## Maintenance Pharmacotherapy for Opioid Use Disorder **Key Point:** Buprenorphine is the gold standard and preferred maintenance agent for opioid use disorder in India, approved under the Narcotic Drugs and Psychotropic Substances (NDPS) Act, 1985, with specific regulations for its use. ### Comparison of Maintenance Agents | Agent | Mechanism | Advantages | Disadvantages | Status in India | |-------|-----------|-----------|---------------|-----------------| | **Buprenorphine** | Partial μ agonist | Ceiling effect on respiratory depression; lower overdose risk; easier withdrawal; can be prescribed in non-hospital settings | Partial agonist may not satisfy some patients | **Gold standard; widely available** | | Methadone | Full μ agonist | Potent, long-acting; once-daily dosing | High overdose risk; respiratory depression; difficult withdrawal; requires daily clinic visits | Restricted; limited availability in India | | Naltrexone | μ antagonist | Blocks euphoria; prevents relapse | Poor compliance; precipitates withdrawal; requires full detoxification first | Limited use; mainly for relapse prevention | | Tramadol | Weak μ agonist + SNRI | Multimodal action | Weak opioid effect; seizure risk; not approved for maintenance | Not indicated for OUD maintenance | **High-Yield:** Buprenorphine's partial agonist activity provides a "ceiling effect" — respiratory depression plateaus at higher doses, making overdose less likely than with full agonists like methadone. This safety profile, combined with lower abuse potential and easier withdrawal, makes it the preferred agent in India. **Clinical Pearl:** In India, buprenorphine maintenance is regulated under the NDPS Rules and can be initiated by trained physicians in primary care settings, improving accessibility compared to methadone, which requires specialized clinics. Buprenorphine is often combined with naloxone (Suboxone) in a 4:1 ratio to deter intravenous abuse. **Mnemonic:** **BUPRE = BEST PARTIAL AGONIST FOR REPLACEMENT AND EASE** — Buprenorphine is the best choice due to its partial agonism, safety, and ease of use in India.
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