## Maintenance Treatment of Opioid Use Disorder **Key Point:** Buprenorphine is the preferred first-line medication for opioid substitution therapy (OST) in India and is endorsed by WHO, NIDA, and Indian guidelines due to its safety profile, lower abuse potential, and ease of administration. ### Comparison of Maintenance Medications | Agent | Type | Onset | Duration | Abuse Potential | Safety in OD | Indian Status | |-------|------|-------|----------|-----------------|--------------|---------------| | **Buprenorphine** | Partial μ-agonist | 30–60 min | 24–72 hrs | **Low** | **High** (ceiling effect) | **Gold standard** | | Methadone | Full μ-agonist | 30 min | 24–36 hrs | High | Moderate (respiratory depression risk) | Available; less preferred | | Naltrexone | μ-antagonist | 1 hr | 24–72 hrs | None | High | Relapse rates high; not maintenance | | Tramadol | Weak μ-agonist + SNRI | 1 hr | 4–6 hrs | Moderate | Low | Not approved for OST | **High-Yield:** Buprenorphine's **ceiling effect** on respiratory depression makes it safer than methadone in overdose — a critical advantage in India where medical supervision is variable. **Clinical Pearl:** Buprenorphine is a **partial agonist** at the μ-receptor; it produces less euphoria than full agonists (methadone, heroin) and has lower abuse potential, making it ideal for outpatient OST. **Mnemonic:** **BUMP** = **B**uprenorphine is **U**nder **M**aintenance **P**rotocols (in India). **Warning:** Methadone, though effective, requires daily supervised dosing and carries higher overdose risk — less practical in resource-limited Indian settings. Naltrexone is an antagonist (not agonist) and is used for relapse prevention, not maintenance.
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