What are the guidelines for medication-assisted therapy (MAT) in treating opioid use disorder?

Guidelines for Medication-Assisted Therapy (MAT) in Treating Opioid Use Disorder

Medication-assisted treatment (MAT) with buprenorphine, methadone, or naltrexone, combined with behavioral therapies, is the recommended first-line approach for patients with opioid use disorder (OUD). 1

First-Line Medication Options

Buprenorphine

• Dosing protocol:
  • Initial dose: 4-8mg sublingually
  • Target first-day dose: 16mg total
  • Maintenance dose: 16-24mg daily (standard)
  • Higher doses (up to 32mg) may improve outcomes in patients who continue to use opioids at 24mg 2
  • Available as sublingual tablets/films, 6-month implant, and transdermal patch 1

Methadone

• Particularly effective for severe OUD
• Higher treatment retention rates than buprenorphine
• Limited accessibility due to federal regulations
• Can only be dispensed through federally certified Opioid Treatment Programs (OTPs) 3

Naltrexone

• Opioid antagonist option
• Requires 7-10 day opioid-free period before initiation 4
• Consider for patients who:
  • Are highly motivated
  • Have high risk of diversion
  • Have co-occurring alcohol use disorder
  • Prefer non-opioid treatment 1

Treatment Approach

1. Assessment and Diagnosis

   • Confirm OUD diagnosis using DSM-5 criteria (at least 2 criteria within 12 months)
   • Screen for co-occurring mental health disorders
   • Evaluate for intimate partner violence (rates exceed 50% in some settings) 1

2. Medication Selection

   • First-line: Buprenorphine or methadone
   • Alternative: Naltrexone when appropriate
   • Consider patient preferences, treatment history, severity of OUD, and access to care

3. Behavioral Component

   • Combine medication with evidence-based behavioral therapies
   • Include support groups like Narcotics Anonymous
   • Establish clear treatment agreement with expectations for:
     • Regular appointment attendance
     • Compliance with consultations
     • Engagement in pain management strategies
     • Regular urine toxicology and prescription monitoring 1

Monitoring Protocol

• Initial phase:

  • Weekly visits initially
  • Urine drug testing to verify adherence
  • Prescription monitoring program checks

• Maintenance phase:

  • Monthly visits once stable
  • Continued urine drug testing
  • Enhanced monitoring for high-risk patients (e.g., those taking benzodiazepines) 1

Special Populations

Pregnant Women

• Buprenorphine without naloxone is recommended
• Coordinated care with obstetric providers is essential 1

Perioperative Management

• Continue buprenorphine in most perioperative situations
• Discontinuation can destabilize patients with OUD 1

Patients with Chronic Pain

• For patients on buprenorphine with inadequate pain control:
  • Increase buprenorphine dosage in divided doses (4-16mg every 8 hours)
  • Consider switching to transdermal buprenorphine formulation
  • If maximum dose is reached, add long-acting potent opioid (fentanyl, morphine, hydromorphone)
  • For persistent inadequate analgesia, consider transitioning from buprenorphine to methadone 5

Common Pitfalls to Avoid

1. Concurrent benzodiazepine use

   • Avoid due to increased overdose risk when combined with buprenorphine 1
   • If necessary to taper both medications, taper opioids first due to greater risks of benzodiazepine withdrawal 5

2. Inadequate duration of treatment

   • Indefinite treatment is recommended to reduce relapse risk
   • Discontinuation significantly increases risk of relapse and mortality 1

3. Failure to screen for co-occurring disorders

   • Mental health screening is essential 1

4. Switching from buprenorphine/methadone to naltrexone without adequate opioid-free period

   • Minimum 7-10 days opioid-free interval required before starting naltrexone
   • Patients transitioning from buprenorphine or methadone may experience withdrawal symptoms for up to 2 weeks 4

Treatment Duration

Treatment should be continued indefinitely for most patients with OUD, as discontinuation significantly increases the risk of relapse and mortality. The focus should be on maintaining stability and improving quality of life rather than tapering medication.