• Kristie Mammen and James Bell.
• The Langton Centre, South Eastern Sydney and Illawarra Area Health Service, Surry Hills, NSW 2010, Australia.
• Expert Opin Pharmacother. 2009 Oct 1; 10 (15): 2537-44.

BackgroundOpioid dependence is a chronic relapsing condition for which long-term opioid substitution treatment (OST) is effective. However, safety and community acceptance of OST is compromised by diversion of prescribed medication. The development of a formulation combining buprenorphine and naloxone is designed to reduce the likelihood of intravenous misuse, and the therefore the value of the medication if diverted to the black market.ObjectiveTo evaluate the evidence for 4:1 buprenorphine-naloxone as an efficacious OST, and as a deterrent to diversion and intravenous misuse.MethodsThe literature on buprenorphine-naloxone in a 4:1 ratio is reviewed.Results/ConclusionThe addition of naloxone does not appear to affect the efficacy of buprenorphine as a maintenance drug. While offering some deterrence of injection through precipitated withdrawal, there are many circumstances where injecting of buprenorphine-naloxone is reinforcing rather than aversive. The combination will reduce, but not eliminate, intravenous misuse; clinicians therefore need to monitor patients in OST, and be selective in providing patients with medication to be taken without observation.

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