Opioid Use Disorder and Rehabilitation
“Opioid” is a term for a number of natural substances (originally derived from the opium poppy) and their semisynthetic and synthetic analogues that bind to specific opioid receptors. Opioids are potent analgesics that are also common drugs of abuse because of their wide availability and euphoriant properties. See also Opioid Analgesics and Opioid Toxicity and Withdrawal.
Heroin is commonly abused, and abuse of prescription analgesic opioids (eg, morphine, oxycodone, hydrocodone, fentanyl) is increasing; some of the increase is due to people who began taking them for legitimate medical purposes. Patients with chronic pain requiring long-term use should not be routinely labeled addicts, although they commonly have tolerance and physical dependence. People who take opioids parenterally are at risk of all the complications of injection drug use.
Opioid use disorder involves compulsive, long-term self-administration of opioids for nonmedical purposes. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) considers opioid use disorder to be present if the pattern of use causes clinically significant impairment or distress as manifested by the presence of ≥ 2 of the following over a 12-mo period:
Taking opioids in larger amounts or for a longer time than intended
Persistently desiring or unsuccessfully attempting to decrease opioid use
Spending a great deal of time obtaining, using, or recovering from opioids
Failing repeatedly to meet obligations at work, home, or school because of opioids
Continuing to use opioids despite having recurrent social or interpersonal problems because of opioids
Giving up important social, work, or recreational activities because of opioids
Using opioids in physically hazardous situations
Continuing to use opioids despite having a physical or mental disorder caused or worsened by opioids
Having tolerance to opioids (not a criterion when use is medically appropriate)
Having opioid withdrawal symptoms or taking opioids because of withdrawal
For severe, relapsing dependence, maintenance preferred to opioid withdrawal and detoxification
For maintenance, buprenorphine or methadone
Ongoing counseling and support
Physicians must be fully aware of federal, state, and local regulations concerning use of an opioid drug to treat an addict. To comply, physicians must establish the existence of physical opioid dependence. In the US, treatment is further complicated by negative societal attitudes toward addicts (including the attitudes of law enforcement officers, physicians, and other health care practitioners) and toward treatment programs, which some view as abetting drug consumption. In most cases, physicians should refer opioid-dependent patients to specialized treatment centers. If trained to do so, physicians may provide office-based treatment for selected patients.
In European countries, access to methadone or buprenorphine maintenance programs and alternative maintenance strategies is easier, and the stigma attached to prescribing psychoactive drugs is less.
Long-term maintenance using an oral opioid such as methadone or buprenorphine (an opioid agonist-antagonist) is an alternative to opioid substitution with tapering. Oral opioids suppress withdrawal symptoms and drug craving without providing a significant high or oversedation and, by eliminating the supply problems of addicts, enable them to be socially productive.
In the US, thousands of opioid addicts are in licensed methadone maintenance programs. For many, such programs work. However, because the participants continue to take an opioid, many people in society disapprove of these programs.
Eligibility criteria include the following:
Clinicians and patients need to decide whether a withdrawal (detoxification) or opioid maintenance approach is indicated. Generally, patients with severe, chronic, relapsing dependence do much better with opioid maintenance. Withdrawal and detoxification, although effective in the short term, have poor outcomes in patients with severe opioid dependence. Whichever course is chosen, it must be accompanied by ongoing counseling and supportive measures.
Methadone is commonly used. Physicians can begin the substitution, but then use of methadone must be supervised in a licensed methadone treatment program.
Buprenorphine is being used increasingly for maintenance. Its effectiveness is comparable to that of methadone, and because it blocks receptors, it inhibits concomitant illicit use of heroin or other opioids. Buprenorphine can be prescribed for office-based treatment by specially trained physicians, including primary care physicians, who have received the required training and have been certified by the federal government.
The typical dosage of buprenorphine is an 8- or 16-mg sublingual tablet once/day. Many patients prefer this option because it eliminates the need for attending a methadone clinic. Buprenorphine is also available in combination with naloxone; the addition of naloxone may further discourage illicit opioid use. The combination formulation is used in office-based treatment.
The SAMHSA website provides additional information on buprenorphine and the training required to qualify for a waiver to prescribe the drug. Protocols for using buprenorphine for detoxification or maintenance therapy are available for download at the US Department of Health and Human Services web site.
Naltrexone, an opioid antagonist, blocks the effects of heroin. The usual dosage is 50 mg po once/day or 350 mg/wk po in 2 or 3 divided doses. A once-monthly depot IM formulation is also available. Because naltrexone is an opioid antagonist and has no direct agonist effects on opioid receptors, naltrexone is often unacceptable to opioid-dependent patients, especially those who have chronic, relapsing opioid dependence. For such patients, opioid maintenance treatment is much more effective.
Naltrexone may be useful for patients with less severe dependence, early-stage opioid dependence, and strong motivation to remain abstinent. For example, opioid-dependent health care practitioners whose future employment is at risk if opioid use persists may be excellent candidates for naltrexone.
Levomethadyl acetate (LAAM), a longer-acting opioid related to methadone, is no longer used because it causes QT-interval abnormalities in some patients. LAAM could be used only 3 times/wk, thereby reducing the expense and problems of daily client visits or take-home drugs. A dose of 100 mg 3 times/wk is comparable to methadone 80 mg once/day.
Most treatment of opioid dependence occurs in outpatient settings, typically in licensed opioid maintenance programs but increasingly in physician’s offices.
The therapeutic community concept, pioneered by Daytop Village and Phoenix House, involves nondrug treatment in communal residential centers, where drug users receive training, education, and redirection to help them build new lives. Residency is usually 15 mo. These communities have helped, even transformed, some users. However, initial dropout rates are extremely high. Questions of how well these communities work, how many will be opened, and how much funding society will give remain unanswered.