What is the recommended treatment for opioid use disorder?

Treatment of Opioid Use Disorder

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

Understanding Opioid Use Disorder

Opioid use disorder (OUD) is a chronic relapsing neurologic disorder characterized by:

• Low rates of spontaneous remission without treatment
• Neurologic changes in the brain's reward center causing cravings and compulsive use
• Potential for severe functional disruption, though some patients may maintain functioning in certain areas 2

First-Line Medication Options

Buprenorphine

• Partial opioid agonist with high receptor affinity
• FDA-approved for patients 16 years and older since 2002
• Typical maintenance dose: 16-24mg daily
• Reduces illicit opioid use by approximately 80% in patients who remain in treatment
• Can be prescribed in office-based settings by waivered physicians
• Formulations include sublingual tablets, films, and newer long-acting injectables 2, 1, 3

Methadone

• Full opioid agonist with long half-life
• Indicated for detoxification and maintenance treatment of OUD
• Must be dispensed through federally certified Opioid Treatment Programs (OTPs)
• Most established evidence base of all OUD medications
• Federal regulations restrict most methadone programs from admitting patients younger than 18 years 2, 4, 5

Naltrexone

• Opioid antagonist that blocks opioid effects
• Limited potential for misuse or diversion
• Available in oral and extended-release injectable formulations
• Requires complete opioid detoxification (7-10 days opioid-free) before initiation
• May be particularly useful for patients with co-occurring alcohol use disorder or those in unstable housing situations 2, 1, 6

Treatment Algorithm

1. Assessment: Evaluate for OUD using DSM-5 criteria
2. Medication Selection:
   • First-line options: Buprenorphine or methadone
     • Buprenorphine: Preferred for office-based treatment, less regulatory restrictions
     • Methadone: Consider for patients with severe OUD or those who haven't responded to buprenorphine
   • Alternative: Naltrexone (for patients who can complete detoxification and prefer a non-opioid option)
3. Initiation:
   • Buprenorphine: Start at 4-8mg sublingually on first day, target 16mg total first-day dose
   • Methadone: Initiated through OTP according to their protocols
   • Naltrexone: Confirm opioid-free status (7-10 days), consider naloxone challenge test
4. Combine with behavioral therapy:
   • Evidence shows enhanced outcomes when medications are combined with psychosocial treatments 2, 1
5. Monitoring:
   • Regular visits (weekly initially, monthly when stable)
   • Urine drug testing
   • Prescription monitoring program checks 1

Special Considerations

Pregnant Women

• Buprenorphine (without naloxone) or methadone is recommended
• Requires coordination with obstetric providers 1

Adolescents

• The American Academy of Pediatrics recommends considering medication-assisted treatment for adolescents and young adults with severe OUD 2
• Buprenorphine is FDA-approved for patients 16 years and older

Co-occurring Conditions

• For patients with co-occurring alcohol use disorder, naltrexone may be particularly beneficial
• Mental health screening is essential as comorbidities are common 1

Common Pitfalls to Avoid

1. Premature discontinuation: Treatment should be continued indefinitely as discontinuation increases relapse risk 7

2. Inadequate dosing: Underdosing of buprenorphine or methadone leads to continued cravings and potential relapse

3. Failure to combine with behavioral therapies: Outcomes are enhanced when medications are combined with psychosocial treatments 2, 1

4. Stigma and limited access: Only 18% of people with substance use disorders receive any treatment, and less than 4% of prescribers had buprenorphine waivers as of 2016 1

5. Inadequate overdose prevention: Prescribe naloxone and provide education on overdose prevention 1

6. Initiating naltrexone too early: Starting naltrexone before complete opioid detoxification can precipitate severe withdrawal 6

7. Discontinuing treatment perioperatively: Increases relapse risk and is not supported by evidence 1

The evidence strongly supports medication-assisted treatment as the standard of care for OUD, with retention in treatment being a key predictor of positive outcomes. Despite strong evidence for effectiveness, access to these life-saving treatments remains limited due to regulatory barriers, stigma, and insufficient provider training.