What treatments are recommended for opioid use disorder?

Treatment Recommendations for Opioid Use Disorder in the United States

Medication-assisted treatment (MAT) with buprenorphine or methadone, combined with behavioral therapies, is the most effective approach for treating opioid use disorder and should be offered as first-line therapy to reduce mortality and improve quality of life. 1

Understanding the Opioid Epidemic

The United States is experiencing a severe opioid epidemic characterized by:

• Dramatic increases in opioid overdose deaths (47,055 deaths in 2014, with 28,647 associated with opioids) 1
• 200% increase in opioid overdose death rates since 2000 1
• Substantial healthcare costs (nearly $16,000 more per patient with opioid use disorder compared to average patient costs) 1
• Widespread impact affecting millions of Americans across all demographics 2

Evidence-Based Treatment Options

First-Line Treatments

1. Medication-Assisted Treatment (MAT):

   • Buprenorphine (partial opioid agonist):

     • Can be prescribed in office-based settings 1
     • Available as sublingual buprenorphine or sublingual buprenorphine/naloxone tablets/strips 1
     • Buprenorphine/naloxone is preferred due to safety features preventing misuse 1
     • Requires physicians to complete 8-hour training and obtain waiver 1

   • Methadone (full opioid agonist):

     • Long-established effective treatment 1
     • Must be administered through federally regulated narcotic treatment programs 1, 3
     • Federal regulations restrict most programs from admitting patients under 18 years 1
     • Indicated for detoxification and maintenance treatment of opioid addiction 3

   • Naltrexone (opioid antagonist):

     • Available in oral or long-acting injectable formulations 1
     • Blocks effects of opioids but requires adherence to daily therapy or monthly injections 1
     • Patients must be opioid-free for 7-10 days before starting treatment 4
     • Most effective for highly motivated individuals 1

2. Behavioral Therapies (should be combined with medications):

   • Cognitive-behavioral therapy
   • Contingency management
   • Relapse prevention
   • Motivational enhancement therapy 1

Treatment Algorithm

1. Assessment:

   • Evaluate for opioid use disorder using DSM-5 criteria 1
   • Screen for risk factors for overdose or complications

2. Medication Selection:

   • First choice for most patients: Buprenorphine/naloxone or methadone
     • For pregnant women: Buprenorphine (without naloxone) or methadone 1
     • For highly motivated patients who can maintain abstinence during induction: Consider naltrexone 1

3. Initiation of Treatment:

   • For buprenorphine: Begin when patient shows signs of withdrawal
   • For methadone: Begin in certified opioid treatment program
   • For naltrexone: Ensure patient is opioid-free for 7-10 days; consider naloxone challenge test to verify 4

4. Maintenance Treatment:

   • Long-term or maintenance treatment is generally indicated rather than brief treatment periods 1
   • Brief detoxification alone is associated with high relapse rates 1

5. Integrated Care:

   • Combine medication with appropriate psychosocial treatments 1
   • Address comorbid conditions
   • Consider naloxone distribution for overdose prevention 1

Important Clinical Considerations

Effectiveness

• Methadone and buprenorphine have been found to increase retention in treatment and decrease illicit opioid use 1
• Effectiveness is enhanced when psychosocial treatments are used in conjunction with medication 1
• Treatment outcomes for opioid use disorder can be comparable to those of other chronic diseases like diabetes, hypertension, and asthma when properly managed 1

Common Pitfalls to Avoid

1. Inadequate treatment duration:

   • Avoid rapid medication tapers or "detoxification only" approaches, which have high relapse rates 1
   • Longer-term maintenance treatment is generally indicated 1

2. Failure to combine medications with behavioral approaches:

   • Most effective treatment involves both medication and behavioral therapies 1

3. Stigma-based treatment limitations:

   • Policies that prevent patients from accessing effective medications may be harmful 1
   • Stigma remains a significant barrier to treatment access 5

4. Inadequate treatment capacity:

   • Treatment need often exceeds capacity to provide buprenorphine or methadone maintenance therapy 1
   • Physicians should consider obtaining buprenorphine waivers, especially in communities with insufficient treatment capacity 1

5. Insurance barriers:

   • Limited insurance coverage for buprenorphine can be a barrier to treatment 1

Special Populations

Adolescents and Young Adults

• Opioid use disorder is a leading cause of morbidity and mortality among US youth 1
• Access to developmentally appropriate treatment is severely restricted for adolescents and young adults 1
• Federal regulations prohibit most methadone programs from admitting patients younger than 18 years 1

Pregnant Women

• Medication-assisted therapy with buprenorphine (without naloxone) or methadone has been associated with improved maternal outcomes 1

By implementing these evidence-based approaches to treatment, healthcare providers can effectively address opioid use disorder and help reduce the devastating impact of the opioid epidemic on individuals and communities across the United States.