TREATMENT

There are effective, evidence-based treatments for treating opioid misuse. These include medications for addiction treatment (buprenorphine, methadone, and naltrexone) with psychosocial treatment. The FDA Commissioner recently stated that everyone who seeks treatment for an opioid use disorder should be offered access to buprenorphine, methadone, and/or naltrexone, as “[A]ll three of these treatments have been demonstrated to be safe and effective in combination with counseling and psychosocial support.”

Medication used for treatment of opioid addiction extends life in persons with opioid use disorder. It increases patient retention and decreases drug use, infectious disease transmission, and criminal activity.

Pregnant women who seek treatment for opioid dependence have better outcomes than pregnant women who quit abruptly. If a woman is unable to quit before becoming pregnant, treatment with methadone or buprenorphine during pregnancy improves the chances of having a healthier baby at birth.

One question frequently asked is whether using medications such as buprenorphine and methadone simply replaces one addiction with another. Buprenorphine and methadone are not just heroin/opioid substitutes. Buprenorphine and methadone have slower onsets of action and produce stable levels of the drug in the brain. As a result, patients taking these medication do not experience a “rush.” If a person treated with one of these medications tries to take an opioid such as heroin, the euphoric effects are dampened or inhibited and the desire to use the opioid is reduced.  

Treatment can occur in a variety of settings, in many different forms, and for various lengths of time. The specific type of treatment or combination of treatments will depend on the person’s needs and the types of drugs they use. Factors such as age, race, culture, sexual orientation, gender, pregnancy, parenting, housing, employment, psychiatric history, and history of physical and sexual abuse should always be considered when planning treatment for persons with opioid disorders.  

The goal of treatment is not only to stop the use of opioids, but also to return people to productive functioning.

Buprenorphine is a generic drug marketed under the brand names Subutex and Suboxone. Tablets/films are placed under your tongue or inside your cheek and allowed to dissolve. When taken in prescribed doses, under a doctor’s supervision, buprenorphine can help you face the challenge of withdrawal and increase your chance for a long-term recovery. Buprenorphine helps you to stay physically comfortable while in the early stages of recovery and blocks your cravings for heroin and other opioid medications, so you can gradually and safely reduce your dependence on opioids.

Subutex contains buprenorphine only, whereas Suboxone contains both buprenorphine and naloxone. Naloxone was combined with buprenorphine in Suboxone to prevent misuse and diversion of the medication. Both Subutex and Suboxone are used as part of a complete treatment program for opioid use disorder, which will include counseling, behavioral therapies, and lifestyle changes.

Methadone is an opioid medication that helps prevent withdrawal symptoms. It also blocks the high you would get from other opioids, like codeine, heroin, hydrocodone, morphine, and oxycodone. While methadone works a lot like morphine and stronger narcotics, its effects come on a lot slower and are significantly milder. To treat addiction, methadone may be given in tablet, powder, or liquid form. Methadone is administered out of a certified opioid treatment program. While the duration of methadone treatment varies from person to person, experts say that it should be administered for at least a year to increase one’s chance for successful recovery. When it is time to stop taking methadone, your doctor will help you stop gradually to prevent withdrawal.

Naltrexone is an opioid antagonist that works by blocking the effects of opioids. Naltrexone is sold under the brand names Vivitrol and ReVia. It is primarily used to manage alcohol or opioid dependence. It is taken by mouth or by injection into a muscle. Vivitrol is a naltrexone formulation for injection. Long-acting injectable naltrexone decreases heroin use more than placebo. Vivitrol, which is the injectable form, is given once per month and has better compliance than the oral formulation. It decreases cravings for opioids after a number of weeks, and decreases the risk of overdose. Naltrexone is used along with counseling and social support to help people stop drinking or using.

The FDA recently approved lofexidine, a non-opioid medication, to help with the abrupt withdrawal of opioids in adults. Lofexidine, an adrenergic receptor agonist, is sold under the brand name Lucemyra. Lofexidine does not eliminate the symptoms of opioid withdrawal, but can lessen their severity. Lofexidine is only approved for up to 14 days and, as such, is primarily considered in situations where an individual is in need of short-term detoxification. Most guidelines recommend the use of methadone or buprenorphine for the long-term treatment of opioid use disorder.

Unfortunately, despite the effectiveness of treatment for opioid use disorders, very few Americans who are in need of treatment receive it. In fact, most people who have an opioid use disorder report that they have never had treatment for it.

According to one study, only 26.19% of persons diagnosed with opioid use disorder used any alcohol or drug treatment within the past year, and only 19.44% had used an opioid-specific treatment. Those least likely to receive treatment are Asian Americans, Black/African Americans, adolescents, the uninsured, and those using prescription opioids.

Black/African Americans
Treatment rates for opioid use disorders are already low in the general population, and especially low in Black/African American communities. SAMHSA recently issued a brief, which discusses the particular challenges that Black/African Americans face in accessing treatment and recovery services. Examples of these barriers include structural racism, unequal access to certain types of treatment, fear of legal consequences, and lack of culturally responsive care. For more information on opioid use disorder and the Black/African American community, access the SAMHSA brief here.

Older Adults
Older Adults have among the highest and most rapidly growing prevalence of opioid use disorder. A recent study found that only about 81,000 Medicare recipients are receiving buprenorphine-naloxone therapy, despite the fact that more than 300,000 Medicare patients struggle with an opioid use disorder and 211,200 require hospitalization for opioid overuse each year.

Only 8% of individuals who misuse prescription opioids will ever seek treatment for it.

It is not known why so few people with prescription opioid disorder seek treatment. Possible explanations include:

• The impression that prescription opioids are less dangerous than illegal drugs, which is simply not true.
• Ambivalence about giving up the rewarding effects of the drug, despite being aware of the harmful effects of these substances.
• Not wishing to discuss potential prescription problems with their doctor because they are afraid that their doctor will not want to write them more prescriptions.
• The stigma associated with having a substance use disorder.
• Not viewing substance use disorder as the medical illness that it is, but as a “moral weakness” or “willful choice.”
• The cost. Many individuals are uninsured. And even for those who have insurance, their insurance may not cover all needed services. There may be restrictions on the doses or length of treatment, or added requirements (e.g., prior authorization) which can make it more difficult to obtain some treatments.
• Fear of legal consequences/incarceration, which is particularly a concern for people of color.
• More than half of rural counties lack a physician with a DEA waiver that permits buprenorphine to treat opioid use disorder, and many physicians with a waiver are not using it to its full extent or at all. Rural patients often must spend significant time and money to travel long distances for treatment.

A survey of chronic pain patients receiving prescription opioids found that nearly 1 in 5 chronic pain patients receiving prescription opioids had experienced an overdose.

Naloxone is medication that can treat an opioid overdose, when given right away. Naloxone is an opioid antagonist, which means that it works by binding to opioid receptors in the brain, blocking the effects of opioids.

Opioids suppress breathing. Naloxone works to rapidly restore normal breathing to someone whose breathing has slowed or stopped due to an opioid overdose.

The FDA has approved three formulations of naloxone, including injectable, auto-injectable, and nasal spray. Both the auto-injector (Evzio) and the nasal spray (Narcan) can be administered by anyone. This means that friends, family members, and other bystanders can administer the auto-injector or nasal spray to the person who has overdosed. It is important to remember to call 911 at the same time, even if the person’s respiration has returned.

Between 1996 and 2014, over 26,500 opioid overdoses in the US have been reversed by laypersons using naloxone. A naloxone distribution program in Massachusetts reduced opioid overdose deaths by 11%, with no increase in opioid use, in the 19 communities that implemented it.

Because of naloxone’s safety and efficacy, most states have passed laws to make naloxone (Narcan) more readily available. You can now get Narcan without a written prescription in 47 U.S. states and the District of Columbia. If you live in one of the three states (i.e., Kansas, Montana, or Wyoming) where a written prescription is still needed to purchase naloxone, you can ask your primary care physician to write a prescription.

The Good Samaritan Law

Good Samaritan laws vary by state. The Massachusetts Good Samaritan Law protects people who call 911 during an overdose from being charged with possession of a controlled substance. It also protects persons administering naloxone for suspected opioid overdoses as well as health care providers prescribing naloxone. The law was passed in the Commonwealth in 2012 to increase the likelihood that witnesses will call 911 during an overdose, so that victims can receive timely and appropriate intervention. A person who has overdosed is much more likely to survive if they receive medical assistance as soon as possible.