Special Topics in Pain: Opioids

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Clinical Management of Opioid Use Disorder.

Author(s): Dunlap, et al.
Journal: JAMA. 2016; 316(3):409:3. 9 references.
Reprint: Adam S Cifu, MD, University of Chicago, 5841 Maryland Ave, MC 3051, Chicago, IL 60637. Email: jvaisman@painandwellnesscenter.com
Faculty Disclosure: Abstracted by N Walea, who has nothing to disclose.
Objective: Review and evaluate the latest advances and newest information in the area of Opioids

Editor's Note:  Opioid use disorder is widespread and dealing with it is best done in a therapeutic setting with drug-assisted therapy, most successfully, buprenorphine/naloxone.

Class: Opioid use disorder

Guidelines for treatment of patients addicted to opiates potentially can improve both patient and public health outcomes. Of the estimated 2.5 million people in the United States with opioid addiction, fewer than half are able to access medication-assisted treatment (MAT), 53.4% of US counties do not have a single prescriber of medications to treat opioid use disorder, and, as of 2014, only 2.2% of US  physicians had obtained the necessary waivers to prescribe buprenorphine.

MAT is an evidence-based approach that combines medical therapy with an opioid agonist or antagonist with counseling and recovery support.  MAT using agonist therapy with methadone or buprenorphine has been shown to be superior to withdrawal ("detox") for important patient-centered outcomes such as overdose death, rates of communicable disease, retention in treatment, and relapse.

The Vancouver Costal Health (VCH) and Providence Health Care Opioid Use Disorder Treatment Guideline Committee developed the Guideline for the Clinical Management of Opioid Addiction. This committee was composed primarily of addiction and primary care specialists within VCH, Providence Health Care, and the British Columbia Ministry of Health. Peer review of the guideline was undertaken by a multidisciplinary group that included patients and families, policy managers with the Ministry of Health, generalist physicians, and physicians with training and expertise in treating patients with addiction. 

A systematic literature review was performed as part of the development process. The literature review was the basis of the guideline. Evidence was summarized using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria. Strong recommendations were given to use of agonist therapy as first-line treatment on the basis of 7 Cochrane reviews published between 2003 and 2014 with high to moderate-quality evidence.

Study heterogeneity and limited outcome information precluded supporting a single approach to psychosocial interventions and support structures. There have been no meta-analyses of residential treatment programs, many of which provide intensive behavioral therapy along with withdrawal or agonist management while removing the patient from prior environmental triggers for opioid use.

 MAT is superior to withdrawal alone. Studies of withdrawal demonstrate that the majority of patients relapse with withdrawal management alone, even with tapering with opioid agonist medications to alleviate withdrawal symptoms. The addition of methadone treatment decreases the rate of relapse.

MAT decreases rates of infectious disease. A 2012 meta-analysis showed an association between methadone treatment and HIV infection, with a 54% reduction in risk of HIV infection among intravenous drug users who were stabilized with methadone vs no treatment.

Comparing MAT agonist therapies, a 2014 Cochrane review showed no difference in retention in treatment or suppression of illicit opioid use between moderate-dose methadone and buprenorphine. There were no meta-analyses that compared buprenorphine/naloxone combination therapy with buprenorphine alone or methadone.

Buprenorphine/naloxone therapy is preferred in this guideline over methadone in appropriate patients, because of several potential advantages, including lower risk of overdose, more flexible at-home dosing, and the lower risk diversion. Combination buprenorphine/naloxone therapy may also be superior to methadone as it allows for induction, stabilization, and maintenance to be performed in the primary care setting.

Methadone may be considered first-line treatment in some patients, such as in severely addicted patients with high daily doses of opioids, or when a challenging induction is anticipated because of prior treatment failures, history of severe withdrawal symptoms, or an expected need for high maintenance treatment doses. 

Important Points:
Opioid withdrawal alone is not recommended for treatment of opioid use disorder in most patients because of increased risks of overdose death and infectious disease, particularly HIV through intravenous drug use, following detoxification. In absence of contraindications, medically supervised opioid agonist treatment should be offered to patients. Buprenorphine/naloxone is the preferred first-line treatment. Psychosocial supports tailored to patient needs may be offered as an adjunct to medical treatment.

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