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I was concerned that the otherwise very thorough review by Simoens et al1 gave little emphasis from their findings as to the superior safety profile of buprenorphine as a maintenance agent. It would have been useful to have some comments in the review as to the comparative overdose and mortality statistics in the studies examined.
Methadone has gained notoriety in the medical press on many occasions in the past, on account of the substantial mortality associated with it, and the Advisory Council on the Misuse of Drugs report, Reducing Drug-Related Deaths,2 confirms our suspicions. However, for many years methadone has been the only pharmacological option open to GPs. As a result, most have lost interest in trying to help heroin addicts — or at worst use the safety argument as a handy excuse to refuse to help, despite the impressive evidence base to support maintenance prescribing of methadone.
Buprenorphine is undoubtedly much safer in practice, for reasons that were only touched on in the review. However, this is one of the most important factors that would lead GPs to consider prescribing it. The research base regarding community buprenorphine prescribing in the UK is still scanty and there is a pressing need to expand the available options for the treatment of opioid addiction beyond methadone. I have had extensive experience prescribing buprenorphine in primary and secondary care over the last 3 years and have found it simpler, quicker and safer to titrate and stabilise patients than by using methadone.