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PMID- 28292795
DA  - 20170315
DCOM- 20170330
LR  - 20170403
IS  - 1715-5258 (Electronic)
IS  - 0008-350X (Linking)
VI  - 63
IP  - 3
DP  - 2017 Mar
TI  - Primary care management of opioid use disorders: Abstinence, methadone, or
PG  - 200-205
AB  - OBJECTIVE: To advise physicians on which treatment options to recommend for
      specific patient populations: abstinence-based treatment, buprenorphine-naloxone 
      maintenance, or methadone maintenance. SOURCES OF INFORMATION: PubMed was
      searched and literature was reviewed on the effectiveness, safety, and side
      effect profiles of abstinence-based treatment, buprenorphine-naloxone treatment, 
      and methadone treatment. Both observational and interventional studies were
      included. MAIN MESSAGE: Both methadone and buprenorphine-naloxone are
      substantially more effective than abstinence-based treatment. Methadone has
      higher treatment retention rates than buprenorphine-naloxone does, while
      buprenorphine-naloxone has a lower risk of overdose. For all patient groups,
      physicians should recommend methadone or buprenorphine-naloxone treatment over
      abstinence-based treatment (level I evidence). Methadone is preferred over
      buprenorphine-naloxone for patients at higher risk of treatment dropout, such as 
      injection opioid users (level I evidence). Youth and pregnant women who inject
      opioids should also receive methadone first (level III evidence). If
      buprenorphine-naloxone is prescribed first, the patient should be promptly
      switched to methadone if withdrawal symptoms, cravings, or opioid use persist
      despite an optimal buprenorphine-naloxone dose (level II evidence).
      Buprenorphine-naloxone is recommended for socially stable prescription oral
      opioid users, particularly if their work or family commitments make it difficult 
      for them to attend the pharmacy daily, if they have a medical or psychiatric
      condition requiring regular primary care (level IV evidence), or if their jobs
      require higher levels of cognitive functioning or psychomotor performance (level 
      III evidence). Buprenorphine-naloxone is also recommended for patients at high
      risk of methadone toxicity, such as the elderly, those taking high doses of
      benzodiazepines or other sedating drugs, heavy drinkers, those with a lower level
      of opioid tolerance, and those at high risk of prolonged QT interval (level III
      evidence). CONCLUSION: Individual patient characteristics and preferences should 
      be taken into consideration when choosing a first-line opioid agonist treatment. 
      For patients at high risk of dropout (such as adolescents and socially unstable
      patients), treatment retention should take precedence over other clinical
      considerations. For patients with high risk of toxicity (such as patients with
      heavy alcohol or benzodiazepine use), safety would likely be the first
      consideration. However, the most important factor to consider is that opioid
      agonist treatment is far more effective than abstinence-based treatment.
CI  - Copyright(c) the College of Family Physicians of Canada.
FAU - Srivastava, Anita
AU  - Srivastava A
AD  - Associate Professor in the Department of Family and Community Medicine at the
      University of Toronto in Ontario and a member of the St Joseph's Urban Family
      Health Team in Toronto. [email protected]
FAU - Kahan, Meldon
AU  - Kahan M
AD  - Associate Professor in the Department of Family and Community Medicine at the
      University of Toronto and Medical Director of the Substance Use Service at
      Women's College Hospital in Toronto.
FAU - Nader, Maya
AU  - Nader M
AD  - Staff physician in the Department of Family and Community Medicine at St
      Michael's Hospital in Toronto.
LA  - eng
PT  - Case Reports
PT  - Journal Article
PT  - Review
PL  - Canada
TA  - Can Fam Physician
JT  - Canadian family physician Medecin de famille canadien
JID - 0120300
RN  - 0 (Buprenorphine, Naloxone Drug Combination)
RN  - 0 (Narcotic Antagonists)
RN  - UC6VBE7V1Z (Methadone)
SB  - IM
MH  - Age Factors
MH  - Buprenorphine, Naloxone Drug Combination/adverse effects/*therapeutic use
MH  - Evidence-Based Medicine
MH  - Female
MH  - Health Status
MH  - Humans
MH  - Methadone/adverse effects/*therapeutic use
MH  - Narcotic Antagonists/adverse effects/*therapeutic use
MH  - Opioid-Related Disorders/*drug therapy/therapy
MH  - Patient Preference
MH  - Primary Health Care/*methods
MH  - Risk Factors
MH  - Risk Reduction Behavior
MH  - Social Environment
MH  - Young Adult
PMC - PMC5349718
EDAT- 2017/03/16 06:00
MHDA- 2017/03/31 06:00
CRDT- 2017/03/16 06:00
AID - 63/3/200 [pii]
PST - ppublish
SO  - Can Fam Physician. 2017 Mar;63(3):200-205.

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