Evidence-Based Reviews

What clinicians need to know about treating opioid use disorder

Current Psychiatry. 2016 August;15(8):20-24,30-31,34,36,39

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Adverse effects. Some of the adverse events reported during treatment with buprenorphine include fever, back pain, nausea, cough, sedation, difficulty with urination, and constipation. Respiratory depression is a less common effect of buprenorphine, compared with full opioid agonists, because of the medication’s mechanism of action as a partial agonist.⁴⁸ As a result, buprenorphine has been shown to have a lower risk of fatal overdose than methadone.⁴⁹ Studies have shown buprenorphine to be more likely than methadone to reduce neonatal abstinence syndromes.⁵⁰

NaltrexoneNaltrexone is an opioid antagonist and is an option to promote relapse prevention. Because of its antagonist properties, naltrexone treatment should always start after opioid detoxification because it can potentiate immediate withdrawal symptoms. Naltrexone is available in oral and long-acting formulations, the latter of which may be considered in patients who have difficulty with adherence.³⁷

Oral naltrexone is taken as a single 50 mg-tablet once daily, whereas dosing for long-acting naltrexone in injectable and implantable formulations varies. These long-acting naltrexone formulations typically are administered monthly. Some of the adverse events reported during treatment with naltrexone are nausea, liver damage, and injection site pain.⁵¹

Buprenorphine/naloxoneBecause of buprenorphine’s agonist effects, it has a relatively high abuse potential compared with other opioids.⁵² Naloxone, on the other hand, is an opioid antagonist and is poorly absorbed when given orally and is associated with withdrawal symptoms if used intravenously. Therefore, naloxone is added to buprenorphine to decrease the likelihood of abuse when both are used as a combination product.⁵³

Buprenorphine is combined with naloxone in a ratio of 4:1. Induction begins by using a 2 mg/0.5 mg tablet with dosage titration until symptoms abate. A combination of buprenorphine and naloxone also is available in film and tablet formulations. Patients must abstain from other opioids for at least 24 hours before initiating buprenorphine/naloxone treatment to prevent the precipitation of withdrawal symptoms.

Bottom LineThere is no consensus on the most effective strategy to achieve complete remission from opioid use disorder. If a patient is actively seeking to abstain from opioids, then either agonist or antagonist treatment can be used. When a patient is not seeking abstinence, then agonist treatment should be preferred to avoid overdose-related complications. Combined medication and psychosocial treatment, such as counseling and peer support programs, can improve adherence to treatment and prevent relapse.

Related Resources

World Health Organization. Guidelines for the psychosocially assisted pharmacological treatment of opioid dependence. http://whqlibdoc.who.int/publications/2009/9789241547543_eng.pdf?ua=1.
Preda A. Opioid abuse treatment & management. Medscape. http://emedicine.medscape.com/article/287790-treatment.

Drug Brand Names
Buprenorphine • Buprenex, Subutex
Buprenorphine/naloxone • Suboxone, Zubsolv, Bunavail
Butorphanol • Stadol
Clonidine • Catapres, Duraclon
Entacapone • Comtan
Methadone • Methadose, Dolophine
Nalbuphine • Nubain
Naloxone • Narcan, Evzio
Naltrexone • ReVia, Vivitrol

Disclosures
The authors declare that there was no financial support of any kind related to the production of this manuscript. Dr. Macaluso has conducted clinical trials research as principal investigator for the following pharmaceutical companies over the last 12 months: Allergan, Alkermes, AssureRx, Eisai, Forum, Janssen, and Aptinyx/Naurex. All clinical trial and study contracts were with, and payments made to, the Kansas University Medical Center Research Institute, a research institute affiliated with Kansas University School of Medicine–Wichita (KUSM-W). Drs. Sohail and Majid report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products. Dr. Kalia has conducted clinical trials research for AssureRx over the last 12 months. All clinical trial and study contracts were with and payments made to the Kansas University Medical Center Research Institute, a research institute affiliated with KUSM-W.

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