Background

Managed withdrawal (detoxification) is a necessary step prior to drug‐free treatment. It may also represent the end point of long‐term opioid replacement treatment such as methadone maintenance.

Objectives

To assess the effectiveness of interventions involving the use of buprenorphine to manage opioid withdrawal, in terms of withdrawal signs and symptoms, completion of withdrawal and adverse effects.

Search methods

We searched the Drugs and Alcohol Group trials register (searched October 2003), Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 3, 2004), Medline (January 1966 to September 2004), Embase (January 1985 to September 2004), PsycINFO (1967 to September 2004), Australian Medical Index (1968 to October 2003) and reference lists of articles.

Selection criteria

Controlled trials comparing buprenorphine with reducing doses of methadone, alpha2 adrenergic agonists, symptomatic medications or placebo, or comparing different buprenorphine‐based regimes, to modify the signs and symptoms of withdrawal in participants who were primarily opioid dependent.

Data collection and analysis

One reviewer assessed studies for inclusion and methodological quality, and undertook data extraction. Inclusion decisions and the overall process was confirmed by consultation between all three reviewers.

Main results

Fourteen studies (11 randomised controlled trials), involving 784 participants, were included. Seven studies compared buprenorphine with clonidine; three compared buprenorphine with methadone; one compared buprenorphine with oxazepam; three compared different rates of buprenorphine dose reduction; one compared three different starting doses of buprenorphine.

For groups treated with buprenorphine, withdrawal severity was less than that in groups treated with clonidine; peak severity was similar to those treated with methadone, but withdrawal symptoms may resolve more quickly with buprenorphine. Withdrawal is probably more severe when doses are tapered rapidly following a period of maintenance treatment.

Buprenorphine is associated with fewer adverse effects than clonidine, and completion of treatment is significantly more likely with buprenorphine (relative risk 1.38, 95% confidence interval 1.21 to 1.57). In the two studies that reported data, there was no statistically significant difference in rates of completion of treatment for buprenorphine compared to methadone in reducing doses. Completion of withdrawal following buprenorphine maintenance treatment may be more likely when doses are reduced gradually.

Authors' conclusions

Buprenorphine is more effective than clonidine for the management of opioid withdrawal. There appears to be no significant difference between buprenorphine and methadone in terms of completion of treatment, but withdrawal symptoms may resolve more quickly with buprenorphine.