There are no other FDA-approved medications for the treatment of other substance use disorders. The New England Journal of Medicine (NEJM) provides an overview of current pharmacological treatment for opioid related conditions which is summarized as follows (Schuckit, 2016): Treatment of acute withdrawal syndromes – medically supervised withdrawal or detoxification – can improve the patient’s health and facilitate his or her participation in a rehabilitation program. However, by itself, medically supervised withdrawal is usually not sufficient to produce long-term recovery, and it may increase the risk of overdose among patients who have lost their tolerance to opioids (i.e., the need for higher doses of the drug to produce effects) and resume the use of these drugs. The abrupt discontinuation of opioids after long-term, intense use produces symptoms that result from physiologic changes during drug use. Symptoms of abstinence syndromes after discontinuation of shorter-acting opioids, such as heroin, begin within hours after receiving the prior dose and decrease greatly by day four, whereas with misuse of longer-acting opioids, such as methadone (Dolophine), withdrawal begins after several days and decreases at approximately day 10. Opioid antagonist- precipitated withdrawal begins almost immediately and lasts approximately an hour after intramuscular or subcutaneous administration of 0.4 to 2 mg of the short-acting antagonist naloxone every two to three minutes (up to a total dose of 10 mg). Acute withdrawal symptoms are followed by weeks to months of protracted withdrawal syndromes that include fatigue, anhedonia, a poor appetite and insomnia. The most effective approach to treating a patient who has withdrawal is to prescribe a long-acting oral opioid (usually methadone or buprenorphine) to relieve symptoms, and then gradually reduce the dose to allow the patient to adjust to the absence of an opioid. However, only licensed addiction- treatment programs (both office-based treatments and inpatient treatments) and physicians who have completed specific training regarding opioid drugs can administer opioids to treat opioid-use disorders. Methadone taper Methadone, an oral mu-opioid agonist, has a half-life of 15 to 40 hours. The patient’s condition is first stabilized with a dose that mitigates withdrawal but does not over sedate. Then, in outpatients, doses are decreased by 10 to 20 percent every one to two days over two to three weeks or longer. The taper can occur over approximately one week in inpatients who are going through withdrawal from short-acting drugs, such as heroin, and, as discussed below, can be as slow as 3 percent of the dose per week in patients who are discontinuing methadone maintenance. Buprenorphine taper Buprenorphine is an analgesic that is available as a sublingual monotherapy or in combination with naloxone as a film strip for sublingual use (e.g., Suboxone or as a generic formulation) or in a buccal dissolving film (Bunavail). Like methadone, it has advantages of oral administration and a long “functional” half-life of three hours. Methadone and buprenorphine produce similar improvements during opioid withdrawal, although buprenorphine is associated with less sedation and respiratory depression. To avoid precipitating more intense withdrawal, buprenorphine should be initiated 12 to 18 hours after the last administration of opioids in patients who misuse shorter-acting opioids (48 hours in patients who are receiving long-acting drugs such as methadone), with initial doses of 4 to 8 mg. Additional doses up to 16 mg may be administered, depending on the patient’s response. After the patient’s condition is stabilized for three to five days, the dose is often decreased over two or more weeks; more opioid-free urine samples are seen with a four-week reduction protocol than with a shorter reduction protocol.
Naltrexone for abstinence-oriented opioid rehabilitation Naltrexone is a mu-opioid receptor antagonist that blocks opioid effects and helps maintain abstinence from opioids in highly motivated patients. It is available in 50-mg daily tablets with effects lasting 24 to 36 hours. To help maintain adherence to treatment when used as part of an outpatient rehabilitation program, it is also available as an extended-release injectable formulation containing 380 mg of naltrexone (Vivitrol) that blocks opioid effects for one month. Medication treatment is most effective when it is administered as part of a cognitive behavioral approach (to enhance motivation, work toward behavioral changes and prevent relapse) with patient participation in a self-help group. Side effects of these medications include gastrointestinal upset, fatigue and insomnia, as well as elevated levels on liver-function tests at higher doses, although naltrexone is relatively safe in persons who consume large amounts of alcohol and those with hepatitis C or HIV infection. Patients who initiate naltrexone treatment must be free of physiological opioid dependence (e.g., more than seven days without acute withdrawal symptoms). Methadone maintenance approaches Maintenance treatment with methadone, an oral mu agonist, has been widely used and intensively studied worldwide. In the United States, methadone is offered only through approved and closely monitored clinics that initially require almost daily patient participation in order to receive the drug, although some take-home doses are usually allowed for patients who adhere to program guidelines. Dangers associated with methadone include overdose if the dose is increased too quickly during the initial treatment stages and cardiac arrhythmias with doses higher than 100 mg per day. The maintenance phase begins at approximately six weeks, with doses adjusted to avoid drug-related euphoria, sedation or opioid craving. The length of the maintenance phase, which depends on the patient’s progress in treatment and his or her motivation, can last years to a lifetime. Tapering off methadone is individualized and may take weeks or months. During and after tapering, maintain close contact with the patient because discontinuing maintenance carries high risks of relapse to the use of illicit drugs and overdoses that may lead to death. Buprenorphine maintenance In the United States, the restriction of methadone to specialized clinics contributed to a search for an alternative oral, long-acting opioid. This search resulted in buprenorphine maintenance therapy. Buprenorphine has effects that last for 24 to more than 36 hours. It reduces opioid-withdrawal symptoms and partially blocks intoxication from other opioids. The risks associated with buprenorphine include overdoses, especially if it is taken along with depressant drugs, and potential illicit diversion of drugs. Beyond pharmacology the treatment system for substance use disorders is comprised of multiple service components, including the following:
● Individual and group counseling. ● Inpatient and residential treatment. ● Intensive outpatient treatment. ● Partial hospital programs. ● Case or care management. ● Recovery support services. ● Peer supports. (SAMHSA, 2016) Massage and opioid disorder
Massage can be effective in treating opioid use disorder as part of the treatment plan and can take place in any inpatient, outpatient, residential or hospital setting. Throughout 2016, the American Massage Therapy Association (AMTA) has been actively engaged with several organizations
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