__________________ Effective Management of Acute and Chronic Pain with Opioid Analgesics, 2nd Edition
EXTENDED-RELEASE NALTREXONE Naltrexone is not an opioid. It is a full antagonist of the mu-opioid receptor, which blocks both the euphoric and analgesic effects of all opioids, including endogenous opioids (i.e., endorphins), and also reduces cravings for opioids. Naltrexone does not cause physical dependence, nor does it produce any of the rewarding effects of opioids. Patients may try to use opioids while on extended-release naltrexone, but it is unlikely that they will experience any rewarding effects from such use unless the binding affinity of naltrexone is overcome. The most common side effects of extended-release naltrexone are injection site pain, nasopharyngitis, insomnia, and toothache. Healthcare Considerations: Naloxone Versus Naltrexone: What’s the Difference? Naloxone (Narcan) is an opioid antagonist given by injection or nasal spray to reverse overdoses. It acts within minutes and lasts for only about an hour due to rapid metabolism. Naltrexone has a very similar chemical structure to Naloxone and is also an opioid antagonist, but it acts more slowly and lasts longer. Extended-release naltrexone is used clinically to block cravings for opioids and other drugs. Treatment initiation requires a 7-10 day period during which the patient is free from all opioids, including methadone and buprenorphine. This is usually achieved with medically supervised withdrawal followed by at least 4 to 7 days without any opioids (including methadone and buprenorphine). This process is a very significant barrier to naltrexone use. Naltrexone is currently available both as a once-daily oral tablet and in a once monthly, extended-release depot injection. Only the extended-release formulation has been approved for OUD by the FDA. Patients may have an increased risk of overdose when they approach the end of the 28-day period of the extended-release formulation [69]. DOES MAT REALLY WORK? Abundant evidence from decades of randomized trials, clinical studies, and meta-analyses suggests that agonist or partial- agonist opioid treatment used for an indefinite period of time is the safest option for treating OUD [70]. Data suggest that MAT is more effective than psychotherapeutic interventions alone and is just as effective whether psychotherapeutic interventions are used concurrently with medication treatment or not.
PSYCHOSOCIAL TREATMENTS Psychosocial and/or behavioral interventions can be used in combination with medications in order to treat the “whole patient” (e.g., comorbid psychiatric symptoms, social support needs). The National Academy of Sciences, however, notes that psychosocial services may not be available to all patients and recommends that the lack of such supports should not be a barrier to using MAT [71]. Findings related to the incremental benefit of psychosocial supports were mixed; however, the most comprehensive and current reviews were supportive of the value of psychosocial supports in addition to pharmacological treatments for OUD. Nonetheless, psychosocial, behavioral, and peer-support interventions may have many profoundly important benefits for patients beyond strictly opioid-related outcomes, such as improving self-confidence, self-advocacy, general quality of life, and improvements in legal, interpersonal, and occupational functioning [72]. Some guidelines and authors advocate for the use of psychosocial interventions but suggest that the lack of such interventions at a given place or time should not be a barrier to the use of MAT [71][73]. TAPERING PROTOCOLS OUD guidelines do not recommend a duration of MAT treatment, which could be for an indefinite period of time because of the high risk of relapse with discontinuation. For example, a population-based retrospective study of 14,602 patients who discontinued methadone treatment found that only 13% had successful outcomes (no treatment reentry, death, or opioid-related hospitalization) within 18 months of taper [74]. Nonetheless, some patients may want to stop opioid agonist therapy. An ideal time frame for a trial of MAT tapering has not been established. Tapering should always be at the patient’s discretion, and all decisions should be based on a thorough dialogue between patient and provider. Goals should be framed functionally, for example maintaining employment, avoiding using illicit opioids or other drugs, continuing with social/ emotional support programs, and so on. MISCONCEPTIONS ABOUT OUD TREATMENT Stigma and misunderstanding surround the issues of addiction in general and OUD in particular. These include counterproductive ideologies that portray addiction as a failure of will or a moral weakness, as opposed to understanding OUD as a chronic disease of the brain requiring medical management, which is no different, in principle, from the approach used to manage other chronic diseases such as diabetes or hypothyroidism (Table 6). Some stigma and misunderstanding may arise from a lack of awareness of how treatment of OUD has evolved in the past 15 years [75].
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MDUT1125
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