An estimated 2.1 million people in the United States had a substance use disorder related to prescription opioid pain medicines in 2016, and only a fraction of these individuals receive treatment for their opioid use disorder. Opioid use disorder (OUD) is defined as a problematic pattern of opioid use that leads to severe impairment or distress. Opioids comprise a large family of naturally and synthetically made pain relievers that originate from the opium poppy plant and are prescribed by healthcare providers to treat severe chronic pain and cancer-related pain. However, overprescribing began in the early 1990s that lead to the first wave of addiction that later resulted in the rapid increase of heroin addiction and synthetic opioid addiction, including fentanyl. As a result, opioid addiction treatment, using medication-assisted treatment (MAT) has been on the rise as a solution to curb the current opioid epidemic that is costing thousands of lives each year. There are many different types of opioid use disorder treatment options, and studies have shown that psychotherapy combined with medication-assisted treatment (MAT) is deemed the most effective form of treatment.
Methadone is a long-acting opioid agonist that is used to treat opioid use disorder under strict guidelines and supervision. Methadone can be administered when an individual still has other opioids in the bloodstream and as a result, is deemed an effective and safe treatment to help curb and prevent severe opioid withdrawal side effects. Methadone is considered a favorable and effective medication in the treatment of opioid use disorder because it does not produce the instantaneous euphoric high that heroin or other short-acting opioids produce. Methadone is administered in a step-wise fashion until opioid withdrawal symptoms are minimized. Once the client is on the correct dose to ease their heroin withdrawals, they will stay on this methadone dose for a few days, weeks or even months and then will be slowly weaned off the methadone in a step-down fashion to ensure addiction to methadone does not occur. Methadone can be a short term or long term treatment for opioid use disorder, depending on the individual client.
Buprenorphine is a partial opioid agonist, meaning that, like opioids, it produces effects such as euphoria or respiratory depression but these effects are weaker than those of full drugs such as heroin and methadone. Buprenorphine’s opioid effects increase with each dose until at moderate doses they level off, even with further dose increases. This “ceiling effect” lowers the risk of misuse, dependency, and side effects. Also, because of buprenorphine’s long-acting agent, many individuals may not have to take it every day. Unlike methadone, the client must have abstained from using opioids for 12-24 hours and be in the early stages of opioid withdrawal. If individuals have opioids in their system, initiating buprenorphine can result in acute withdrawal symptoms. Unlike methadone treatment, which must be performed in a highly structured clinic, buprenorphine is the first medication to treat opioid dependency that is permitted to be prescribed or dispensed in physician offices, significantly increasing treatment access. The FDA has approved the following buprenorphine products:
- Bunavail (buprenorphine and naloxone) buccal film
- Suboxone (buprenorphine and naloxone) film
- Zubsolv (buprenorphine and naloxone) sublingual tablets
- Buprenorphine-containing transmucosal products for opioid dependency
In November 2017, the U.S. Food and Drug Administration approved Sublocade, the first once-monthly buprenorphine injection for moderate-to-severe opioid use disorder in adult patients who have initiated treatment with the transmucosal buprenorphine-containing products. This medication, in addition to Probuphine, an implantable buprenorphine formulation approved in May 2016, eliminate the need for daily dosing and improve treatment retention.
Unlike methadone or buprenorphine, naltrexone is not an opioid agonist but instead works by blocking the opioid receptors as a way to prevent opioid cravings. As a result, there is no abuse potential with naltrexone. Naltrexone can only be taken once the individual is no longer in the acute withdrawal phase and has not used opioids in at least 48 hours. Similar to buprenorphine, naloxone can be prescribed on an outpatient basis by any healthcare professional who is licensed to prescribe medications. The FDA has approved the following naltrexone products:
- ReVia pill form
- Depade pill form
- Vivitrol injectable monthly extended release