What is the treatment for opioid addiction?

Treatment of Opioid Use Disorder

Medication-assisted treatment (MAT) combining FDA-approved medications with behavioral therapy is the standard of care for opioid use disorder, with three primary options: buprenorphine, methadone, and naltrexone—each proven to reduce relapse, prevent overdoses, and decrease mortality. 1

First-Line Medication Options

Buprenorphine (Preferred for Most Settings)

• Buprenorphine is a partial mu-opioid receptor agonist with high receptor affinity that reduces cravings and withdrawal while having a ceiling effect on respiratory depression, making it safer than full agonists like methadone. 2
• FDA-approved for patients 16 years and older, with extensive evidence supporting efficacy in adults and growing evidence in adolescents. 1
• Can be prescribed in primary care settings by physicians who complete 8 hours of training and obtain a DEA waiver (though recent regulations have simplified this process). 1
• Critical initiation requirement: Buprenorphine must ONLY be started when patients are in active opioid withdrawal to avoid precipitated withdrawal—confirm using both history and physical examination with the Clinical Opiate Withdrawal Scale (COWS). 2
• Therapeutic dose range is 8-16 mg daily, with 16 mg being optimal for most patients. 2

Methadone (Gold Standard for Severe Cases)

• Methadone is a full opioid agonist with a long half-life that has been established as highly effective for treating opioid addiction. 1
• Can be initiated at any stage of withdrawal, unlike buprenorphine, making it advantageous for patients in acute distress. 3
• Federal regulations restrict methadone to certified Opioid Treatment Programs (OTPs), and most programs prohibit admission of patients younger than 18 years. 1, 4
• Requires daily supervised administration initially, which limits accessibility but ensures compliance. 4

Naltrexone (For Highly Motivated Patients)

• Naltrexone is an opioid antagonist with high affinity for opioid receptors that blocks euphoric effects of opioids and reduces cravings. 1, 5
• Has very limited potential for misuse or diversion compared to opioid agonists. 1
• Extended-release injectable formulation (Vivitrol, 380 mg monthly) reduces adherence burden and is FDA-approved for opioid use disorder. 5, 6
• Patients must be completely opioid-free for a minimum of 7-10 days (for short-acting opioids) or up to 2 weeks (for buprenorphine/methadone) before initiating naltrexone to avoid precipitating severe withdrawal. 6
• Most effective in highly motivated populations such as healthcare professionals, criminal justice populations, and those who cannot or do not wish to take continuous opioid agonist therapy. 5, 6
• May be particularly beneficial for adolescents and young adults with co-occurring alcohol use disorder or those in unstable housing situations. 1

Essential Treatment Components

Behavioral Therapy Integration

• Medication alone is insufficient—buprenorphine and methadone must be combined with counseling and behavioral therapies to provide comprehensive "whole-patient" care. 2
• Behavioral interventions include cognitive-behavioral therapy, contingency management, relapse prevention, and motivational enhancement therapy. 1
• The addition of psychosocial care significantly reduces treatment dropouts and rates of opioid use during treatment and at follow-up. 5

Monitoring Requirements

• Conduct regular urine drug testing to assess for continued illicit opioid use. 2
• Assess patients using DSM-5 criteria for opioid use disorder during follow-up visits. 2
• Offer hepatitis C and HIV screening as part of comprehensive care, given the association with intravenous drug use. 1, 2
• For naltrexone: perform liver function tests at baseline and every 3-6 months due to potential hepatotoxicity at supratherapeutic doses. 5, 6

Special Populations

Adolescents and Young Adults

• The American Academy of Pediatrics recommends that pediatricians consider offering medication-assisted treatment to adolescent and young adult patients with severe opioid use disorders or refer to other providers for this service. 1
• Adolescents are at particularly high risk for addiction due to enhanced neuroplasticity of their developing brains, which allows them to condition to drugs more rapidly. 1
• Buprenorphine is FDA-approved for patients 16 years and older, with no age-specific safety concerns identified to date. 1
• Federal regulations prohibit most methadone programs from admitting patients younger than 18 years. 1

Pregnant Patients

• Buprenorphine alone (Subutex) is preferred over buprenorphine/naloxone combination (Suboxone) during pregnancy. 2

Acute Pain Management in Patients on MAT

• For patients on buprenorphine maintenance requiring acute pain management, continue the usual buprenorphine dose and use short-acting opioid analgesics as needed for breakthrough pain. 2
• Buprenorphine's high binding affinity may block effects of other opioids at lower doses, potentially requiring higher analgesic doses. 2
• Patients on naltrexone cannot receive opioid pain relief—oral naltrexone should be held for 2-3 days prior to elective procedures if opioids are expected; extended-release naltrexone should be held for 24-30 days after the last injection. 5

Common Pitfalls and How to Avoid Them

Precipitated Withdrawal with Buprenorphine

• Never initiate buprenorphine until objective withdrawal symptoms are present (COWS score typically ≥8-12)—starting too early precipitates severe withdrawal. 2
• Patients must be opioid-free including tramadol before starting. 6

Precipitated Withdrawal with Naltrexone

• Perform naloxone challenge test if there is any question of occult opioid dependence before initiating naltrexone. 6
• Do not perform the challenge in patients showing clinical signs of withdrawal or whose urine contains opioids. 6
• If switching from buprenorphine or methadone, patients may be vulnerable to precipitated withdrawal for as long as 2 weeks. 6

Overdose Risk After Treatment Discontinuation

• Patients who discontinue naltrexone have increased risk of opioid overdose and death due to decreased opioid tolerance—provide opioid overdose education and naloxone. 5
• This applies to all MAT discontinuation, as tolerance decreases during treatment. 5

Underutilization and Access Barriers

• Despite proven efficacy, medications for opioid use disorder are severely underutilized—less than 50% of addiction treatment programs offer MAT, and only 34% of opioid-dependent patients in treatment receive medication. 1
• Confusion, stigma, and limited resources restrict access, particularly for adolescents and young adults. 1
• Policies and attitudes that prevent patients from accessing life-saving medication may be harmful to patient health. 1

Treatment Outcomes and Prognosis

• Opioid use disorder is a chronic relapsing neurologic disorder with low rates of spontaneous recovery, but outcomes can be significantly improved with medication-assisted treatment. 1
• MAT reduces relapse rates, prevents overdoses, prevents HIV transmission, and improves quality of life. 1
• Recovery is an expectable result of comprehensive, continuing care and monitoring—addiction should be managed as a chronic condition requiring continuous treatment. 1
• Successful outcomes with MAT are as likely as for other chronic diseases such as diabetes, hypertension, and asthma. 1