cost-effectiveness of observed versus unobserved administration of buprenorphinenaloxone for heroin dependence. Addiction. 2007;102(12):1899–1907.