CCSAD | OUD Medications Offer Different Benefits, Drawbacks

Although many addiction treatment practitioners are in recovery, Jake Nichols, PharmD, MBA, a pharmacist in long-term recovery himself, told Cape Cod Symposium on Addictive Disorders attendees on Friday that it is important to keep in mind that more treatment modalities exist beyond what worked for the caregivers themselves.

“It’s dangerous to assume the way you or I did it has to be the same way other patients will do it,” Nichols said.

To that end, Nichols delivered a presentation that broke down the 3 main medications used to treat opioid use disorder, and the reasons why each might be a more appropriate intervention for certain patients. Use of medication-assisted treatment for OUD patients overall still is not widespread. According to a 2018 study, less than one-third of patients were provided with any medication for OUD in their first year following an overdose, and just 23% of publicly funded treatment programs offer FDA-approved medications for SUD, Nichols said.

The most well-established of the three, methadone, is a full mu opioid receptor agonist that relieves symptoms associated with withdrawal from opioids without causing euphoria or intoxication (with stable dosing). Some providers who offer methadone, however, can increase dose amounts too high, too quickly, leading to intoxication in patients.

Buprenorphine, meanwhile, has become “the medication of choice” for treating OUD, Nichols said. Offered in three forms—pills, sublingual film and a long-acting injectable—buprenorphine is a mixed agonist/antagonist opioid medication. Twice daily dosing is most common, but dosing can be increased to three times per day at smaller doses, a regimen that could be more beneficial for patients with a concurrent pain condition, Nichols said. The target dose of buprenorphine is 16mg daily, with a recommended dose range of 4-24 mg daily. If patients need to exceed that range, it might be time to consider transitioning them to methadone, Nichols said.

Diversion is a potential issue with methadone and buprenorphine, Nichols said. The majority of studies evaluating buprenorphine diversion, however, have demonstrated patients are using it primarily for self-medication purposes, largely because they reported that treatment wasn’t accessible.

Naltrexone, the third FDA-approved medication, is an opioid receptor antagonist delivered monthly as an extended-release injectable that has to be administered by a healthcare professional. Nichols offered two notes about the use of naltrexone: Administration of the medication can be painful at the injection site, and because it blocks the receptor that modulates mood, depression and suicidality can be concerns, and therefore, for patients with a comorbid behavioral health issue, naltrexone might not be the best option.

Tapering

A question from many patients and their families is how soon patients can begin to taper off their medications. Nichols said this is a misplaced focus.

“I think we need to stop worrying about how long people need to be on buprenorphine and focus more on whether they are meeting the criteria for a substance use disorder,” he said. “Are they engaging with treatment? Are they engaging with their social lives? Are they working? Those are better markers of recovery than whether they are on medication.”

Patients should maintain continuous sobriety for at least 1 to 2 years before discussing tapering, as studies have shown worse outcomes among patient with treatment lasting less than 6 months. Successful methadone-assisted treatment typically is maintained for at least 24 months, buprenorphine for at least 18 months. Nichols added that 95% of methadone patients do not achieve abstinence when attempting to taper off, and more than 90% of buprenorphine patients relapse within 8 weeks after tapering.

Choosing a medication

Which medication is right for each patient? There is no single playbook to answer that question, Nichols said.

“You aren’t going to find guidelines out there that say, ‘If a patient has X, Y and Z, they get methadone. If they have Q, R, S, they get buprenorphine, and if they have A, B and C, they get naltrexone,” he said. “It doesn’t exist.”

He did offer that antagonist therapy might be more suitable for patients who fit into the following categories:

• Young adults
• New to treatment
• Brief history of addiction
• Motivated for opioid-free treatment
• Employed in professions that prohibit or test for opioid use
• Re-entering community after incarceration

Pain management for OUD patients can be challenging, but it shouldn’t be avoided. Left untreated, patients will often attempt to self-medicate, and their risk of relapse is high. For patients with co-occurring pain issues, buprenorphine should be strongly considered for OUD treatment. Methadone is a riskier option, but may be used. Naltrexone should be avoided, Nichols said.

Regardless of approach, he added, all patients should be frequently assessed.