Starting Treatment With Agonist Replacement Therapies (START)

• ClinicalTrials.gov Identifier: NCT00315341
• Recruitment Status: Completed
• First Posted: April 18, 2006
• Results First Posted: January 6, 2017
• Last Update Posted: January 6, 2017
• Sponsor: University of California, Los Angeles
• Collaborator: National Institute on Drug Abuse (NIDA)
• Information provided by (Responsible Party): Walter Ling, University of California, Los Angeles

Study Description

Brief Summary:

The Food and Drug Administration (FDA) has requested a study comparing buprenorphine/naloxone (BUP/NX) and methadone (MET) on indices of hepatic safety.

Condition or disease	Intervention/treatment	Phase
Opiate-related Disorders	Drug: Buprenorphine/naloxone; Drug: Methadone	Phase 4

Detailed Description:

This is a randomized, open-label, multi-center, Phase 4 study to assess the changes in liver enzymes related to treatment with buprenorphine/naloxone (BUP/NX) and methadone (MET) in participants entering opioid agonist treatment. Randomization will be stratified, within site, according to normal versus abnormal screening liver function tests. Participants meeting entry criteria will be dosed for 24 weeks during the active phase of the study with assessment of liver function at weeks 1, 2, 4, 8, 12, 16, 20, 24 and with follow-up assessments at week 32. Clinicians will be encouraged to treat with adequate doses of BUP/NX and MET.

Study Design

• Study Type: Interventional (Clinical Trial)
• Actual Enrollment: 1269 participants
• Allocation: Randomized
• Intervention Model: Parallel Assignment
• Masking: None (Open Label)
• Primary Purpose: Treatment
• Official Title: Starting Treatment With Agonist Replacement Therapies (START)
• Study Start Date: April 2006
• Actual Primary Completion Date: August 2010
• Actual Study Completion Date: August 2010

Arms and Interventions

Arm	Intervention/treatment
Experimental: Buprenorphine/Nx; For the BUP/NX group, all participants will receive up to 16 mg BUP/4 mg NX on day 1 and up to 32 mg BUP/8 mg NX on day 2. It is recommended that dose changes be made in 2 to 8 mg buprenorphine increments, with the range of allowable daily doses between 2 mg and 32 mg starting on day 3 and thereafter according to clinical impression and depending upon the participant's clinical need. Investigators are encouraged to dose adequately to decrease craving and to obtain negative urine toxicology specimens.	Drug: Buprenorphine/naloxone; Participants receive up to 16 mg BUP/4 mg NX on day 1 and up to 32 mg BUP/8 mg NX on day 2. It is recommended that dose changes be made in 2 to 8 mg increments, with the range of allowable daily doses between 2 mg and 32 mg starting on day 3 and thereafter according to clinical impression and depending upon the participant's clinical need.
Active Comparator: Methadone; For the MET group, all participants will receive a maximum of 30 mg for the first dose and a maximum of 40 mg on Day 1. It is recommended that participants receive a dose on day 2 that is 10 mg higher than their total day 1 dose, and a dose on day 3 that is 10 mg higher than their total day 2 dose, unless, in the clinical judgment of the physician, a slower induction is needed. Doses will be adjusted on Day 4 and thereafter according to clinical impression and depending upon the participant's clinical need with no specific upper limit. Investigators are encouraged to dose adequately to decrease craving and to obtain negative urine toxicology specimens.	Drug: Methadone; Participants will receive a maximum of 30 mg for the first dose and a maximum of 40 mg on Day 1. It is recommended that participants receive a dose on day 2 that is 10 mg higher than their total day 1 dose, and a dose on day 3 that is 10 mg higher than their total day 2 dose, unless, in the clinical judgment of the physician, a slower induction is needed. Doses will be adjusted on Day 4 and thereafter according to clinical impression and depending upon the participant's clinical need with no specific upper limit.

Outcome Measures

Primary Outcome Measures :

1. Hepatic Safety [ Time Frame: 24 Weeks ]

   Participants were categorized according liver transaminase (ALT, AST) levels in blood comparing the baseline sample to any and all subsequent samples in the following manner:

   A: both ALT and AST started at less than or equal to two times the ULN and remained at two times or less ULN throughout the study

   B: either ALT or AST started at less than or equal to 2 x ULN and at any point in study exceeded 2 x ULN

   C: Either ALT or AST started > 2 x ULN, decreased (both ALT and AST) to < 2 x ULN, and remained < 2 x ULN

   D: Either ALT or AST started > 2 x ULN and remained above 2 x ULN throughout the study

Eligibility Criteria

• Ages Eligible for Study: 18 Years and older (Adult, Older Adult)
• Sexes Eligible for Study: All
• Accepts Healthy Volunteers: No

Criteria

Inclusion Criteria:

1. Were age 18 years or older,
2. Met DSM-IV-TR criteria for opioid dependence,
3. Were in good general health, or, in case of a medical/psychiatric condition requiring ongoing treatment, were under the care of a physician willing to continue participant's medical management and cooperate with study physicians,

4. For female participants, use of one of the following acceptable methods of birth control:

   1. oral contraceptives
   2. barrier (diaphragm or condom) with spermicide
   3. IUD
   4. intrauterine progesterone contraceptive system
   5. levonorgestrel implant
   6. medroxyprogesterone acetate contraceptive injection
   7. contraceptive transdermal patch
   8. hormonal vaginal contraceptive ring
   9. surgical sterilization
   10. complete abstinence from sexual intercourse
5. Able to read and verbalize understanding of the study and voluntarily sign study informed consent form.

Exclusion Criteria:

1. ALT or AST values > 5 times the upper limit of normal as per testing laboratory range criteria,
2. ALP values >3 times the upper limit of normal per testing laboratory criteria,
3. Any documented past or present history of ascites, presence of esophageal or gastric varices, hepatic encephalopathy or other signs of significant liver disease as indicated by a Model for Endstage Liver Disease score (Kamath et al., 2001) of ≥11,
4. Total bilirubin > 2.0 mg/dl (participants with documented Gilbert's syndrome were not excluded based on this criterion),
5. Prothrombin time more than 3 seconds prolonged,
6. Albumin level less than 2.5 g/dl,

7. Any cardiopathy or risk factor listed below without evidence of a normal ECG* with report performed within 6 months prior to first study medication dose,

   1. Congestive heart failure
   2. Left ventricular hypertrophy
   3. Bradycardia
   4. Hereditary QT prolongation
   5. Uncorrected electrolyte imbalance
   6. Concomitant medications that are known to have a risk of QT interval prolongation; refer to Appendix D for a list of medications.

   Note: The list was not all-inclusive.

   *An ECG was abnormal if one or more of the following occurred:

   Significant ST segment abnormalities:

   • ST segment elevations in two or more continuous leads of > 0.1 mV
   • ST segment depression of greater than 1 mm that are flat or down-sloping at 80 msec after the J point ST segment abnormalities identified as "non-specific" are acceptable. If a potential participant's ECG indicated ST segment elevations or depression consistent with ischemia, the physician obtained a medical history of cardiac symptoms and referred the participant for evaluation.

   Conduction abnormalities:

   • Mobitz II 2nd degree or 3rd degree heart block
   • Atrial fibrillation, atrial flutter, or any non-sinus tachyarrhythmia
   • Three or more consecutive ectopic ventricular complexes at a rate of > 100 per minute.
   • QTc greater than 450 msec in men and 480 msec in women

   Repolarization abnormalities:

   • Acute medical condition that would make participation, in the opinion of the study physician, medically hazardous (e.g., unstable pancreatic, cardiovascular or renal disease, significant anemia)

8. Known allergy or sensitivity to BUP, naloxone or MET or to any of the inactive ingredients in the study medications (including lactose, mannitol, cornstarch, povidone K30, citric acid, sodium citrate, FD&C Yellow No.6 color, magnesium stearate, Acesulfame K sweetener)
9. Known diagnosis of acute psychosis, severe depression or imminent suicide risk as determined via clinical interview by study physician or surrogates
10. DSM-IV diagnosis of dependence on alcohol requiring immediate medical attention.
11. DSM-IV diagnosis of dependence on benzodiazepines requiring immediate medical attention
12. DSM-IV diagnosis of dependence on other depressants, or stimulants requiring immediate medical attention
13. Participation in an investigational drug study within the past 30 days
14. Treatment with MET, BUP/NX, or BUP for more than 15 of the past 30 days (illicit use of these medications is allowed)
15. Pending legal action that could prohibit study participation
16. Unable or unwilling to comply with study requirements
17. Unable or unwilling to remain in the local area for duration of treatment
18. Poor venous access such that venipuncture could not be accomplished from a vein in an extremity during eligibility
19. Pregnant or lactating (females only)

Contacts and Locations

Locations

United States, California

Matrix Institute

Los Angeles, California, United States, 90016

Bi-Valley Medical Clinic INC.

Sacramento, California, United States, 95816

BAART; Turk Street Clinic

San Francisco, California, United States, 94102

United States, Connecticut

Hartford Dispensary

Hartford, Connecticut, United States, 06120

CT Counseling Centers

Waterbury, Connecticut, United States, 06705

United States, New York

Addiction Research & Treatment Corp

Brooklyn, New York, United States, 11201

United States, Oregon

CODA-Research

Portland, Oregon, United States, 97214

United States, Pennsylvania

NET Steps

Philadelphia, Pennsylvania, United States, 19137

United States, Washington

Evergreen Treatment Services

Seattle, Washington, United States, 98134

Sponsors and Collaborators

University of California, Los Angeles

National Institute on Drug Abuse (NIDA)

Investigators

• Principal Investigator: Walter Ling, M.D.; University of California, Los Angeles
• Principal Investigator: Andrew Saxon, M.D.; University of Washington

More Information

Publications of Results:

Saxon AJ, Ling W, Hillhouse M, Thomas C, Hasson A, Ang A, Doraimani G, Tasissa G, Lokhnygina Y, Leimberger J, Bruce RD, McCarthy J, Wiest K, McLaughlin P, Bilangi R, Cohen A, Woody G, Jacobs P. Buprenorphine/Naloxone and methadone effects on laboratory indices of liver health: a randomized trial. Drug Alcohol Depend. 2013 Feb 1;128(1-2):71-6. doi: 10.1016/j.drugalcdep.2012.08.002. Epub 2012 Aug 22.

Publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):

Crist RC, Li J, Doyle GA, Gilbert A, Dechairo BM, Berrettini WH. Pharmacogenetic analysis of opioid dependence treatment dose and dropout rate. Am J Drug Alcohol Abuse. 2018;44(4):431-440. doi: 10.1080/00952990.2017.1420795. Epub 2018 Jan 15.

Woody GE, Bruce D, Korthuis PT, Chhatre S, Poole S, Hillhouse M, Jacobs P, Sorensen J, Saxon AJ, Metzger D, Ling W. HIV risk reduction with buprenorphine-naloxone or methadone: findings from a randomized trial. J Acquir Immune Defic Syndr. 2014 Jul 1;66(3):288-93. doi: 10.1097/QAI.0000000000000165.

Hser YI, Saxon AJ, Huang D, Hasson A, Thomas C, Hillhouse M, Jacobs P, Teruya C, McLaughlin P, Wiest K, Cohen A, Ling W. Treatment retention among patients randomized to buprenorphine/naloxone compared to methadone in a multi-site trial. Addiction. 2014 Jan;109(1):79-87. doi: 10.1111/add.12333. Epub 2013 Oct 9.

• Responsible Party: Walter Ling, Principal Investigator, University of California, Los Angeles
• ClinicalTrials.gov Identifier: NCT00315341
• Other Study ID Numbers: NIDA-CTN-0027; U10DA013045 ( U.S. NIH Grant/Contract )
• First Posted: April 18, 2006
• Results First Posted: January 6, 2017
• Last Update Posted: January 6, 2017
• Last Verified: November 2016

Individual Participant Data (IPD) Sharing Statement:

• Plan to Share IPD: No

Additional relevant MeSH terms:

Buprenorphine; Methadone; Buprenorphine, Naloxone Drug Combination; Naloxone; Analgesics, Opioid; Narcotics; Central Nervous System Depressants; Physiological Effects of Drugs; Analgesics; Sensory System Agents; Peripheral Nervous System Agents; Narcotic Antagonists; Antitussive Agents; Respiratory System Agents