Opioid Abuse: Treatment Guidelines

Molecular model of the drug buprenorphine

The U.S. Surgeon General recently sent a letter to all physicians about the danger of prescription opioids, particularly when used in combination with benzodiazepines (i.e. Valium, Xanax).  This combination greatly increases the risk of overdose death.

Clinicians can successfully assist those with opioid use disorders. Marc Schuckit, M.D. recently published a nice summary review of entitled "Treatment of Opioid-Use Disorder" in the New England Journal of Medicine (see citation below).

The review contains some nice tables including tables related to:

• Diagnostic criteria of opioid use disorder
• An opiate withdrawal rating scale
• Opioid free treatment aids in management of opioid withdrawal
• Opioid agonist aids in management of opioid withdrawal
• Opioid agonist use in long-term maintenance

Opioid withdrawal is generally non-life threatening, but extremely uncomfortable and a strong motivator for return to opioid use.

Use of opioid agonists such as buprenorphine (pictured in molecular model above) is the best tolerated and least uncomfortable pathway to treatment of opioid withdrawal. However, it is restricted to prescription by a small group of physicians who have completed a special training program.

This means many opioid users end up with less tolerated and more uncomfortable withdrawal episodes treated with drugs such as clonidine, diazepam or even over-the-counter drugs such as Imodium.

The review notes that with high relapse rates, supervised opioid maintenance with prescribed opioids such as methadone or buprenorphine often are required for long-term abstinence. One barrier to using these types of interventions is availability and cost. Buprenorphine can be expensive and requires regular monitoring in a physicians office.

With high costs and lack of access to supervised opioid management, opioid users commonly return to street heroin or prescription opioid pills (licit or illicit). 

Readers with more interest in this topic can access the free full-text manuscript by clicking on the DOI link in the citation below.

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Model of buprenorphine is from a Wikipedia Creative Commons File attributed to:

Crystallographic data from J. Mazurek, M. Hoffmann, A. Fernandez Casares, P. D. Cox and M. D. Minardi (June 2014). "Buprenorphine". Acta Cryst. E70, o635. DOI:10.1107/S1600536814009672

Schuckit, M. (2016). Treatment of Opioid-Use Disorders New England Journal of Medicine, 375 (4), 357-368 DOI: 10.1056/NEJMra1604339