Abstract: We included two trials involving 189 participants. One study, with 35 participants, compared methadone with levo-alpha-acetylmethadol (LAAM) for maintenance treatment lasting 16 weeks, after which patients were detoxified. The other study, with 154 participants, compared maintenance treatment with buprenorphine-naloxone and detoxification with buprenorphine. We did not perform meta-analysis because the two studies assessed different comparisons. In the study comparing methadone and LAAM, the authors declared that there was no difference in the use of a substance of abuse or social functioning (data not shown). The quality of the evidence was very low. No side effects, such as nausea, vomiting, constipation, weakness or fatigue, were reported by study participants. In the comparison between buprenorphine maintenance and buprenorphine detoxification, maintenance treatment appeared to be more efficacious in retaining patients in treatment (drop-out risk ratio (RR) 0.37; 95% confidence interval (CI) 0.26 to 0.54), but not in reducing the number of patients with a positive urine test at the end of the study (RR 0.97; 95% CI 0.78 to 1.22). Self reported opioid use at one-year follow-up was significantly lower in the maintenance group, even though both groups reported a high level of opioid use (RR 0.73; 95% CI 0.57 to 0.95). More patients in the maintenance group were enrolled in other addiction treatment programmes at 12-month follow-up (RR 1.33; 95% CI 0.94 to 1.88). The quality of the evidence was low. No serious side effects attributable to buprenorphine-naloxone were reported by study participants and no patients were removed from the study due to side effects. The most common side effect was headache, which was reported by 16% to 21% of patients in both groups It is difficult to draft conclusions on the basis of only two trials. One of the possible reasons for the lack of evidence could be the difficulty of conducting trials with young people for practical and ethical reasons. There is an urgent need for further randomised controlled trials comparing maintenance treatment with detoxification treatment or psychosocial treatment alone before carrying out studies that compare different pharmacological maintenance treatments. These studies should have long follow-up and measure relapse rates after the end of treatment and social functioning (integration at school or at work, family relationships).

Plain-language summary: The review authors searched the literature and identified two controlled trials from the USA that involved 187 heroin addicts, aged 14 to 21 years; the participants were treated as outpatients. One study of 37 participants compared methadone with levo-alpha-acetylmethadol (LAAM) for maintenance treatment. After 16 weeks of maintenance treatment the adolescents were detoxified. The second trial of 150 adolescents compared buprenorphine and naloxone as maintenance treatment for nine weeks followed by tapered doses for up to 12 weeks with buprenorphine detoxification over 14 days. In the first trial methadone and LAAM led to similar improvements in social functioning. No side effects were reported. In the second trial the maintenance treatment seemed to be more effective in retaining patients in treatment but not in reducing the use of drugs of abuse. At one-year follow-up, self reported opioid use was clearly less in the maintenance group and more adolescents were enrolled in other addiction programmes. The most common side effect in both groups was headache. No participants left the study because of side effects. It is difficult to draw conclusions about the use of maintenance pharmacological interventions from only two trials. Conducting trials with young people may be difficult for both practical and ethical reasons. This review was limited by the very low number of trials retrieved. The quality of the evidence was very low for the comparison between methadone and LAAM and low for the comparison between buprenorphine detoxification and buprenorphine maintenance. The evidence is current to January 2014.