__________________________________ Prescription Opioids: Risk Management and Strategies for Safe Use [193]. Patients requiring high-dose methadone for more severe opioid addiction are unlikely to achieve the same benefit from higher-dose buprenorphine [119]. Methadone has been reported to have higher retention rates, whereas buprenorphine has a lower risk of overdose fatality. These risks should be appropriately weighed by the treating or referring physician [191]. can offer much of what pharmacotherapy cannot provide [186].
The effectiveness of methadone and buprenorphine has only been shown in their use as long-term main- tenance, and there is little evidence to support their use as a short-term therapy course. This has been a source of patient and provider frustration. In clini- cians, this probably reflects the antiquated percep- tion that withdrawal and craving are the cardinal manifestations of addiction that, if properly treated for a brief period, should lead to full remission. It is now known that no short-term treatment can reverse the typically decades-long opioid-induced genetic expression, neurobiologically based cue- induced craving and withdrawal, or alteration in brain reward, motivation, and memory circuits characterizing long-term opioid addiction. There is increasingly widespread awareness that addiction should be viewed as a chronic disease, with great similarity to other chronic disease, such as diabetes and hypertension, whereby remission is dependent on medical management, lifestyle changes, and significant social supports [186]. Considerations in Addressing Chronic Pain Although methadone and buprenorphine are highly effective in the treatment of some chronic pain con- ditions, the protocol by which they are administered to treat opioid use disorder is unlikely to provide sufficient analgesia for patients with chronic pain. With methadone, the 4- to 8-hour duration of anal- gesic action is significantly shorter than the 24- to 48-hour duration it suppresses opioid withdrawal and craving. The typical once-daily dosing results in a narrow window of analgesia, and contrary to popular belief, it is usually not adequate for analgesia in patients with chronic pain. Additional therapies are required. With patients often describing a six- to eight-hour window of analgesia from their usual morning dose, a single long-acting opioid dose in the afternoon or early evening may be sufficient for pain control for the remainder of the day [197]. With buprenorphine therapy, concurrent opioid analgesic use is complicated by buprenorphine pharmacodynamics. With high mu opioid receptor affinity, buprenorphine displaces or competes with
Sustained stabilization on methadone or buprenor- phine can greatly enhance the capacity for normal functioning, including holding a job, avoiding crime, and reducing exposure to infectious disease from injection drug use or risky sexual behavior. Stabilized patients are much more likely to benefit from counseling and group therapy, essential com- ponents of recovery [185]. Although patients may experience sedation during the induction phase, tolerance to this effect develops over several weeks, after which the ability to work safely or operate a car or machinery is no longer impaired. Cognitive research has found that, during stabilization, the methadone-maintained patient is just as capable as a healthy, non-addicted person in job performance, assuming education and skill is comparable and abstinence from opioids and other drugs of abuse is ongoing [194]. Unfortunately, serious stigma sur- rounds methadone treatment, experienced most acutely by patients but also by professionals, which may pose a barrier to treatment support [195]. While methadone and buprenorphine can effec- tively treat pathologic opioid use, they do not appear to significantly reduce non-opioid substance abuse. Both medications are approved for use as part of a broader, comprehensive, recovery-oriented medical and social support plan. Importantly, these medica- tions are compatible with a recovery-oriented treat- ment approach, which research suggests can be an essential—but not sufficient—element of recovery from opioid addiction [196]. While methadone and buprenorphine can provide the patient with stabilization by suppressing withdrawal symptoms, craving, and dysphoria, many patients also experi- ence mental health problems, deterioration in per- sonal and social relationships, and greatly impaired occupational functioning. The addition of counsel- ing, social services, monitoring, and peer supports
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MDMS1526
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