Medications underused in treating opioid addiction

Along with addiction counseling, the drugs naltrexone, buprenorphine and methadone all have a place in treatment for opioid use disorder, says Tyler Oesterle, M.D., medical director of Mayo Clinic Health System's Fountain Centers drug and alcohol treatment programs. Evidence of the three drugs' effectiveness in treating opioid use disorder is well-established, says Dr. Oesterle, the review's lead author. This review uses data from available medical literature to provide a framework for determining the optimal approach for medication-assisted treatments.

"We have an opioid epidemic in this country that has been caused by many factors, including overzealous use of medication, the widespread availability of legal and illegal opioids, and societal expectations that all pain can be eliminated," Dr. Oesterle says. "We clearly cannot medicate our way out of the problem, but we have the opportunity to mediate the problem through more judicious use of prescription opioids."

Each drug has strengths and weaknesses, and the appropriate risks and benefits should be discussed with each patient suffering from an opioid use disorder, according to the study.

Naltrexone, which is approved to treat opioid and alcohol dependence, and block the effects of opioids in adults, is longer-acting and ideal as an opioid blocking agent, the review says. Patient compliance with buprenorphine is relatively high and associated with improved rates of sobriety and a reduction in accidental overdoses. The principal benefits of methadone are relief of narcotic craving, suppression of withdrawal syndrome, and blocking of the euphoric effects associated with heroin.

According to the review, the three drugs may be underused in part because access is limited by some legal requirements regarding who can write prescriptions. The one exception is naltrexone, which can be ordered by any prescriber.

Another challenge in treating opioid use disorder is that it can be slow in developing, making it difficult to identify for primary care providers. "The development of an opioid use disorder can happen slowly, over time, and that makes it difficult to identify in primary care," Dr. Oesterle says. "We are currently researching better ways to identify details and advise patients."

Effectively responding to the opioid crisis requires moving beyond a medication-only approach, according to Dr. Oesterle. "We need to establish a generalizable framework that utilizes the full repertoire of responses and resources we have at our disposal." This includes medications, counseling, mental health services, workforce rehabilitation and social support, he says.