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The FDA has approved three effective drugs for the treatment of opioid addiction: methadone (a complete opioid agonist), buprenorphine (a partial agonist), and naltrexone (an opioid antagonist). 10b For many years, methadone has been used successfully for both opioid detoxification and maintenance treatment. A3 Unlike buprenorphine and naltrexone, which can be prescribed by doctors in their offices (though doctors who want to prescribe buprenorphine for the treatment of opioid use disorder must first complete specialized training and certification), methadone is only available in specially licensed treatment programs for the treatment of opioid use disorder. Methadone is a long-acting -receptor agonist with a late onset of peak effects (usually 2 to 6 hours) and a slow offset of activity, making it suitable for once-daily use. Methadone blocks or attenuates the effects of other opioid use by reducing opioid demand and inducing cross-tolerance. Although the therapeutic dose of methadone for a given person may vary, doses of 60 mg or higher have been demonstrated to be more effective than lower doses; there is some evidence that even greater doses (e.g., 80 mg or more per day) may be more beneficial than 60 mg. Methadone treatment has been demonstrated to decrease opiate consumption, enhance employment, minimize criminal behavior, and lower the risk of HIV infection.
When a patient in a methadone treatment program experiences acute pain (e.g., postoperatively) that necessitates opioid analgesia, the patient should continue to receive the baseline methadone maintenance treatment dose for the addiction and receive a different opioid for pain treatment (Chapter 27), or if additional methadone is the analgesic of choice, it should be given every 6 to 8 hours in addition to the usual daily dose for the opioid use disorder. It's a good idea to double-check the methadone dose with the patient's treatment plan before providing it. The fact that the patient takes methadone on a daily basis does not negate the requirement for opioid analgesia. As a result of cross-tolerance to other opioid medicines, many patients seeking methadone treatment for opioid use disorder will require a relatively high dose of opioids.
The Drug Addiction Treatment Act of 2000 revolutionized the treatment of opioid use disorder by allowing the partial opioid agonist buprenorphine to be approved for the treatment of opioid dependence and allowing buprenorphine treatment to be administered in doctors' offices rather than only in specialized opioid treatment programs. Physicians must apply to the Substance Abuse and Mental Health Services Administration for a waiver allowing them to prescribe buprenorphine after completing an 8-hour buprenorphine training course. Physicians may treat up to 100, or in some situations, 275 patients with buprenorphine in their office practice at the time of this writing. Because of its partial agonist qualities, buprenorphine, a partial agonist and -antagonist, has a better safety profile than methadone. Because of its partial agonist qualities, which provide a plateau of opioid effects as the dose increases, respiratory depression, which can be generated by full agonists and is responsible for certain overdose deaths, is significantly less likely to occur with buprenorphine. Buprenorphine is given sublingually in tablet or film form for the treatment of opioid use disorder, either as buprenorphine alone (sometimes referred to as the "mono" product) or as a combination product of buprenorphine and naloxone (more commonly used in the United States). The naloxone in the combination product is added to discourage users from dissolving and injecting the medication because the naloxone in the combination product will cause withdrawal Both opioid detoxification and maintenance treatment have been found to be successful with buprenorphine. In opioid-addicted teens aged 15 to 21, randomized trials have shown that sustained therapy with buprenorphine-naloxone produces substantially better outcomes than short-term detoxification. A4 For minimizing subsequent usage of inpatient addiction treatment facilities, initiating this combination in opioid-dependent individuals treated in an emergency department is also better than referral to treatment or a brief intervention followed by facilitated treatment referral. A5 Sublingual buprenorphine in doses of 12 to 16 mg per day appears to be as effective as methadone in doses up to 60 mg per day. Buprenorphine is also beneficial for heroin addiction maintenance therapy,A6, but people who need considerably greater doses of methadone may respond better to it than to buprenorphine. An FDA-approved implanted formulation of buprenorphine can deliver a low, consistent level of the medicine for 1 monthA7b or even 6 months, which can help with adherence, diversion, and nonmedical use.