What is the recommended treatment for Opioid Use Disorder (OUD)?

Medication-Assisted Treatment is the First-Line Approach for Opioid Use Disorder

Medication-assisted treatment (MAT) with buprenorphine/naloxone is the recommended first-line treatment for opioid use disorder (OUD), reducing mortality by up to threefold compared to withdrawal management alone. 1

Medication Options for OUD

First-Line: Buprenorphine/Naloxone

• Target dose: 16mg sublingual daily (range 4-24mg based on individual response) 1
• Advantages:
  • Office-based treatment accessibility
  • Superior safety profile with ceiling effect on respiratory depression 2
  • Reduces cravings and blocks effects of other opioids
  • Preferred over buprenorphine alone due to abuse-deterrent properties 1
  • Reduces likelihood of overdose death by up to threefold 2

Alternative Options:

1. Methadone:

   • Best suited for severe, long-standing OUD
   • For patients who haven't responded to buprenorphine
   • Requires daily supervised dosing at specialized clinics 1
   • Strongest evidence for effectiveness but less accessible 3

2. Naltrexone:

   • Pure opioid receptor antagonist
   • Available as daily oral tablets or monthly injections
   • Requires complete opioid detoxification (7-10 days opioid-free) before initiation 4
   • Blocks effects of opioid agonists 1

Initiation Protocol for Buprenorphine/Naloxone

Assessment Before Initiation

• Confirm OUD diagnosis using DSM-5 criteria
• Assess for withdrawal severity using Clinical Opiate Withdrawal Scale (COWS) 2
• Verify time since last opioid use:
  • Short-acting opioids (heroin, immediate-release formulations): >12 hours
  • Extended-release formulations: >24 hours
  • Methadone: >72 hours 2

Dosing Protocol

1. Initial dose based on withdrawal severity:

   • Mild withdrawal (COWS <8): No buprenorphine indicated, reassess in 1-2 hours
   • Moderate to severe withdrawal (COWS >8): 4-8mg sublingual buprenorphine 2

2. Reassess after 30-60 minutes

3. Target dose: 16mg daily for most patients 2, 1

4. Discharge planning:

   • Prescribe buprenorphine/naloxone for 3-7 days until follow-up appointment
   • Non-waivered providers: Patients may return for up to 3 consecutive days for interim treatment 2

Monitoring and Maintenance

• Initial phase: Weekly visits during the first month
• Stable phase: Monthly visits once stabilized
• Regular monitoring:
  • Urine drug testing to verify adherence and detect illicit drug use
  • Assessment for medication side effects, withdrawal symptoms, and cravings
  • Evaluation for responsible medication handling and compliance 1

Addressing Common Challenges

Concomitant Benzodiazepine Use

• Concomitant use increases risk of adverse reactions including overdose and death
• Do not categorically deny treatment to patients taking benzodiazepines
• Educate patients about risks of combined use
• Develop strategies to manage prescribed or illicit benzodiazepine use
• Consider gradual tapering of benzodiazepines when appropriate 5

Risk of Precipitated Withdrawal

• Ensure patient is in adequate withdrawal before administering first buprenorphine dose
• Use COWS score to objectively assess withdrawal severity
• Consider microdosing initiation strategies for patients unable to tolerate traditional initiation 6

Special Populations

• Pregnant women: Use buprenorphine alone (without naloxone) with coordinated obstetric care 1
• Hepatic impairment: May require dose adjustments 1, 5
• Perioperative management: Requires special considerations to avoid withdrawal 1

Comprehensive Approach

• Combine medication with behavioral therapies:

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

• Provide overdose prevention education and take-home naloxone kits 2

• Consider hepatitis C and HIV screening 2

Treatment Outcomes

Patients who continue to misuse buprenorphine or other opioids despite appropriate treatment should be referred to more intensive structured treatment or considered for methadone maintenance 1. Long-term treatment is associated with better outcomes, allowing restoration of social connections 3.

Medication-assisted treatment has demonstrated effectiveness and saves lives, but remains limited by lack of access and stigma 3. Expanding access to approved treatments, particularly buprenorphine/naloxone, is crucial to addressing the opioid epidemic.