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Research Summary

Buprenorphine with Drug Counseling Is Superior to Oral Naltrexone with Counseling or Counseling Alone for Heroin Dependence

Opiate dependence and injection drug use are major vectors for HIV transmission across the globe, but many nations prohibit effective opioid a treatment (OST). In this randomized, double-blind, placebo-controlled trial conducted in Malaysia, subjects were assigned to placebo (n=39), oral naltrexone (n=43), or sublingual buprenorphine (n=44) after standardized 14-day residential detoxification and initiation of group drug counseling. The study was stopped early because, over 24 weeks of follow-up,

  • treatment retention was significantly higher for buprenorphine compared with naltrexone (hazard ratio [HR], 1.55) or placebo (HR, 2.15).

  • time to first heroin use was significantly higher for buprenorphine compared with naltrexone (HR, 1.87) or placebo (HR, 2.02).

  • time to heroin relapse (defined as 3 consecutive opiate-positive or missing urine tests) was significantly higher for buprenorphine compared with naltrexone (HR, 1.56) or placebo (HR, 2.17).

  • no differences were detected between oral naltrexone and placebo.

  • HIV risk behaviors did not differ between any of the groups.


Studies from around the world have demonstrated that OST with counseling is superior to counseling alone. The superiority of OST over the oral form of the opiate antagonist naltrexone is similarly well-established. Nonetheless, significant barriers remain to the expansion of OST both within the United States and internationally. Implementation and policy initiatives are needed to change “hearts and minds” about these evidence-based treatments for opiate dependence.

Peter D. Friedmann, MD, MPH



Schottenfeld RS, Chawarski MC, Mazlan M. Maintenance treatment with buprenorphine and naltrexone for heroin dependence in Malaysia: a randomised, double-blind, placebo-controlled trial. Lancet. 2008;371(9631):2192–2200.