Opioid dependence treatment - KFP-style written assessment

KFP 1 (10 marks)

A 32-year-old man with heroin dependence wants to start treatment. He has been using daily for four years, injecting intravenously. He wants to know which medication is better. ^[1]

1. What are the first-line pharmacotherapy options and how do they compare? (4) ^[1]
2. What does the evidence show about mortality during treatment? (3) ^{[1] [2]}
3. What safety precautions apply during methadone induction? (3) ^{[1] [2]}

Model answers

1. Methadone and buprenorphine-naloxone are both first-line. Meta-analysis shows equivalent retention rates between them (no significant difference in RCTs), though buprenorphine's partial mu-agonism provides a ceiling effect on respiratory depression making it safer in overdose. Methadone may retain some severe-dependence patients better. ^[1]
2. All-cause mortality during OAT is less than half that during time out of treatment (RR 0.47). Pooled mortality rates: 11.3 per 1000 PY during methadone vs 36.1 out; 4.3 vs 9.5 for buprenorphine. Suicide, drug-related, alcohol-related, cardiovascular and cancer mortality are all reduced during OAT. ^{[1] [2]}
3. Methadone induction carries almost double the all-cause mortality risk in the first four weeks. Start low (10-20 mg), titrate slowly, monitor closely. Buprenorphine requires mild-to-moderate withdrawal before first dose to avoid precipitated withdrawal. ^{[1] [2]}