Medication-Assisted Treatment for Opioid Use Disorder

Author: Leslie R. Dye, MD, FACMT; VP, Editor-in-Chief, Medical and Drug Content

Drug overdose deaths increased by 54% from 2011 to 2016 in the United States and opioids continue to top the list, according to data recently released by the CDC. The number of overdose deaths involving heroin rose threefold, from 4571 deaths in 2011 to 15,961 deaths in 2016.1 One doesn’t need to see the statistics to be aware of the continuing opioid epidemic and to recognize that treatment remains challenging.

Is medication-assisted treatment for opioid use disorder still controversial?

Despite evidence from numerous studies and the support of addiction medicine experts, controversy still surrounds the use of medication-assisted treatment (MAT) for the treatment of opioid use disorder (OUD). Critics of MAT argue that one drug is being substituted for another, so using these drugs is no solution. Those opposed to the use of MAT believe abstinence is the only solution, while others believe that MAT should only be used as a last resort after multiple failed attempts at abstinence. While withdrawal from opioids is not life-threatening, most people find the powerful cravings and urge to use opioids so overwhelming that they use again rather than struggle until the withdrawal symptoms abate. Those without personal experience cannot understand why willpower alone is not enough to overcome the effects of withdrawal and just stop the dangerous cycle. It is akin to expecting someone to use willpower to control explosive diarrhea. MAT drugs effectively control the withdrawal symptoms without causing significant euphoria, allowing the person to navigate withdrawal without relapsing.

Methadone is a full agonist at the opioid receptor, which means it binds fully to the receptor and generates some opioid effect. Buprenorphine is a partial agonist that produces a small opioid effect when used sublingually; when mixed, buprenorphine and naloxone will not produce euphoric effects if injected, limiting diversion. Naloxone is not used to treat OUD, but only used to limit diversion or treat overdose. As a partial agonist, buprenorphine has a ceiling effect, so does not result in respiratory depression. Therefore, buprenorphine is generally considered safer than methadone. Naltrexone, the third drug used for OUD, is an opioid antagonist that binds to the receptor and blocks the effects.

Since the safety profile of buprenorphine is better than that of methadone and administration is less restrictive, some physicians prefer its use. However, overall, buprenorphine may be more expensive.

Is there evidence that MAT works?

Experts in the field of addiction medicine consider MAT to be the standard of care for the treatment of OUD2 as it limits withdrawal and cravings, allowing patients to feel “normal.” More importantly, studies support the practice: The Multi-Site Prescription Opioid Addiction Treatment Study3 of over 300 patients reported 51.2% abstinent after 18 months. Those who used MAT were more likely to report abstinence from other opioids than those not using MAT. Buprenorphine-naloxone was the drug combination primarily used in this study, although some participants switched to methadone later. Counseling was included early in the study, but not required as it progressed, and approximately 40% participated in self-help groups (eg, Alcoholics Anonymous, Narcotics Anonymous) at some point. In a Cochrane review from 2009, methadone maintenance therapy reduced heroin use more than no MAT.4 A study in Baltimore from 1995 to 2009 concluded that expansion of MAT with buprenorphine or methadone was associated with a decrease in heroin overdose deaths.5

How long should MAT be continued?

While experts usually concur that MAT is the best option for the treatment of OUD, there is still disagreement regarding the length of treatment. Some regimens taper the medication after one year with a goal of eventual total abstinence. But studies demonstrate permanent changes in the neurologic pathways in those with OUD,6 suggesting that lifetime medication is required. If that is true, discontinuing medication in a patient with OUD when they are doing well is like discontinuing antihypertensive medication in a patient with hypertension when it is successfully controlling blood pressure. The disease is still there, it is just controlled by the medication.

Prognosis for OUD still gloomy

The sad fact about OUD is that no treatment has a very high success rate, but the alternative is dismal. How much the addition of counseling and self-help groups contribute to triumph over the disease is also variable. Many believe trying MAT is a better option than allowing a person with OUD who is in the grips of withdrawal and craving to search for heroin on the street and end up dying from a fatal dose of fentanyl. There are countless examples of those with OUD who have been treated successfully in a MAT program and then are incarcerated for a previous crime. He or she receives no further treatment in jail, as most do not provide MAT, and the inmate goes through withdrawal. After enduring withdrawal, upon release from prison after finishing the sentence without MAT, counseling, or self-help group support, the person decides to use the same amount of opioid, often heroin, that he or she used before entering into MAT. Due to the prolonged time since using heroin, his or her tolerance is diminished and the dose upon release from jail results in death. Fortunately, some in the criminal justice system are starting to allow MAT in incarcerated patients.7,8

While we still have a long way to go in this battle against the opioid epidemic, we have made much progress. We have learned a great deal about the disease of addiction and have educated millions in the professional and public world. The stigma of OUD is slowly being eroded; more people are willing to seek treatment, and advances in research and technology continue to produce innovative and successful ways to treat this fatal disease that is stealing the lives of so many people, both young and old.

 

For more information on the diagnosis and treatment of Opioid Use Disorder and Opioid Withdrawal, see the Clinical Overview about each topic on ClinicalKey.

Clinical Overviews, produced by Elsevier’s team of experienced physicians and reviewed by authoritative subject matter experts, synthesize the most current, evidence-based literature. They are regularly updated to provide relevant and reliable point-of-care information for practicing clinicians.

 

  1. CDC: Opioid Overdose: Drug Overdose Death Data. CDC website. Updated December 19, 2017. Accessed December 17, 2018. https://www.cdc.gov/drugoverdose/data/statedeaths.html
  2. American Society of Addiction Medicine: The ASAM National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. The ASAM website. Published June 1, 2015. Accessed October 19, 2018. https://www.asam.org/docs/default-source/practice-support/guidelines-and-consensus-docs/asam-national-practice-guideline-supplement.pdf
  3. Potter JS et al: The multi-site prescription opioid addiction treatment study: 18-month outcomes. J Substance Abuse Treat. 48(1):62-9, 2015
  4. Mattick RP et al: Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database Syst Rev. 3:CD002209, 2009
  5. Schwartz RP et al: Opioid agonist treatments and heroin overdose deaths in Baltimore, Maryland, 1995-2009. Am J Public Health. 103(5):917-22, 2013
  6. Kosten TR et al: The neurobiology of opioid dependence: implications for treatment. Sci Pract Perspect. 1(1):13-20, 2002
  7. Vestal C: At Riker’s Island, a legacy of medication-assisted opioid treatment. The Pew Charitable Trusts website. Published May 23, 2006. Accessed December 18, 2018. https://www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2016/05/23/at-rikers-island-a-legacy-of-medication-assisted-opioid-treatment
  8. Freyer FJ: Court orders Essex County to provide methadone to inmate. The Boston Globe website. Published November 27, 2018. Accessed December 18, 2018. https://www.bostonglobe.com/metro/2018/11/27/court-orders-essex-county-provide-methadone-inmate/iz5GxxfwgKPmi5CNWtNrnK/story.html
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