## Maintenance Pharmacotherapy for Opioid Use Disorder **Key Point:** Buprenorphine is the gold standard for opioid maintenance treatment in India and is preferred over methadone due to its safety profile, lower abuse potential, and regulatory approval. ### Comparison of Maintenance Medications | Drug | Mechanism | Abuse Potential | Overdose Risk | Status in India | Advantages | |------|-----------|-----------------|---------------|-----------------|-------------| | **Buprenorphine** | Partial μ-agonist | Low | Low (ceiling effect) | **Gold standard** | Safer, less diversion, easier dispensing | | Methadone | Full μ-agonist | High | High (QT prolongation) | Restricted use | Longer half-life, once-daily dosing | | Naltrexone | μ-antagonist | None | None | Adjunctive only | No euphoria, but poor compliance | | Tramadol | Weak μ-agonist + SNRI | Moderate | Moderate | Not for maintenance | Weak opioid, not suitable for severe OUD | **High-Yield:** Buprenorphine has a **ceiling effect** on respiratory depression, making it significantly safer than full μ-agonists like methadone. This pharmacological property is why it is preferred in India's opioid substitution therapy (OST) programs. **Clinical Pearl:** Buprenorphine is often combined with naloxone (as in Suboxone) to further reduce abuse potential by preventing IV misuse — if crushed and injected, the naloxone precipitates withdrawal. **Mnemonic:** **BUMP** = **B**uprenorphine = **U**nderused but **M**ost **P**referred (in India for OUD maintenance). **Warning:** Methadone, while effective, carries higher risks of overdose, QT prolongation, and drug interactions; it is not the first-line choice in the Indian context due to regulatory and safety constraints.
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