_________________________________________________________________________ Opioid Use Disorder
another, the clinical benefits strongly support this treatment modality [56]. When compared to active street heroin users, these benefits include a four-times lower HIV seroprevalence rates, 70% fewer crime-days per year, and a one-year mortality rate of 1% (versus 8%) [60]. Methadone The first demonstrated efficacy of methadone treatment for opioid dependence was published in 1965. Methadone is now the most inexpensive and empirically validated agent available for use in opioid replacement therapy. Studies have shown one-year treatment retention rates of 80%, with significant reductions in illicit opioid use [56]. Individual and group coun- seling are the main ancillary therapies and consist primarily of cognitive-behavioral and supportive-expressive approaches. There is some evidence that augmentation of methadone with intensive psychosocial therapy significantly improves outcomes [56]. Efforts to provide methadone in an office-based setting have been successful, although federal regulation has limited the flexibility of providers [84; 107]. As noted, methadone maintenance treatment offers substantial benefits over no treatment, including reduced risk of death and disease, reduced heroin use, reduced criminal involvement, and improved well-being. However, the benefits are less with poor-quality or under-funded programs. The quality of the staff-patient interaction, attitudes of staff, good management of clinics, and good record-keeping characterize higher-quality programs [153]. Methadone maintenance is also cost-effective [56]. A 1997 study of Veterans’ Affairs patients showed that the estimated six-month costs are about $21,000 for an untreated drug abuser, $20,000 for an incarcerated drug abuser, and $1,750 for a patient enrolled in a methadone maintenance program [154]. A study using data from one healthcare plan reached a similar conclusion regarding cost-effectiveness (albeit with dif- fering cost estimates) [155]. The annual costs (in 2004 dollars) were $18,694 for patients receiving no methadone with 0 or 1 outpatient addiction treatment visits; $14,157 for patients receiving no methadone with 2 or more visits; and $7,163 for patients receiving methadone.
There is an unrealistic expectation that opioid users should be able to stop using all drugs. Although some do successfully stop, dependence is a chronic problem for most patients, associated with frequent relapses, serious health risks, and psychosocial impairment [153]. Unfortunately, a serious stigma surrounds methadone treatment, which is experienced most acutely by patients but also by professionals. This may pose a barrier to treatment support [153]. Treatment is initiated with a dose of 25–30 mg and is gradually titrated in 5- to 10-mg increments per day to a desired range of 60–120 mg. Low-dose treatment is associated with less positive outcomes than doses of 60–120 mg/day or greater [55; 60]. One published review of efficacy literature concluded that high doses of methadone (>50 mg daily) are more effective than low doses (<50 mg daily) in reducing illicit opioid use. This may be due to the increased availability of highly pure heroin [60]. Additionally, high doses of methadone are more effective than low doses of buprenorphine (<8 mg daily). High dosages of methadone are comparable to high dosages of buprenorphine (>8 mg daily) on measures of treatment retention and reduc- tion of illicit opioid use [77]. Methadone is contraindicated for the following patients [55; 107]: • Those with known hypersensitivity to methadone hydrochloride • Those experiencing respiratory depression • Those with acute bronchial asthma or hypercapnia • Those with known or suspected paralytic ileus Buprenorphine Buprenorphine offers several advantages over methadone, including lower cost, milder withdrawal symptoms following abrupt cessation, lower risk of overdose, and longer duration of action, allowing alternate-day dosing [56; 156]. Identifying subpopulations of opioid addicts who differentially respond to buprenorphine versus methadone has not been clearly established. However, patients with less chronic and less severe heroin dependence benefit more fully from buprenorphine than from a pure opioid agonist like methadone [56]. Studies support buprenorphine as a viable alternative for opioid maintenance therapy. However, its mixed agonist/ antagonist action entails special considerations. Buprenor- phine may precipitate opioid withdrawal, and patients being switched from short-acting opioids must abstain from illicit opioid use for at least 24 hours before initiating buprenor- phine therapy [56; 107]. Another drawback is associated with the sublingual route of administration. This administration presents some difficulties because the tablet is relatively large and slow to dissolve under the tongue and swallowing dimin- ishes its effectiveness. Also, the transition to buprenorphine from long-acting opioids is difficult [30]. The ASAM warns that diversion and misuse are possible with buprenorphine, as is physical dependence. Respiratory depression may occur if buprenorphine is used with CNS depressants including
When considering initiation of methadone, the American Pain Society recommends that clinicians perform an individualized medical and behavioral risk evaluation to assess risks and benefits of methadone, given methadone’s specific pharmacologic
properties and adverse effect profile. (https://www.jpain.org/article/S1526-5900(14)00522-7/ fulltext. Last accessed March 21, 2024.) Strength of Recommendation/Level of Evidence : Strong/low
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MDRI2026
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