What is the best approach to treating a patient with heroin (opioid) use disorder, potentially complicated by co-use of other substances?

Treatment of Heroin Use Disorder

For patients with heroin (opioid) use disorder, medication-assisted treatment (MAT) with methadone, buprenorphine, or naltrexone combined with behavioral therapies is the gold standard and should be initiated immediately, as this approach decreases opioid use, reduces mortality from overdose, decreases criminal activity, and improves overall functioning. 1, 2

Initial Assessment and Screening

• Screen all patients using validated tools such as the single-question screen: "How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?" (sensitivity 90-100%, specificity 74%) 1
• If positive, use the Drug Abuse Screening Test-10 (DAST-10) for more detailed assessment (sensitivity 90-100%, specificity 77%) 1
• Assess for polysubstance use, as heroin users commonly use tobacco, alcohol, tramadol, and benzodiazepines concurrently 3
• Screen for co-occurring mental health disorders, as these are highly prevalent and require integrated treatment 2
• Screen for HIV, hepatitis C, and intimate partner violence, as rates exceed 50% in some populations with substance use disorders 1

First-Line Pharmacotherapy Options

Methadone Maintenance Treatment

• Most effective for severe heroin dependence with long history of use 4, 5
• Requires enrollment in federally certified Opioid Treatment Programs (OTPs) 6
• Optimal dosing: 80-120 mg/day or higher to achieve craving relief, suppress withdrawal, and block euphoric effects 5
• Lower doses (<80 mg/day) are less effective and do not provide adequate blockade 5
• Treatment duration should be indefinite, as methadone is corrective but not curative 5
• Reduces heroin use, mortality, criminal activity, and HIV transmission 1, 4, 5

Buprenorphine/Naloxone

• Preferred for office-based treatment and patients with less severe dependence 2, 7
• Can be prescribed by waivered physicians (now up to 275 patients per provider) 1
• Critical timing requirement: Patient must be in active opioid withdrawal before first dose to avoid precipitated withdrawal 1, 7
• Use Clinical Opiate Withdrawal Scale (COWS) to confirm withdrawal severity (COWS >8 indicates readiness for induction) 1
• Initial dose: 4-8 mg sublingual based on withdrawal severity 1
• Target maintenance dose: 16 mg/day for most patients 1
• For patients transitioning from methadone, wait at least 72 hours and be prepared for severe precipitated withdrawal lasting up to 2 weeks 1, 8

Naltrexone

• Only appropriate after complete opioid detoxification (7-10 days opioid-free for short-acting opioids) 8
• Requires naloxone challenge test before initiation to confirm absence of physical dependence 8
• Dose: 50 mg daily or alternative schedules (100 mg every other day, 150 mg every third day) 8
• Less effective than agonist therapy for most patients but useful for highly motivated individuals or those with contraindications to agonist therapy 1, 2

Behavioral Therapy Integration

• Combine pharmacotherapy with cognitive-behavioral therapy (CBT), contingency management, or motivational enhancement therapy 2
• Combined pharmacotherapy with CBT shows greater efficacy than pharmacotherapy alone 2
• Brief counseling using motivational interviewing decreases quantity and frequency of drug use 1
• Contingency management plus Community Reinforcement Approach is most effective (only 4 patients need treatment for 1 additional patient to achieve abstinence) 9

Management of Acute Pain in Patients on MAT

Common pitfall: The maintenance opioid (methadone or buprenorphine) does NOT provide analgesia for acute pain 1

• Continue the patient's usual maintenance dose—verify with their provider or program 1
• Add separate opioid analgesics for pain management at higher doses and shorter intervals than typical due to cross-tolerance 1
• Use scheduled dosing rather than as-needed to prevent pain recurrence and patient anxiety 1
• Avoid mixed agonist-antagonist opioids (pentazocine, nalbuphine, butorphanol) as they precipitate withdrawal 1
• Consider patient-controlled analgesia for postoperative pain 1
• Use multimodal analgesia with NSAIDs, acetaminophen, and adjuvant analgesics to reduce total opioid requirements 1

Harm Reduction Services

• Provide naloxone for overdose reversal to all patients and their families 1, 2
• Offer overdose prevention education 1
• Refer to syringe service programs to reduce HIV and hepatitis C transmission 2, 9
• Educate on safer use practices 2

Critical Pitfalls to Avoid

• Never abruptly discontinue opioid agonist therapy—this constitutes patient abandonment and increases overdose risk 1
• Never withhold MAT due to concerns about drug interactions with HIV or HCV treatments—these medications are safe to use together 2
• Never use beta-blockers for cocaine-associated chest pain in polysubstance users, as they worsen coronary vasoconstriction 9
• Never rely solely on abstinence-based approaches—harm reduction is evidence-based and saves lives 1, 2
• Never administer buprenorphine to patients not in active withdrawal, as this precipitates severe withdrawal 1, 7
• Never use selective β1-blockers in patients who may continue cocaine use due to unopposed α-adrenergic stimulation 9

Ongoing Management

• Monitor treatment response with regular follow-up (weekly initially, then monthly) 1
• Urine drug testing can support diagnosis and monitor treatment but should not be used punitively 1
• Reassess regularly for relapse risk, which is highest in early recovery 1
• Maintain a nonjudgmental, blame-free environment to encourage continued engagement 1
• For patients with continued heroin use during MMT, increase methadone dose by 10 mg increments (each 10 mg increase reduces odds of continued use by 10%) 3