Opioid Use Disorder and Rehabilitation

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 people with opioid use disorder, enable them to be socially productive.

In the US, thousands of people with opioid use disorder 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 Withdrawal and detoxification Opioids are euphoriants that cause sedation. Respiratory depression may occur with high doses and can be managed with antidotes (eg, naloxone) or endotracheal intubation and mechanical ventilation... read more , 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. The 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 US Substance Abuse and Mental Health Services Administration (SAMHSA) 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.

Naltrexone, an opioid antagonist, blocks the effects of heroin and other opioids. An every-4-week depot IM formulation is available and is the preferred method of administration. 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.

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 such centers as Samaritan 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 months. 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.