What medication is indicated for a 36-year-old male with a history of methamphetamine and fentanyl (opioid) addiction, currently undergoing detoxification?

From the Guidelines

For a 36-year-old male with a long history of methamphetamine and fentanyl addiction since age 11 who is seeking recovery, a comprehensive medication regimen would typically include buprenorphine/naloxone (Suboxone) as the primary medication, as recommended by the CDC guideline for prescribing opioids for chronic pain 1. The recommended starting dose is 8-16mg daily, titrated based on withdrawal symptoms, with maintenance doses typically ranging from 16-24mg daily. This medication helps manage opioid withdrawal symptoms and cravings by partially activating opioid receptors. For methamphetamine addiction, there is no FDA-approved medication specifically for treatment, but supportive medications may include:

• mirtazapine (15-45mg at bedtime) to help with sleep and appetite,
• bupropion (150-300mg daily) to address depression and cravings,
• gabapentin (300-600mg three times daily) may help with anxiety, insomnia, and pain during withdrawal. The patient should be monitored for at least 6-12 months on medication, with potential long-term maintenance depending on stability, as suggested by a primary care approach to substance misuse 1. These medications work best when combined with behavioral therapy, counseling, and support groups. The extended duration of his addiction (25 years) and early onset (age 11) suggests he may need longer treatment and more intensive support for successful recovery, and 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.

From the FDA Drug Label

All patients treated with opioids require careful and frequent reevaluation for signs of misuse, abuse, and addiction, because use of opioid analgesic products carries the risk of addiction even under appropriate medical use Buprenorphine hydrochloride should not be abruptly discontinued in a physically-dependent patient [see DOSAGE AND ADMINISTRATION] If buprenorphine hydrochloride is abruptly discontinued in a physically-dependent patient, a withdrawal syndrome may occur, typically characterized by restlessness, lacrimation, rhinorrhea, perspiration, chills, myalgia, and mydriasis

The patient likely needs buprenorphine as part of their treatment for opioid addiction, given their history of addiction to methamphetamine and fentanyl, and considering the information provided in the drug label 2.

• Buprenorphine can help manage withdrawal symptoms and reduce cravings.
• It is essential to carefully monitor the patient for signs of misuse, abuse, and addiction.
• The patient should be closely evaluated for physical dependence before initiating or discontinuing buprenorphine treatment.

From the Research

Medication for Methamphetamine and Fentanyl Addiction

To address the medication needs of a 36-year-old male who has been addicted to methamphetamine and fentanyl since he was 11 years old and is now getting clean, we need to consider the available evidence on treatments for these substances.

• Methadone Maintenance Treatment (MMT): A study published in 2020 3 found that MMT is safe and effective for patients with fentanyl use disorder, with 75% of patients achieving remission within 12 months.
• Buprenorphine: Research from 2015 4 suggests that buprenorphine can reduce methamphetamine cravings in individuals undergoing treatment, with significant reductions in craving scores and positive urine tests compared to a placebo group.
• Stimulant Agonist Treatment: A systematic review from 2020 5 found that stimulant agonist treatment, such as dexamphetamine and methylphenidate, shows promise in reducing methamphetamine use, although more research is needed to confirm these findings.
• Naltrexone and Topiramate: The same systematic review 5 found that naltrexone and topiramate may also be effective in reducing methamphetamine use, although the evidence is not yet conclusive.

Considerations for Co-Occurring Opioid and Stimulant Use

When treating individuals with co-occurring opioid and stimulant use disorders, it is essential to consider the potential interactions between medications and the risks of serotonin toxicity 6. However, the available evidence suggests that medications like buprenorphine and methadone can be effective in reducing cravings and promoting remission in individuals with these co-occurring disorders.

• Medication-Assisted Treatment: The most effective approach may involve a combination of medication-assisted treatment (MAT) and behavioral therapies, such as the Matrix program used in the buprenorphine study 4.
• Individualized Treatment: Treatment should be individualized to address the specific needs and circumstances of each patient, taking into account their medical history, substance use patterns, and other factors.