Also, in February 2003, the Royal College of General Practitioners published guidance and developed a training programme (Ford et al. 2003). The guidance outlines the indications, contraindications and precautions for buprenorphine, and examines topics such as dosage regimens, maintenance treatment, prescribing, detoxification and shared care. It recommends that, initially, buprenorphine should be dispensed daily and, if possible its consumption should be supervised by a pharmacist for at least three months. In addition, it emphasises the importance of patient education. However, the guidance also states that patients who are responding well to existing treatment (whether buprenorphine or methadone) should remain on their current treatment.

Further, Ford et al. (2003) state that there appears to be increasing consensus among clinicians experienced in using both buprenorphine and methadone that:

• buprenorphine may be better suited to those who wish to cease using heroin, as the blockade effects of even moderate dose buprenorphine interfere with the subjective effects of additional heroin use. To achieve the same effect with methadone, a much higher dose is required. So, those patients who wish to continue to use heroin may prefer low dose buprenorphine treatment;
• withdrawal from buprenorphine appears to be milder than from methadone, and as such may be preferred for those considering a detoxification program;
• the transition from buprenorphine to naltrexone can be accomplished much earlier than that from methadone to naltrexone, and consequently, those considering naltrexone treatment may be better suited to buprenorphine.

Ford et al. (2003) then go on to compare buprenorphine to methadone, suggesting that:

• it is less dangerous in overdose;
• with maintenance doses between eight and 32 µg the effects of other opioids used ‘on top’ are markedly reduced, with optimal effect at a dosage of between 12 to 24 µg daily;
• it is useful in maintenance and detoxification, being easier to withdraw from; and
• patients report that they remain clearer headed with less ‘clouding’ effect (this may be positive or negative for different patients).

Disadvantages are that:

• it is highly soluble leading to potential for injection;
• it can precipitate acute opiate withdrawal if used incorrectly; and
• it is more expensive than methadone.

References
Ford, C., Morton, S., Lintzeris, N., Bury, J. and Gerada, C. (2004). Guidance for the use of buprenorphine for the treatment of opioid dependence in primary care. Drug & Alcohol Misuse Training Programme, Substance Misuse Management in General Practice and Royal College of General Practitioners Sex, Drugs and HIV Task Group. Royal College of General Practitioners. London.