Addressing unmet needs in opiate dependence: supporting detoxification and advances in relapse prevention

Abstract

SUMMARY Despite record-breaking numbers of opiate related deaths in the UK in 2019, pharmacological management of opiate dependence has evolved little since the advent of methadone in 1965. Along with harm minimisation and psychosocial interventions, the mainstay of pharmacological treatment remains opioid substitution therapy (OST) using methadone or buprenorphine, with many patients receiving OST for many years. Even with these treatments, opiate users continue to face mortality risks 12 times higher than the general population, and emerging evidence suggests that individuals who remain on long-term OST present with a range of physical and cognitive impairments. Therefore, with a growing ageing opiate dependent population who would benefit from detoxification from OST, this article provides an overview of the current state of opiate dependence in clinical practice, explores the reasons why availability and acceptability of detoxification pathways are declining, and discusses emerging pharmacological therapies that could provide benefit in relapse prevention.

Opioid use disorder and the brain: a clinical perspective

“…As a result, the needs of patients with OUD are not being met with the current treatment options available. This is of particular importance in countries with a growing ageing opioid‐dependent population who are more likely to have significant health consequences as a result of chronic opioid use and who would probably benefit from detoxification and abstinence [3].…”

“…As a result, the needs of patients with OUD are not being met with the current treatment options available. This is of particular importance in countries with a growing ageing opioid-dependent population who are more likely to have significant health consequences as a result of chronic opioid use and who would probably benefit from detoxification and abstinence [3]. Imaging research is now focusing upon identifying neural 'biomarkers', which may clarify under what circumstances treatments are effective as well as expose factors affecting individual vulnerability to relapse [108].…”

“…There are three main receptors with their endogenous ligand, namely μ‐ and β‐endorphin, kappa and dynorphin and delta and enkephalins. The μ receptor system is key in addiction as it mediates reward, analgesia and also respiratory depression with the kappa system contributing to dysphoria and aversive states seen in withdrawal (see [3] for more information). Opioid receptors are present in all the brain regions that play an important role in addiction, e.g.…”

Multiple relapses into opiate and crack misuse among people in recovery: An interpretative phenomenological analysis

“…It is recognized that 75% of people who misuse opiates or psychostimulants, particularly crack, relapse within 3–6 months of exiting treatment (Appiah et al., 2018; Hendershot et al., 2011). Relapse increases the likelihood of drug overdose death (Herlinger & Lingford‐Hughes, 2021; Public Health England, 2020), adding pressure to relevant addiction professionals. This is reflected in current data trends which show a significant increase in crack‐related treatment re‐entries and opiate‐related overdose deaths (World Drug Report, 2019; European Drug Report, 2021).…”

‘Nico’—A lone voyager in Strange Seas

“…Why is it that there have been so few substantial advances in developing enhanced approaches to the pharmacological treatment of patients with opiate dependence over the last 35 years? Since 1965, the mainstay of pharmacological treatment has been opioid substitution therapy using methadone or buprenorphine (Herlinger & Lingford‐Hughes, 2021). Responding to the current ‘opioid crisis’ within the United States, its National Institute on Drug Abuse highlighted a range of potential mechanisms and novel targets for innovative approaches to opiate dependence; including the evaluation of orexin receptor antagonists, GABA‐B agonists, muscarinic M5 antagonists, dopamine D3 receptor partial agonists, and cannabinoid CB1 receptor antagonists (Rasmussen et al., 2019).…”