{"doi":"10.1111/add.12376","title":"Commentary on <scp>H</scp>ser <i>et al</i>. (2014): To retain or not to retain—open questions in opioid maintenance therapy","abstract":null,"journal":"Addiction","year":2014,"id":625194,"datarank":0.20794415416798362,"base_score":1.3862943611198906,"endowment":1.3862943611198906,"self_citation_contribution":0.20794415416798362,"citation_network_contribution":0.0,"self_endowment_contribution":0.20794415416798362,"citer_contribution":0.0,"corpus_percentile":null,"corpus_rank":null,"citation_count":3,"citer_count":0,"citers_with_citation_signal":0,"citers_with_endowment":0,"datacite_reuse_total":0,"is_dataset":false,"is_dataset_confidence":null,"is_data_producer":false,"deposit_databanks":null,"is_oa":false,"file_count":0,"downloads":0,"has_version_chain":false,"published_date":null,"fair_score":null,"fair_percentile":null,"algorithm_id":"datarank_citation_only_1hop_v6","ranking_scope":"data_only","authors":[{"id":1616575,"name":"Thomas Hillemacher","orcid":null,"position":1,"is_corresponding":false},{"id":644378,"name":"Michael Soyka","orcid":"0000-0003-4179-4989","position":0,"is_corresponding":false}],"reference_count":0,"raw_metadata":{"has_enrichment":true,"resolved":true,"title":"Commentary on <scp>H</scp>ser <i>et al</i>. (2014): To retain or not to retain—open questions in opioid maintenance therapy","abstract":"Methadone, buprenorphine and the buprenorphine/naloxone combination are established first-line medications for the treatment of opioid dependence 1-4, but may have different indications in different people. Furthermore, in several countries oral or intravenous diamorphine or oral morphine treatment are used for maintenance treatment in special subgroups of opioid-dependent patients 5, 6. In this issue, Hser et al. 7 present data from an important study in 1267 opioid-dependent individuals randomized to open-label buprenorphine/naloxone or methadone treatment. Three findings are of relevance: first, the treatment completion rate was much higher with methadone than with buprenorphine/naloxone (74 versus 46%); secondly, the completion rate with buprenorphine/naloxone increased linearly as the dose was increased, reaching 60% with doses of 30–32 mg/day—higher doses than are usually given in clinical practice or studies (8); and thirdly, buprenorphine/naloxone was associated with a lower rate of continued illicit drug use. A number of other studies, but not all 9, have also shown somewhat better retention rates for methadone than for buprenorphine 10, although a 28% difference is striking. Retention rates are relevant for opioid maintenance treatment (no patients, no success), but vary considerably between treatment settings. Naturalistic long-term studies do not indicate that methadone has a higher retention rate than buprenorphine 11. One should keep in mind that regulatory authorities stipulate that the primary outcome of an opioid maintenance drug must be decreased opioid consumption. Retention per se is not the goal and may vary. Retention depends upon many setting variables: supervised versus unsupervised dosage, strict versus less strict urinary controls, take-home supply versus daily clinic attendance, zero or maximum tolerance with respect to alcohol intake, etc. Not surprisingly, many patients favour less controlling settings; such settings may show better treatment retention, but not necessarily reduced opioid use. Largely unsupervised settings that use a maximum dose are lax about performing urine analyses and in which physicians and social workers do not ask too many questions may meet many patients' wishes more than stricter settings, but they do not guarantee long-term success. In other words, retention is important, but it is just one aspect of opioid maintenance treatment. However, in special treatment situations, e.g. the treatment of pregnant opioid-dependent women, retention rate is very important, more so than in other patient groups 12. In line with the results of Hser et al., a recent study showed that in pregnant women the retention rate is higher with methadone than with buprenorphine 13. The results of this study also highlight again the essential role of the induction phase in initiating opioid maintenance therapy. The greatest differences in retention rates emerged within the first weeks of treatment. Stepped-care approaches may be helpful 14. One may speculate whether the results presented by Hser et al. fit into a differential typology of opioid users, often heard among clinicians but not well established, that affects the choice of opioid maintenance drug: methadone may be more appropriate for the long-term addict with a high level of physical dependence, while buprenorphine may be better for the more motivated, possibly abstinence-orientated patient, because it is easier to taper off. Future studies may address this question in more detail. Buprenorphine and methadone also differ in their elimination and pharmacological interactions, which may facilitate clinical decisions 15, 16. A final comment on buprenorphine dosing: the data from Hser et al. are in line with other findings indicating better retention with higher buprenorphine dosage 17, but they are not supported by neuroimaging studies. Just a handful of opioid receptor positron emission tomography (PET) studies have been performed with buprenorphine. Greenwald et al. 18 demonstrated that 16 mg buprenorphine reduced mu-opioid receptor availability by 85–92%, while 32 mg reduced it by 94–98%, with minimal interindividual variability. Similar findings for 16 mg were published by Zubieta et al. 19. These data make it difficult to understand why 32 mg buprenorphine may be more effective than 16 mg (or 20–24 mg). However, we are treating patients, not PET scans. Clinical data show the way! Nevertheless, basic research may address the question of why a higher dose than needed for maximum receptor binding may work better than we expect on the basis of opioid receptor PET studies. The authors thank Jacquie Klesing, Board-Certified Editor in the Life Sciences (ELS), for editing assistance with this commentary. Michael Soyka has received unrestricted research grants or has worked as a consultant for Lundbeck, Prempharm, Essex, Sanofi Aventis and Reckitt Benckiser. Thomas Hillemacher has received unrestricted research grants or has worked as a consultant for Lundbeck, Servier, Otsuka, BMS, Jansen and Astra Zeneca.","is_dataset_classified":null,"base_score":1.3862943611198906,"endowment":1.3862943611198906,"datacite_reuse_total":0,"file_count":0,"downloads":0,"views":0,"has_version_chain":false,"is_dataset":false,"is_oa":false,"pmid":"24438113","pmcid":null,"openalex_id":"https://openalex.org/W1975094265","authors":[],"funders":[],"total_grants":0,"fwci":null,"citation_percentile":null,"influential_citations":0,"citation_trend":[{"year":2017,"count":1},{"year":2021,"count":1},{"year":2023,"count":1}],"oa_status":"bronze","license":"http://onlinelibrary.wiley.com/termsAndConditions#vor","oa_locations":[{"url":"https://onlinelibrary.wiley.com/doi/pdfdirect/10.1111/add.12376","host_type":"journal"},{"url":"https://onlinelibrary.wiley.com/doi/pdfdirect/10.1111/add.12376","host_type":"publisher"},{"url":"https://api.wiley.com/onlinelibrary/tdm/v1/articles/10.1111%2Fadd.12376","host_type":"publisher"},{"url":"https://onlinelibrary.wiley.com/doi/pdf/10.1111/add.12376","host_type":"publisher"},{"url":"https://doi.org/10.1111/add.12376","host_type":"journal"},{"url":"https://pubmed.ncbi.nlm.nih.gov/24438113","host_type":"repository"}],"fields_of_study":["Opioid Use Disorder Treatment","Prenatal Substance Exposure Effects","Substance Abuse Treatment and Outcomes"],"mesh_terms":["Buprenorphine, Naloxone Drug Combination","Assessment of Medication Adherence","Analgesics, Opioid","Buprenorphine","Female","Humans","Male","Methadone","Naloxone","Narcotic Antagonists","Opioid-Related Disorders","Drug Monitoring","Medication Adherence","Opiate Substitution Treatment"],"keywords":["Buprenorphine","Methadone","(+)-Naloxone","Opioid","Medicine","Opioid use disorder","Anesthesia","Morphine","Opiate Substitution Treatment","Internal medicine","Therapy","Opioids","Opioid Dependence"],"sdg_mappings":[{"sdg_number":0,"sdg_label":"Good health and well-being"}],"linked_datasets":[],"clinical_trials":[],"software_tools":[],"database_accessions":[],"source":"live","citation_network_status":"fetched"},"created_at":"2026-08-04T06:03:28.176456Z","pmid":null,"pmcid":null,"fwci":null,"citation_percentile":null,"influential_citations":0,"oa_status":null,"license":null,"views":0,"total_file_size_bytes":0,"version_count":0,"fair_f":null,"fair_a":null,"fair_i":null,"fair_r":null,"fair_zscore":null,"fair_rationale":null,"fair_model":null,"fair_agent_version":null,"fair_fulltext_source":null,"fair_has_llm":null,"fair_computed_at":null,"clinical_trials":[],"software_tools":[],"db_accessions":[],"linked_datasets":[],"topics":[]}