Medication-Assisted Treatment of Opioid Use Disorder

Abstract

Medication-assisted treatment of opioid use disorder with physiological dependence at least doubles rates of opioid-abstinence outcomes in randomized, controlled trials comparing psychosocial treatment of opioid use disorder with medication versus with placebo or no medication. This article reviews the current evidence for medication-assisted treatment of opioid use disorder and also presents clinical practice imperatives for preventing opioid overdose and the transmission of infectious disease. The evidence strongly supports the use of agonist therapies to reduce opioid use and to retain patients in treatment, with methadone maintenance remaining the gold standard of care. Combined buprenorphine/naloxone, however, also demonstrates significant efficacy and favorable safety and tolerability in multiple populations, including youth and prescription opioid-dependent individuals, as does buprenorphine monotherapy in pregnant women. The evidence for antagonist therapies is weak. Oral naltrexone demonstrates poor adherence and increased mortality rates, although the early evidence looks more favorable for extended-release naltrexone, which has the advantages that it is not subject to misuse or diversion and that it does not present a risk of overdose on its own. Two perspectives-individualized treatment and population management-are presented for selecting among the three available Food and Drug Administration-approved maintenance therapies for opioid use disorder. The currently unmet challenges in treating opioid use disorder are discussed, as are the directions for future research.

Evaluating Slow-Release Oral Morphine to Narrow the Treatment Gap for Opioid Use Disorders

“…Existing studies suggest that OAT has efficacy rates similar to those of methadone in suppressing illicit opioid use and retaining patients in care, with a better safety profile and greater improvements in several patient-reported outcomes, including tolerability, treatment satisfaction, and mental symptoms, as well as alleviation of cravings and withdrawal symptoms (8). These findings are highly relevant, because research has indicated that failure to meet patients’ self-perceived needs is an important contributor to the high attrition rates observed in traditional OAT programs, which, in turn, are associated with a high risk for relapse and death (5, 7). Moreover, the lower risk for drug–drug interactions with SROM may represent an additional safety advantage over methadone, given the high prevalence of comorbid conditions among persons with OUD (such as HIV, hepatitis C virus infection, and mental health disorders) that may require concomitant medications (5).…”

“…However, despite the proven individual- and community-level benefits of opioid agonist therapy (OAT)—with buprenorphine or methadone (5, 6)—several health system and regulatory barriers to this treatment persist throughout North America, significantly undermining the population-level effect of these programs (6). In addition, buprenorphine and methadone may not be effective for all patients, with some studies indicating that fewer than 50% of persons who begin OAT with these medications are still receiving treatment at 6 months (7).…”

“…Besides continued efforts to increase access to and expand the capacity of existing treatment programs, alternative evidence-based treatment options are needed to better address the different needs of persons with OUD. Recent U.S. Food and Drug Administration (FDA) approvals of long-acting formulations of buprenorphine and naltrexone are important steps in that direction (2, 5, 6). However, the evidence base for these medications is somewhat limited, and their higher relative costs may pose an additional burden to the health system (5, 6).…”

“…Recent U.S. Food and Drug Administration (FDA) approvals of long-acting formulations of buprenorphine and naltrexone are important steps in that direction (2, 5, 6). However, the evidence base for these medications is somewhat limited, and their higher relative costs may pose an additional burden to the health system (5, 6). Moreover, experience with these medications has predominantly been with persons with more stable OUD (5, 6).…”

“…However, the evidence base for these medications is somewhat limited, and their higher relative costs may pose an additional burden to the health system (5, 6). Moreover, experience with these medications has predominantly been with persons with more stable OUD (5, 6). Therefore, a critical knowledge gap remains regarding the optimal treatment approach for persons with less stable disease, including those who have not benefited from buprenorphine- or methadone-based OAT.…”