What is the initial treatment approach for severe opioid use disorder (OUD)?

From the Guidelines

Treatment for severe opioid use disorder should begin with medication-assisted treatment (MAT), which combines FDA-approved medications with counseling and behavioral therapies, as recommended by the CDC guideline for prescribing opioids for chronic pain - United States, 2016 1. The first-line medication options include methadone, buprenorphine, or naltrexone.

• Methadone (typically 60-120 mg daily) is administered at specialized opioid treatment programs with daily observed dosing initially.
• Buprenorphine (typically 16-24 mg daily) can be prescribed by certified physicians in office-based settings, starting with an induction phase when the patient is in mild to moderate withdrawal.
• Extended-release naltrexone (380 mg monthly injection) requires complete opioid detoxification before initiation. Alongside medication, patients should receive comprehensive care including:
• Behavioral counseling
• Treatment for co-occurring mental health conditions
• Support for social needs like housing and employment For severe cases, inpatient or residential treatment may be necessary initially to provide a stable environment for detoxification and early recovery. These medications work by either replacing harmful opioid use with controlled doses that prevent withdrawal (methadone, buprenorphine) or by blocking opioid effects (naltrexone), reducing cravings and allowing patients to focus on recovery, as supported by the American Academy of Pediatrics (AAP) recommendations for medication-assisted treatment of adolescents with opioid use disorders 1. Treatment should be individualized and typically continues long-term, as opioid use disorder is a chronic condition requiring ongoing management, with the goal of reducing morbidity, mortality, and improving quality of life 1.

From the FDA Drug Label

INDICATIONS AND USAGE Detoxification treatment of opioid addiction (heroin or other morphine-like drugs). Maintenance treatment of opioid addiction (heroin or other morphine-like drugs), in conjunction with appropriate social and medical services NOTE Outpatient maintenance and outpatient detoxification treatment may be provided only by Opioid Treatment Programs (OTPs) certified by the Federal Substance Abuse and Mental Health Services Administration (SAMHSA) and registered by the Drug Enforcement Administration (DEA)

To start treatment for severe opioid use disorder, methadone can be used for detoxification and maintenance treatment of opioid addiction, in conjunction with appropriate social and medical services, as indicated in the FDA drug label for Methadone (PO) 2.

• Detoxification treatment is used to treat opioid addiction.
• Maintenance treatment is used to treat opioid addiction in conjunction with social and medical services. Treatment should be provided by certified Opioid Treatment Programs (OTPs).

From the Research

Treatment Options for Severe Opioid Use Disorder

• Medication-assisted treatment (MAT) is a highly effective approach for treating opioid use disorder, with medications such as methadone, buprenorphine, and naltrexone being FDA-approved options 3, 4, 5, 6, 7.
• Methadone and buprenorphine are opioid agonists that have been shown to reduce mortality, opioid use, and transmission of HIV and hepatitis C virus, while increasing treatment retention 3, 5.
• Buprenorphine is a partial opioid agonist that has been found to be effective in treating opioid use disorder, with different formulations available, including long-acting injectable formulations 4, 6.
• Naltrexone is an opioid receptor antagonist that can reduce opioid use and craving, but its use is limited by the need for patients to abstain from opioids for approximately one week before initiation 3, 5.

Initiating Treatment

• Family physicians and primary care providers are well-positioned to diagnose opioid use disorder and provide evidence-based treatment with buprenorphine or naltrexone, or refer patients for methadone treatment as appropriate 3, 6.
• Patients should be encouraged to continue treatment indefinitely, as discontinuation of pharmacotherapy increases the risk of relapse 3.
• A practical decision-making algorithm can be used to address pertinent psychiatric and medical comorbidities when prescribing pharmacology for opioid use disorder 7.

Barriers to Treatment

• Despite the effectiveness of MAT, many patients with opioid use disorder do not receive treatment, highlighting the need to increase access to comprehensive treatment and reduce stigma around opioid use disorder 4, 6.
• The COVID-19 pandemic has led to changes in the way MAT care is managed, with a need for novel point-of-care approaches to provide care to patients 6.