Practice Profile: Buprenorphine Maintenance Treatment

This is a medication-assisted treatment for individuals with opioid dependence. Similar to methadone, buprenorphine works by occupying the opioid receptor and blocking the high that usually comes from illicit opioid drug use; however, buprenorphine exerts a weaker effect at opioid receptor sites because it is a partial agonist. The practice is rated Effective for reducing heroin/opioid use and increasing retention in treatment; however, it is rated Ineffective for reducing use of benzodiazepines.

Practice Goals

Buprenorphine maintenance treatment (BMT) is a medication-assisted treatment for individuals with opioid dependence. The goals of BMT are to alleviate withdrawal symptoms, suppress opiate effects and cravings, and decrease the risk of overdose as a result of the illicit use of opioids.

Practice Components

Opioids, such as heroin or morphine, cause a release of excess dopamine in the body. Users become dependent on the drug because they need opiates to continuously occupy the opioid receptor in the brain. Similar to methadone, buprenorphine works by occupying this receptor and blocking the high that usually comes from illicit opioid drug use. While methadone causes a stronger agonist effect because it is a full agonist, buprenorphine exerts a weaker agonist effect at opioid receptor sites because it is a partial agonist.

The effects of buprenorphine increase as the dosage of the drug is increased; however, at moderate doses, the effects reach a plateau and no longer continue to grow (known as the ceiling effect). Because there is no ceiling to the level of effects that methadone can induce, illicit drug use can lead to fatal overdoses. Thus, buprenorphine can be used as a viable pharmacological alternative to methadone because it carries a lower risk of abuse, overdose, and side effects than do full opioid agonists.

Another benefit to BMT is the dosing schedule. Although the effects of buprenorphine are not as strong as methadone, they last longer. While methadone requires daily dosing, buprenorphine can be taken once every 2 days. This can be an advantage because opioid-addicted patients may not be able to adhere to treatment that requires daily dosage and visits to the clinics.

In addition, buprenorphine can be dispensed in office-based settings. Although methadone can only be dispensed from federally licensed opioid treatment programs, buprenorphine can be administered by physicians in their offices.

There are generally three stages of BMT: induction, stabilization, and maintenance. During the induction phase, patients are medically monitored during the beginning of the buprenorphine therapy. The stabilization phase begins once patients have greatly reduced or stopped their opioid abuse. During this phase, they no longer have cravings and experience few or no side effects. The dosage may also be adjusted during this phase. The maintenance phase begins once patients are on a steady dose of buprenorphine. The length of time that patients continue to receive BMT varies by individual and may be indefinite (SAMHSA 2019).

In addition to medication, BMT can include providing patients with comprehensive rehabilitation services, such as group therapy, individual therapy, medical services, and referrals to community-based agencies.

While the results from the meta-analysis by Mattick and colleagues (2014) showed that participants who received high-dose buprenorphine maintenance treatment (BMT) (defined as 16mg or more) were less likely to test positive for heroin/opioid use, compared with the control group participants who received placebos, the authors found no statistically significant differences between the BMT and control groups when looking at low- and medium-dose BMT (defined as 15mg or less).

Mattick and colleagues (2014) also compared BMT with methadone maintenance treatment (MMT) on several factors. They found that there was greater retention in treatment for individuals given flexible does of MMT, compared with individuals given flexible doses of BMT. However, there were no statistically significant differences between MMT and BMT on heroin/opioid use (as measured by self-reports and morphine-positive urine) or use of cocaine and benzodiazepine (as measured by positive urine). This suggests that while MMT is more effective in retaining people in treatment, MMT and BMT are equally effective at reducing illicit drug use.

These sources were used in the development of the practice profile:

These sources were used in the development of the practice profile:

Krook, Aud L., Odd Brørs, Jannicke Dahlberg, Kirsten Grouff, P. Magnus, E. Røysamb, and Helge Waal. 2002. “A Placebo-Controlled Study of High Dose Buprenorphine in Opiate Dependents Waiting for Medication-Assisted Rehabilitation in Oslo, Norway.” Addiction 97:533–42.

Fudala, Paul J., T. Peter Bridge, Susan Herbert, William O. Williford, C. Nora Chiang, Karen Jones, Joseph Collins, Dennis Raisch, Paul Casadonte, R. Jeffrey Goldsmith, Walter Ling, Usha Malkerneker, Laura McNicholas, John Renner, Susan Stine, and Donald Tusel. 2003. “Office-Based Treatment of Opiate Addiction with a Sublingual-Tablet Formulation of Buprenorphine and Naloxone.” New England Journal of Medicine 349(10):949–56.

Kakko, J., K.D. Svanborg, M.J. Kreek, and M. Heilig. 2003. “1-Year Retention and Social Function After Buprenorphine-Assisted Relapse Prevention Treatment for Heroin Dependence in Sweden: A Randomised, Placebo-Controlled Trial.” Lancet 361(9358):662–68.

Katz, Elizabeth C., Robert P. Schwartz, Stuart King, David A. Highfield, Kevin E. O’Grady, Timothy Billings, Devang Gandhi, Eric Weintraub, David Glovinsky, Wardell Barksdale, and Barry S. Brown. 2009. “Brief Versus Extended Buprenorphine Detoxification in a Community Treatment Program: Engagement and Short-Term Outcomes.” American Journal of Drug and Alcohol Abuse 35:63–67.

Kinlock, Timothy W., Michael S. Gordon, Robert S. Schwartz, and Terrence T. Fitzgerald. 2010. “Developing and Implementing a New Prison-Based Buprenorphine Treatment Program.” Journal of Offender Rehabilitation 49:91–109.

Krook, A.L., O. Brørs, J. Dahlberg, K. Grouff, P. Magnus, E. Røysamb, and H. Waal. 2002. “A Placebo-Controlled Study of High Dose Buprenorphine in Opiate Dependents Waiting for Medication-Assisted Rehabilitation in Oslo, Norway.” Addiction 97(5):533–42.

Ling, W., C. Charuvastra, J.F. Collins, S. Batki, L.S. Brown Jr., P. Kintaudi … D. Segal. 1998. “Buprenorphine Maintenance Treatment of Opiate Dependence: A Multicenter, Randomised Clinical Trial.” Addiction 93(4):475–86.

Ling, W., P. Casadonte, G. Beglow, K.M. Kampman, A. Patkar, G.L. Bailey… K.L. Beebe. 2010. “Buprenorphine Implants for Treatment of Opioid Dependence: A Randomized Controlled Trial.” JAMA 304(14):1576–1583.

Lintzeris, Nicholas, Alison Ritter, Mary Panjari, Nicholas Clark, Jozica Kutin, and Gabriele Bammer. 2004. “Implementing Buprenorphine Treatment in Community Settings in Australia: Experiences from the Buprenorphine Implementation Trial.” The American Journal on Addictions 13:S29–S41.

(SAMHSA) Substance Abuse and Mental Health Services Administration. 2019. “Buprenorphine.” Rockville, Md.: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration.

Washington State Institute for Public Policy. 2018. Buprenorphine (or Buprenorphine/Naloxone) Maintenance Treatment for Opioid Use Disorder. Olympia, Wash.: Washington State Institute for Public Policy.