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
Overall, the cost-effectiveness of intramuscular naltrexone is unclear. State-administered insurance programs vary in their requirements for coverage of naltrexone treatment.31
Comprehensive medication reconciliation is vital
Overall fragmentation of care within OTPs places patients at risk for adverse events, such as drug interactions.32 Under Title 42 of the US Code,33 patients must provide written consent for an OTP provider to disclose their history of a substance use disorder. Allowing the patient to decide which medical providers can access their treatment records for an OUD benefits patient confidentiality but poses numerous issues worth exploring.
All prescribed controlled substances are recorded in the prescription drug monitoring program, or PDMP, a state-level electronic database accessible to health care professionals to inform prescribing decisions and identify drug interactions. The PDMP has substantially reduced opioid overprescribing and improved identification of patients at risk for overdose or misuse of opioids.
Unlike all other controlled substances, however, prescriptions ordered by an OTP are not recorded in the PDMP (although there are recent exceptions to this scenario). Without such information, a physician might not have important information about the patient when making medical decisions—placing the patient at risk for harmful outcomes, such as drug–drug and drug–disease interactions.
For example: Methadone is associated with a prolonged QT interval,34 increasing the risk for a fatal arrhythmia. Concurrent QT-prolonging medications, such as azithromycin and citalopram, further increase this risk.35 Because methadone dispensing is isolated from the patient’s medical record, the clinician who prescribes MOUD has an incomplete patient history and could make a potentially fatal treatment decision.
Continue to: Diversion is unlikely
