Is maintenance therapy effective for opioid addiction?

Maintenance Therapy is Highly Effective for Opioid Addiction

Yes, maintenance therapy with methadone or buprenorphine is highly effective for treating opioid addiction and should be offered to patients with opioid use disorder. This treatment substantially reduces mortality, illicit drug use, criminal activity, HIV transmission, and improves overall functioning 1.

Evidence for Effectiveness

Maintenance therapy with opioid agonists (methadone or buprenorphine) decreases opioid and other drug abuse, increases treatment retention, decreases criminal activity, improves individual functioning, and decreases HIV seroconversion 1. The evidence is particularly strong for mortality reduction:

• Methadone maintenance reduces all-cause mortality by approximately two-thirds, with mortality rates of 11.3 per 1,000 person-years during treatment compared to 36.1 per 1,000 person-years out of treatment (rate ratio 3.20) 1
• This translates to approximately 25 fewer deaths per 1,000 person-years among patients maintained on methadone compared to those who discontinue 1
• Buprenorphine maintenance shows even lower mortality rates (4.3 per 1,000 person-years in treatment vs 9.5 out of treatment) 1

Clinical Recommendation

Clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder 1. This is a Category A recommendation based on moderate to high quality evidence 1.

Key Treatment Principles

• Methadone maintenance reduces heroin use in 50-80% of patients, with most reporting no heroin use in the preceding month 2
• Higher doses (>50-60 mg daily) are more effective than lower doses, with optimal clinical stability typically achieved at 80-120 mg/day 3, 4
• The treatment goal should be successful maintenance rather than forced abstinence, as premature pressure to discontinue is associated with poor outcomes 5, 4
• Combining medication with behavioral therapies reduces opioid misuse and increases retention during maintenance therapy 1

Critical Safety Considerations

High-Risk Periods

The induction phase (first 4 weeks) of methadone and the period immediately after cessation of either methadone or buprenorphine carry particularly high mortality risk 1:

• Initial methadone dosing should not exceed 30-40 mg on the first day, with careful titration over the first week 3
• Deaths have occurred in early treatment due to cumulative effects of the first several days' dosing 3
• Mortality risk in the 4 weeks immediately after treatment cessation can exceed 30 deaths per 1,000 person-years 1

Treatment Retention is Critical

Retention in treatment is associated with the substantial mortality reductions, making strategies to keep patients engaged in treatment essential 1. Patients should be informed of the high risk of relapse and overdose death associated with discontinuation 3.

Practical Implementation

Methadone maintenance must be provided through certified Opioid Treatment Programs (OTPs) registered by SAMHSA and DEA for outpatient treatment 3. Buprenorphine can be prescribed in office-based settings by qualified providers 1.

Alternative Options

• Buprenorphine may be preferred for some patients due to lower overdose risk and greater flexibility in prescribing 1
• Naltrexone (oral or long-acting injectable) can be used in highly motivated non-pregnant adults, though evidence for effectiveness is less robust than for agonist therapy 1
• For pregnant women with opioid use disorder, buprenorphine (without naloxone) or methadone should be offered as it improves maternal outcomes 1

Common Pitfalls to Avoid

• Do not use inadequate doses: Doses below 60 mg of methadone compromise effectiveness 5
• Do not pressure patients toward premature abstinence: This significantly worsens outcomes 5, 4
• Do not withhold treatment due to psychiatric comorbidity or pregnancy: These are not contraindications 5
• Do not assume maintenance therapy provides analgesia for acute pain: The duration of analgesic effect (4-8 hours) is much shorter than withdrawal suppression (24-48 hours), requiring separate pain management strategies 1