Effective Management of Acute and Chronic Pain with Opioid Analgesics, 2nd Edition _ ________________
MISCONCEPTIONS VERSUS REALITIES OF OUD TREATMENT Misconceptions Reality
Buprenorphine treatment is more dangerous than other chronic disease management.
Buprenorphine treatment is less risky than many other routine treatments, such as titrating insulin or starting anticoagulation, and is easier to administer. It is also safer than prescribing many opioids (e.g., oxycodone, morphine). Addiction is compulsive use of a drug despite harm. When taken as prescribed, methadone and buprenorphine improve function, autonomy, and quality of life, and patients using these drugs do not meet the definition of addiction. No data show that detoxification programs are effective for OUD, and, in fact, such interventions may increase the risk of overdose death by eliminating tolerance. Buprenorphine treatment can be readily managed in a primary care setting, and in-office induction or intensive behavioral therapy are not required for effective treatment.
Using methadone or buprenorphine is simply a “replacement” addiction.
Detoxification for OUD is effective.
Prescribing buprenorphine is time consuming and burdensome.
Source: [76]
Table 6
ADDRESSING STIGMA High levels of stigma persist toward people with OUD and medications used to treat OUD. An opinion survey titled “A National Portrait of Public Attitudes Toward Opioid Use in the U.S.: A Latent Class Analysis” published in 2023 found that 37% of respondents belonged to a “high stigma/high punitive policy” class. An updated survey showed three-fourths of physicians believed that OUD was a chronic medical condition. Few physicians endorsed beliefs that people with OUD lack willpower for using medication (13%), have only themselves to blame (12%), or have poor moral character (6%). Most primary care physicians endorsed the belief that people with OUD could return to productive lives with treatment (92%) [77]. PREGNANCY AND OUD Pregnant women with untreated OUD have more maternal complications than women without OUD, including low birth weight and fetal distress, while neonatal complications among babies born to mothers with OUD range from neonatal abstinence syndrome and neurobehavioral problems to an increase in sudden infant death syndrome. Both methadone and buprenorphine are recommended for treating OUD in pregnancy to improve outcomes for both mother and newborn. The efficacy and safety of methadone treatment for OUD in pregnant women was established in the 1980s, showing that maternal and neonatal outcomes in women on methadone treatment during pregnancy are similar to women and infants not exposed to methadone. More recent research suggests that buprenorphine treatment has similar, or superior, benefits in this population [78].
The safety of extended-release naltrexone has not yet been established for pregnant women, and naltrexone is currently not recommended for the treatment of OUD in pregnant women. Despite this solid evidence base, most pregnant women with OUD do not receive any treatment with medications [79]. Among women who do receive treatment during pregnancy, many fall out of treatment during the postpartum period due to gaps in insurance coverage and other systemic barriers. An integrated approach with close collaboration between OUD treatment providers and prenatal providers has been described as the “gold standard” for care. TREATING ACUTE PAIN IN PATIENTS ON MAT Some physicians may not prescribe effective opioid analgesia for patients with OUD on MAT due to concerns about respiratory depression, overdose, or drug diversion. As a result, this population is at particular risk of undertreatment for acute pain. Physicians may also mistakenly assume that acute pain is adequately controlled with the long-term opioid agonist (i.e., methadone) or partial agonist (i.e., buprenorphine). Although potent analgesics, methadone and buprenorphine have an analgesic duration of action (4 to 8 hours) that is substantially shorter than their suppression of opioid withdrawal (24 to 48 hours). Nonopioid analgesics (e.g., acetaminophen and NSAIDs) are first-line options for treating acute pain in this population. For moderate-to-severe pain not adequately controlled with nonopioids, however, judicious use of opioid analgesics should be considered. Patients on MAT generally have a high cross-tolerance for analgesia, leading to shorter durations of analgesic effects.
20
MDUT1125
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