Abstract
BackgroundMany drug users present to primary care requesting detoxification from illicit opiates. There are a number of detoxification agents but no recommended drug of choice. The purpose of this study is to compare buprenorphine with dihydrocodeine for detoxification from illicit opiates in primary care.MethodsOpen label randomised controlled trial in NHS Primary Care (General Practices), Leeds, UK. Sixty consenting adults using illicit opiates received either daily sublingual buprenorphine or daily oral dihydrocodeine. Reducing regimens for both interventions were at the discretion of prescribing doctor within a standard regimen of not more than 15 days. Primary outcome was abstinence from illicit opiates at final prescription as indicated by a urine sample. Secondary outcomes during detoxification period and at three and six months post detoxification were recorded.ResultsOnly 23% completed the prescribed course of detoxification medication and gave a urine sample on collection of their final prescription. Risk of non-completion of detoxification was reduced if allocated buprenorphine (68% vs 88%, RR 0.58 CI 0.35–0.96, p = 0.065). A higher proportion of people allocated to buprenorphine provided a clean urine sample compared with those who received dihydrocodeine (21% vs 3%, RR 2.06 CI 1.33–3.21, p = 0.028). People allocated to buprenorphine had fewer visits to professional carers during detoxification and more were abstinent at three months (10 vs 4, RR 1.55 CI 0.96–2.52) and six months post detoxification (7 vs 3, RR 1.45 CI 0.84–2.49).ConclusionInformative randomised trials evaluating routine care within the primary care setting are possible amongst drug using populations. This small study generates unique data on commonly used treatment regimens.
Highlights
Many drug users present to primary care requesting detoxification from illicit opiates
By intention to treat analysis we found a higher proportion of people allocated to buprenorphine provided a urine sample negative for opiates compared with those who received dihydrocodeine (21% vs 3%, RR 2.06 CI 1.33–3.21, p = 0.028)
A higher proportion of people randomised to buprenorphine provided a final urine sample negative for
Summary
Many drug users present to primary care requesting detoxification from illicit opiates. In the United Kingdom (UK), policy directives have highlighted the importance of offering either maintenance or detoxification to illicit opiate users within an agreed plan of care [1]. This is in response to routine practice by some treatment providers of 'gradual reduction' of opiate maintenance treatment – a regimen without a supporting evidence base [2]. Methadone has a long half life [5,6] and patients often report distressing withdrawal symptoms in the latter stages of detoxification [6] This has meant increasing use of alternative agents such as clonidine, lofexidine, dihydrocodeine and, more recently, buprenorphine. The hypotensive effects of clonidine [4] have make it unacceptable for use in primary care and the reduced ability of lofexidine to control withdrawal, coupled with its high cost have resulted in limited clinical uptake [4]
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