Difficulties with buprenorphine

Taikato et al (Psychiatric Bulletin, June 2005, 29, 225-227) provide a useful summary of the benefits of buprenorphine as a treatment for heroin misuse. However, the optimism with which it is described may have misled readers. Most importantly, they claim superior efficacy compared with methadone without citing supporting evidence. In terms of the most important outcome measures (retaining individuals in treatment and reducing heroin use) a recent Cochrane review clearly came down on the side of methadone (Mattick et al, 2004, Mattick et al, 2004).

Buprenorphine undoubtedly remains an important treatment option because of its safety profile. However, in Cornwall, where we have more than 200 people receiving it and where supervised consumption at the local chemist has become the norm, this apparent advantage may not justify the extra cost and may be negated by problems with administration. Our experience has been that community pharmacists are unable to properly supervise consumption of the drug because administration under the tongue takes so long (sometimes up to 5 min). This difficulty, which is in contrast to methadone, has led to diversion of buprenorphine onto the black market, and subsequent intravenous use. Unfortunately, in France intravenous use has been linked with a large number of deaths (Kintz, 2001).