[Table], Recommendations for treatment of the individual patient - Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence

		Strength of recommendation	Quality of evidence
Choice of treatment	For the pharmacological treatment of opioid dependence, clinicians should offer opioid withdrawal, opioid agonist maintenance and opioid antagonist (naltrexone) treatment, but most patients should be advised to use opioid agonist maintenance treatment.	Strong	Low to moderate
	For opioid-dependent patients not commencing opioid agonist maintenance treatment, consider antagonist pharmacotherapy using naltrexone following the completion of opioid withdrawal.	Standard	Low
Opioid agonist maintenance treatment	For opioid agonist maintenance treatment, most patients should be advised to use methadone in adequate doses in preference to buprenorphine.	Strong	High
	During methadone induction, the initial daily dose should depend on the level of neuroadaptation; it should generally not be more than 20 mg, and certainly not more than 30mg.	Strong	Very low
	On average, methadone maintenance doses should be in the range of 60–120 mg per day.	Strong	low
	Average buprenorphine maintenance doses should be at least 8 mg per day.	Standard	Very low
	Methadone and buprenorphine doses should be directly supervised in the early phase of treatment.	Strong	Very low
	Take-away doses may be provided for patients when the benefits of reduced frequency of attendance are considered to outweigh the risk of diversion, subject to regular review.	Standard	Very low
	Psychosocial support should be offered routinely in association with pharmacological treatment for opioid dependence.	Strong	High
Management of opioid withdrawal	For the management of opioid withdrawal, tapered doses of opioid agonists should generally be used, although alpha-2 adrenergic agonists may also be used.	Standard	Moderate
	Clinicians should not routinely use the combination of opioid antagonists and minimal sedation in the management of opioid withdrawal.	Standard	Very low
	Clinicians should not use the combination of opioid antagonists with heavy sedation in the management of opioid withdrawal.	Strong	low
	Psychosocial services should be routinely offered in combination with pharmacological treatment of opioid withdrawal.	Standard	Moderate
Pregnancy	Opioid agonist maintenance treatment should be used for the treatment of opioid dependence in pregnancy.	Strong	Very low
	Methadone maintenance should be used in pregnancy in preference to buprenorphine maintenance for the treatment of opioid dependence; although there is less evidence about the safety of buprenorphine, it might also be offered.	Standard	Very low

Strength of recommendation

Quality of evidence

Choice of treatment

For the pharmacological treatment of opioid dependence, clinicians should offer opioid withdrawal, opioid agonist maintenance and opioid antagonist (naltrexone) treatment, but most patients should be advised to use opioid agonist maintenance treatment.

Strong

Low to moderate

For opioid-dependent patients not commencing opioid agonist maintenance treatment, consider antagonist pharmacotherapy using naltrexone following the completion of opioid withdrawal.

Standard

Low

Opioid agonist maintenance treatment

For opioid agonist maintenance treatment, most patients should be advised to use methadone in adequate doses in preference to buprenorphine.

Strong

High

During methadone induction, the initial daily dose should depend on the level of neuroadaptation; it should generally not be more than 20 mg, and certainly not more than 30mg.

Strong

Very low

On average, methadone maintenance doses should be in the range of 60–120 mg per day.

Strong

low

Average buprenorphine maintenance doses should be at least 8 mg per day.

Standard

Very low

Methadone and buprenorphine doses should be directly supervised in the early phase of treatment.

Strong

Very low

Take-away doses may be provided for patients when the benefits of reduced frequency of attendance are considered to outweigh the risk of diversion, subject to regular review.

Standard

Very low

Psychosocial support should be offered routinely in association with pharmacological treatment for opioid dependence.

Strong

High

Management of opioid withdrawal

For the management of opioid withdrawal, tapered doses of opioid agonists should generally be used, although alpha-2 adrenergic agonists may also be used.

Standard

Moderate

Clinicians should not routinely use the combination of opioid antagonists and minimal sedation in the management of opioid withdrawal.

Standard

Very low

Clinicians should not use the combination of opioid antagonists with heavy sedation in the management of opioid withdrawal.

Strong

low

Psychosocial services should be routinely offered in combination with pharmacological treatment of opioid withdrawal.

Standard

Moderate

Pregnancy

Opioid agonist maintenance treatment should be used for the treatment of opioid dependence in pregnancy.

Strong

Very low

Methadone maintenance should be used in pregnancy in preference to buprenorphine maintenance for the treatment of opioid dependence; although there is less evidence about the safety of buprenorphine, it might also be offered.

Standard

Very low

From: Executive summary

Guidelines for the Psychosocially Assisted Pharmacological Treatment of Opioid Dependence.

Geneva: World Health Organization; 2009.

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