Opioid Use Disorder __________________________________________________________________________
sedation does not confer additional benefits in terms of less severe withdrawal or increased rates of initiation and retention on naltrexone maintenance treatment. The risk for adverse events, the high monetary cost, and use of scarce intensive care resources suggest that this form of treatment should not be pursued [149; 150]. Additionally, UROD has not undergone the processes of therapeutic protocols, which are recognized as essential in scientific medicine, and no animal studies have been conducted with the procedure [142]. AGONIST REPLACEMENT OR ABSTINENCE THERAPY Two principle treatment modalities are offered for opioid- dependent patients: agonist maintenance or detoxification followed by outpatient or residential drug-free treatment. Both can be effective, with no clear indication for each, although agonist maintenance leads to greater treatment retention [151]. A reasonable approach is initial outpatient or residential treat- ment referral for patients relatively new to treatment, with agonist maintenance appropriate for patients with history of treatment failures, greater disease severity, or a history of drug overdoses. Naltrexone is best reserved for patients with strong legal incentives to abstain, family involvement to monitor treatment, or concurrent enrollment and involvement in a psychosocial intervention [152]. At present, there are no direct interventions that are capable of reversing the effects of drugs of dependence on learning and motivation systems [30]. Instead, the management of opioid dependence often consists of pharmacotherapy with methadone and buprenorphine, which do not eliminate physical dependence on opioids. These medications instead reduce the use of illicit opioids and produce very strong positive health outcomes as measured by decreased mortal- ity, improved mental and physical health, and reduced risk of disease transmission [30]. Considering the high rate of relapse after detoxification, maintenance therapy with methadone or buprenorphine is currently considered to be the first-line treatment for opioid-dependent patients [77; 107]. Both agents are superior to withdrawal management alone and both sig- nificantly reduce illicit opioid use [107]. Any treatment for opioid dependence must take into consid- eration the chronic relapsing nature of opioid dependence, characterized by a variable course of relapse and remission in many patients. Treatments should emphasize patient moti- vation, psychoeducation, continuity of care, integration of pharmacotherapy and psychosocial support, and improved liaison between the treatment staff and the judicial system. Pharmacotherapy must be offered in a comprehensive health- care context that also addresses the psychosocial aspects of dependence [77; 107]. Opioid-dependent patients frequently suffer from physical and psychiatric disorders, and targeted interventions of psychiatric comorbidity are essential in improving treatment outcome for these patients [77; 107]. Polysubstance abuse is the rule rather than the exception in opioid dependence, and concurrent use of other substances
should be carefully monitored and treated when necessary [77]. Concurrent use of other drugs or active engagement in other addictive behaviors should lead to consideration of other treatment plan components for the patient. The pres- ence of co-occurring substance use disorders should provoke a re-evaluation of the level of care in which the patient is treated [107]. Incarceration should never automatically result in dis- continuation of an existing treatment; imprisonment offers a window of opportunity to initiate or restart treatment with a necessary continuation after release [77; 107]. Agonist Replacement Therapy The goal of opioid replacement therapy is to reduce illicit drug use and associated health risks, with secondary goals of reducing unsafe sexual practices, improving vocational and psychosocial functioning, and enhancing quality of life [56]. The theoretical basis of opioid replacement stems from the finding that chronic opioid use results in an endogenous opioid deficiency as a result of the down-regulation of opioid production. This creates overwhelming cravings and necessi- tates interventions that shift the dependent patient’s attention and drive from obsessive preoccupation with the next use of opioids to more adaptive areas of focus, such as work, relation- ships, and non-drug leisure activities [56]. The neurobiologic changes resulting from prolonged opioid exposure provide a rationale for specific pharmacotherapies, such as long-acting opioid agonists, that are aimed at stabilizing these complex systems [84]. Opioid agonist maintenance treat- ment stabilizes brain neurochemistry by replacing short-acting opioids, which can create rapid changes in opioid levels in the serum and brain, with a long-acting opioid that has relative steady-state pharmacokinetics. Opioid agonist maintenance treatment is designed to have minimal euphoric effect, block the euphoria associated with administration of exogenous opioids (competitive antagonism), eliminate the risk of infec- tious disease and health consequences associated with injection drug use, and prevent opioid withdrawal [84]. Successful maintenance treatment entails stabilization of opi- oid dependence through opioid receptor occupation. Positron emission tomography studies have revealed that only 25% to 35% of brain opioid receptors are occupied during steady- state methadone maintenance, suggesting that unoccupied opioid receptors disrupted during cycles of opioid abuse could normalize during methadone maintenance [56]. Additionally, opioid replacement therapy blocks much of the euphoria from illicit heroin use. Long-term opioid agonist treatment also has a positive impact on public health, through significantly reducing overdose deaths, criminal activity, and the spread of infectious disease [56]. As of 2020, 1,090,357 patients in the United States were enrolled in opioid replacement therapy in 1,754 opioid treat- ment programs [111]. However, this represents less than 20% of all opioid-dependent patients. Although some have criticized the practice of methadone and buprenorphine therapy on the grounds that one opioid is merely being substituted for
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MDRI2026
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