Opioid use disorder frequently starts with prescription opioid medications that patients may misuse to get high. So, it can seem counterintuitive to say that the best way to treat it is with more prescription medicines... some of which are opioids! This has led some healthcare professionals, addiction specialists, and policy makers to dismiss medication-assisted treatment as "just replacing one drug with another." But that's a fundamental misunderstanding of how pharmacotherapy works. Its goal is to use safe and effective medication along with counseling and behavioral supports to mitigate the symptoms of OUD and allow patients the best chance at recovery. Three medications have been approved by the FDA for the treatment of OUD: methadone, buprenorphine, or naltrexone.
Methadone has been in use the longest. It's a full agonist, meaning that it binds to the opioid receptors in a patient's brain and the response it produces is directly proportional to the dose. It's an opioid, but it metabolizes slowly enough for patients to take it once a day, without the peaks and valleys seen with other opioid pain relievers. It reduces withdrawal symptoms, helps to control drug cravings, and blocks euphoric effects at the appropriate dose. But by law, methadone for the treatment of OUD can only be administered in specialized opioid treatment programs. Methadone treatment requires that patients visit the treatment programs at least six days per week for the first few months. This can be challenging for many patients.
Buprenorphine is an opioid medication that, like methadone, blocks euphoric effects, reduces withdrawal symptoms, and controls drug cravings. It is prescribed by physicians and taken at home. It's a partial agonist, meaning it binds to the brain's opioid receptors but triggers only a limited response. However, prescribers must complete additional training and obtain a special DATA-2000 waiver and DEA license to prescribe buprenorphine as treatment for OUD.
Naltrexone works differently than methadone or buprenorphine, because it acts as an antagonist on opioid receptors, producing no effect and blocking the effects of opioids. But, as an antagonist, Naltrexone doesn’t block withdrawal and can precipitate acute and painful withdrawal if taken by someone who has opioids in their system. Decades of moralizing about addiction might make us want to help patients "quit" or "get clean." Controlling an addiction with medication might feel like an uncomfortable compromise.
But the truth is, many chronic conditions that have strong genetic, environmental, and behavioral components require regular medication along with behavior change. And pharmacotherapy for OUD is tremendously effective. Receiving buprenorphine or methadone halves the likelihood that patients will die of overdose, compared to those receiving counseling alone. With pharmacotherapy, instead of experiencing the powerful highs and lows of cravings and withdrawal, patients experience steady relief. This helps keep their moods and health stable enough for them to participate in counseling and rebuild their lives. Like with other chronic conditions, some patients may eventually taper off these medications, while others may need ongoing pharmacotherapy.
Using medication to treat OUD helps people achieve recovery, which SAMHSA defines as "a process of change through which individuals with substance use disorders improve their health and wellness, live self-directed lives, and strive to reach their full potential." Focusing on the health, wellbeing, and function of people with OUD goes hand in hand. By moving the discussion of OUD from a moral model to a medical one, we ensure that we're using evidence-based treatments like pharmacotherapy to provide the best standard of care.
Even if you have reservations about using an opioid to treat opioid use disorder, it is important to recognize that without such treatment, your patients' risk of overdose is significantly higher. Pursuing a goal of recovery, and embracing every means to achieve it, will help more people with OUD survive and live happy, stable lives.