What is the recommended treatment for opium abuse?

Treatment for Opium Abuse

The recommended treatment for opium abuse is medication-assisted treatment (MAT) with buprenorphine or methadone maintenance therapy in combination with behavioral therapies. 1

Diagnosis and Assessment

• Assess for opioid use disorder using DSM-5 criteria (requires at least 2 of the defined criteria occurring within a year)
• Consider using the Clinical Opiate Withdrawal Score (COWS) to evaluate withdrawal severity 2
• Rule out concurrent substance use through urine drug testing and prescription drug monitoring program checks

Medication Options

First-Line Medications:

1. Buprenorphine

   • Partial opioid agonist
   • Advantages: office-based treatment, lower overdose risk, flexible dosing
   • Initiate only when patient is in moderate withdrawal (COWS >8)
   • Starting dose: 2-4mg sublingual, titrate to effective dose (typically 16-24mg daily)
   • For high-risk patients (e.g., fentanyl users), consider low-dose initiation (0.5-2mg) 2

2. Methadone

   • Full opioid agonist
   • Advantages: higher retention rates, effective for severe dependence
   • Must be dispensed through specialized opioid treatment programs 3
   • Initial dose typically 20-30mg daily, capped at 40mg/day
   • Requires close monitoring due to long half-life and risk of accumulation 2

3. Naltrexone

   • Opioid antagonist
   • Available as oral daily medication or monthly injectable (extended-release)
   • Requires complete opioid detoxification (7-10 days opioid-free) before initiation 4
   • Better suited for highly motivated patients 1
   • Less effective than agonist therapies for retention in treatment 5, 6

Treatment Algorithm

1. For most patients with opium abuse:

   • Begin with buprenorphine or methadone based on:
     • Severity of dependence (methadone for more severe cases)
     • Access to treatment facilities (buprenorphine more accessible)
     • Patient preference and prior treatment history 7

2. For pregnant women:

   • Buprenorphine (without naloxone) or methadone is recommended 1
   • Do not attempt detoxification during pregnancy due to risk of relapse and fetal harm

3. For patients with prescription opioid dependence:

   • Buprenorphine/naloxone has shown effectiveness in preventing relapse 1

4. For patients unable/unwilling to use agonist therapy:

   • Consider extended-release naltrexone after complete detoxification 4
   • Note: Oral naltrexone has poor adherence and limited effectiveness 5, 6

Behavioral Therapies

All medication treatments should be combined with behavioral interventions:

• Cognitive-behavioral therapy
• Motivational enhancement therapy
• Contingency management
• Group therapy
• Support groups

These behavioral therapies help reduce opioid misuse, increase treatment retention, and improve compliance 1, 2

Common Pitfalls and Caveats

• Precipitated withdrawal: Initiating buprenorphine too early can cause severe withdrawal. Ensure patient is in moderate withdrawal before first dose 2
• Medication diversion: Monitor for signs of medication misuse or diversion
• Concurrent benzodiazepine use: Increases risk of respiratory depression and overdose; requires enhanced monitoring 2
• Inadequate dosing: Underdosing of maintenance medications increases risk of relapse
• Premature discontinuation: Maintenance therapy typically requires long-term treatment; abrupt discontinuation leads to high relapse rates 5
• Stigma: Address stigma associated with MAT which can be a barrier to treatment engagement 8

Overdose Prevention

• Offer naloxone for overdose prevention to all patients with opioid use disorder 1
• Educate patients and family members on naloxone administration

Treatment Capacity and Access

• Physicians can obtain a waiver from SAMHSA to prescribe buprenorphine in office-based settings
• Methadone for opioid use disorder can only be dispensed through certified opioid treatment programs 3
• Treatment need often exceeds available capacity; clinicians should identify local treatment resources 1

Research consistently shows that maintenance medication provides the best opportunity for patients to achieve recovery from opiate addiction, with significant reductions in mortality, illicit opioid use, and HIV risk behaviors 5, 6, 9.