Medications for Opioid Use Disorder Save Lives (2019) / Chapter Skim
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2 The Effectiveness of Medication-Based Treatment for Opioid Use Disorder
2 The Effectiveness of Medication-Based Treatment for Opioid Use Disorder
Pages 33-62
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From page 33... ...
Long-term retention on medication for OUD is associated with improved outcomes. A lack of availability of behavioral interventions is not a sufficient justification to withhold medications to treat OUD.
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From page 34... ...
The chapter also explores the use of behavioral interventions in conjunction with medications to treat OUD. METHADONE Methadone is a synthetic, long-lasting opioid agonist (Kreek, 2000)
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From page 35... ...
As an agonist, methadone sustains the opioid tolerance and physical dependence of the patient, so missing doses can cause opioid withdrawal. The major risk to patients on methadone -- opioid overdose death -- is ele vated within the first 2 weeks of methadone treatment (Degenhardt et al., 2009)
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From page 36... ...
As with methadone, buprenorphine sustains opioid tolerance and physical dependence in patients, so discontinuation can lead to withdrawal -- lthough a buprenorphine's withdrawal syndrome may be less severe. The most prominent risk of buprenorphine to patients with OUD is precipitation of nonlife-threatening opioid withdrawal at first dose.
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From page 37... ...
The oral formulation was found to be no better than a placebo in retaining patients in treatment or eliminating their opioid use (Minozzi et al., 2011) and patients treated with oral naltrexone have an increased risk of overdose compared to methadone (Degenhardt et al., 2015)
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From page 38... ...
. EVIDENCE ON THE EFFECTIVENESS OF FDA-APPROVED MEDICATIONS IN TREATING OUD A wealth of evidence about medications to treat OUD has been amassed over the past half century from clinical studies, randomized controlled t rials, systematic reviews, and meta-analyses.
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From page 39... ...
. Increased access to treatment using agonist medication is associated with reduced opioid overdose deaths (Schwartz et al., 2013)
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. A review of 11 randomized controlled trials found that, compared with a placebo or non pharmacological therapy, people who received methadone were more than four times more likely to stay in treatment and had significantly lower rates of heroin use (Mattick et al., 2009)
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From page 41... ...
reported that in controlled trials in which individuals had not already undergone opioid detoxification, only 63 percent of indi viduals randomized to extended-release naltrexone successfully received even a single dose of medication -- the equivalent of 4 weeks of treatment. In real-world community treatment settings, only 10.5 percent of patients were adherent to extended-release naltrexone at 6 months (Jarvis et al., 2018)
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From page 42... ...
. Although it is not approved in the United States for treating opioid withdrawal, clonidine is used extensively off-label and the American Society of Addiction Medicine has recommended its inclusion in practice guidelines for managing withdrawal symptoms (Kampman and Jarvis, 2015)
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From page 43... ...
Expanding the Number of OUD Treatment Medications Expanding the treatment toolkit for OUD has the potential to increase treatment rates and provide more effective, individualized care for people with OUD. Treatment options that warrant further exploration include slow-release oral morphine (SROM)
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From page 44... ...
Many of these options would require not just approval by FDA, but also changes to the Harrison Narcotics Tax Act of 1914.6 Slow-Release Oral Morphine SROM is a full agonist opioid with a slow-release oral formulation that has been proposed as an alternative maintenance therapy for people who do not respond adequately to the other available types of medications to treat OUD. As yet, no definitive evidence indicates that SROM is equivalent or superior as a treatment option, but SROM appeared to be similar in effectiveness to methadone in one study that directly compared the two for maintenance treatment (Beck et al., 2014)
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From page 45... ...
"Medical marijuana" has received significant attention because many OUD patients consume recreational marijuana either as a reward substitution in attempts to reduce overdose risk (because cannabis has low mortality risk) or to alleviate anxiety symptoms during opioid withdrawal (Wiese and Wilson-Poe, 2018)
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From page 46... ...
Developing novel, non-opioid treatments that can help to relieve shortand long-term opioid withdrawal symptoms and cravings would require
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BEHAVIORAL THERAPY IN CONJUNCTION WITH MEDICATIONS Behavioral interventions are often used in conjunction with medications in treating OUD, for two primary reasons. The first is to target a broad range of problems and issues not addressed by the medications themselves (e.g., comorbid psychiatric symptoms, concurrent use of other drugs, the need for social support, HIV risk behaviors, behavioral changes, motivation)
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From page 48... ...
Methadone Treatment Combined with Behavioral Interventions There is robust evidence that contingency management interventions that reward positive behaviors are effective as behavioral adjuncts to m ethadone treatment. Furthermore, treatment retention improves when patients are permitted to take the medication home.
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From page 49... ...
Buprenorphine Treatment Combined with Behavioral Interventions A systematic review of eight randomized controlled trials found mixed results with respect to the additional benefit of adding behavioral intervention to medical management in office-based buprenorphine treatment (Carroll and Weiss, 2017)
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From page 50... ...
. Given the mortality benefit of the medications, more research into behavioral interventions that result in improved treatment adherence is critical; behavioral techniques also have promising potential to assist patients in achieving good long-term functional outcomes.
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. Peer support groups to supplement treatment for addiction have promising potential to increase treatment engagement and to reduce substance use and risk behaviors for infectious disease transmission, but more rigorous studies are needed (Tracy and Wallace, 2016)
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From page 52... ...
However, evidence-based behav ioral interventions can be useful in engaging people with OUD in treatment, retaining them in treatment, improving outcomes, and helping them resume a healthy functioning life. There is inadequate evidence about which behavioral interventions provided in conjunction with medications for OUD are most helpful for which patients, including evidence on how effective peer support is; more research is needed to address this knowledge deficit.
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From page 53... ...
2017. The role of behavioral interventions in buprenorphine maintenance treatment: A review.
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2002. Contingency management to enhance naltrexone treatment of opioid dependence: A randomized clini cal trial of reinforcement magnitude.
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2003. Methadone maintenance at different dosages for opioid dependence.
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2018. Safety and efficacy of lofexidine for medically managed opioid withdrawal: A randomized controlled clinical trial.
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2017. Fatal and non-fatal opioid overdose in opioid dependent patients treated with methadone, buprenorphine, or implant naltrexone.
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2009. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence.
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2006. Behavioral therapy to augment oral naltrexone for opioid dependence: A ceiling on effectiveness?
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2007. A randomized controlled trial of interim methadone maintenance: 10-month follow-up.
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2011. Adjunctive counseling during brief and extended b uprenorphine-naloxone treatment for prescription opioid dependence: A 2-phase r andomized controlled trial.
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1991. A randomized trial of an interim methadone maintenance clinic.
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