Medication-assisted recovery for opioid use disorder: A guide
Considering offering medical intervention for OUD to reduce mortality? It’s essential to understand the clinical benefits, limitations, and regulation of available agents.
PRACTICE RECOMMENDATIONS
› Consider resource availability (eg, treatment programs and regulatory barriers), in addition to patient- and medicationspecific factors, when designing the most individualized, advantageous medication-assisted recovery plan, to reduce the risk for mortality. B
› Schedule early (< 2 weeks) and frequent follow-up with patients who are starting medications for opioid use disorder (particularly methadone), to manage risk when mortality is highest and to support recovery. C
› Set and manage patient expectations for control of withdrawal symptoms when initiating medications for opioid use disorder (particularly buprenorphine). B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Second, because naltrexone does not address withdrawal symptoms, supportive therapies should be incorporated into the treatment plan, including:
- clonidine for hyperadrenergic symptoms (anxiety, diaphoresis, hypertension)
- nonopioid analgesics for pain
- antiemetics, such as ondansetron and metoclopramide, for nausea or vomiting
- loperamide for diarrhea
- diphenhydramine for insomnia.
Third, patients taking naltrexone have a diminished response to opioids. This complicates pain management in the event of an emergent surgical procedure.
Last, when naltrexone wears off, patients are effectively opioid-naïve, which increases the risk for overdose in those who stop therapy abruptly.29 The increased risk for overdose should be communicated to all patients with OUD who are being treated with naltrexone.
This nonopioid option is appealing to policymakers and is often prioritized in the criminal justice system; however, the decreased efficacy of naltrexone (compared to methadone and buprenorphine), potential for overdose, and challenges in initiating treatment are concerning and limit the drug’s use in many real-world settings.
Because naltrexone is not a controlled substance, regulations regarding maintaining inventory and distribution are more flexible.
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