Optimizing Medication-Assisted Treatment for Opioid Use

The opioid epidemic may have gotten less news coverage this year in the face of COVID-19, but it is still a large issue in the United States. During a presentation at the Neuroscience Education Institute Max! Virtual Meeting, William M. Sauvé, MD, regional medical director of Greenbrook TMS NeuroHealth Centers, discussed medication-assisted treatment (MAT) strategies available for patients with opioid use disorder (OUD).

Two million Americans are addicted to prescription opioids annually. Individuals with a history of substance use disorder and psychiatric disorder have a greater risk for opioid misuse. A total of 11.5 millionpeople in the United States used opioid pills in a manner that was not as prescribed, and about one in five out of 62.3 million people who filled at least one prescription for opioids shared pills with someone for whom the treatment was not indicated.

Three MATs are approved for OUD, all of which act on the mu opioid receptor: methadone, buprenorphine, and naltrexone. Methadone was the first FDA-approved MAT for OUD and allows people to discontinue the use of heroin without experiencing withdrawal symptoms. It is only available through specialty clinics and is associated with increased risk for respiratory depression. A lot of patients do not like the requirement to go daily to a specialty clinic to receive methadone, Dr. Sauvé said.

Buprenorphine may precipitate active withdrawal symptoms in individuals currently using heroin or prescription opioids, so patients should be experiencing at least some mild withdrawal before initiating buprenorphine. “That’s going to be the hardest thing in the clinic,” he said. Buprenorphine does not need to be administered at specialty clinics, although specialty licensing is required for the prescriber. There is less risk for respiratory depression compared with methadone; however, use with benzodiazepines can lead to overdose. The buprenorphine implant is FDA-approved for maintenance treatment of opioid dependence. Dr. Sauvé said the optimal patient for implant use has been on an oral dose of buprenorphine first and has been stable before considering the implant, as the implant dose cannot be altered like the oral formulation.

Naltrexone should be admitted to individuals who are free of opioid agonists for seven to 10 days, and it does not require specialty facilities or licenses. There is relatively little risk of respiratory depression or overdose. “The beauty of naltrexone,” he said, is that opioid drugs do not work if a patient relapses while on naltrexone, so this could actually help with abstinence by avoiding a high, he explained.

Withdrawal symptoms taking place during transition to MAT or between MAT can be managed with other agents. Anxiety and restlessness can be treated with benzodiazepines and antihistamines; insomnia can be treated with sedating antidepressants, non-benzodiazepine hypnotics, and sedating atypical antipsychotics; and musculoskeletal pain can be treated with non-steroidal anti-inflammatory drugs, aniline analgesics, and antispasmodics.

For patients who overdose from fentanyl, these drugs are so powerful that methadone, naltrexone, and buprenorphine do notblock fentanyl overdoses. He said that in clinical trials, a vaccine against fentanyl has been effective in animals and needs to be moved into human studies.

“We are still struggling to find a way to address this,” he said of the opioid epidemic. MAT is the best therapy right now, but that’s because that’s all there is, he said. Mitigating withdrawal symptoms with MAT and non-opioid therapies may provide patients with OUD the best opportunity for maintained abstinence and recovery.

“We have a real opportunity to not just get people off these drugs but to get them their life back,” Dr. Sauvé concluded.

Presentation: Psychiatry’s Role in Tackling the Opioid Crisis: How to Optimize Medication-Assisted Treatment. Presented at the Neuroscience Education Institute Max! Virtual Meeting, Nov. 5-8, 2020.