Buprenorphine And Beyond: Treatment Of Opioid Use Disorders

In recent months, I’ve written quite a lot about opioid use disorders and our best options for treating them. As the debate about treatment methodologies continues, I sometimes wonder if there’s more to say about this now well-documented epidemic. However, the recent passing of music icon Prince and speculations about whether an opioid overdose caused his death to remind me how important it is to keep this conversation going in the clinical community. In that vein, this week’s post reiterates some of the “basics” we need to understand the treatment of opioid use disorders.

Opioid disorders are similar, but not identical, to other substance use disorders. The best treatment outcomes are achieved by applying many of the same principles as are used in the treatment of similar disorders, but with important adjustments. Physical withdrawal symptoms are often what motivate people to seek treatment for opioid addiction, so managing these symptoms is the first step for these patients.

The alpha-2 adrenergic agonists, such as clonidine, along with other symptomatic medications, were the primary agents used for many years. They are of limited effectiveness, however, and carry their own dangers, such as hypotension and sedation. Since 2003, significantly safer and more effective protocols have been developed through the use of the partial opioid agonist, buprenorphine. This medication can relieve or eliminate withdrawal symptoms within hours. Patients regularly use the word “normal” rather than “high” to describe the effect that buprenorphine has on them.

Although these physical issues are important to address, the heart of addiction treatment is psychological and social. Unless addicts make fundamental changes in those areas of their lives, even the best medical withdrawal management rarely leads to a stable state of recovery. Accordingly, participation in an intensive, group-based environment is recommended with a goal of abstinence from all euphorogenic substances. Some can achieve this without this level of treatment by engaging solely in a community recovery support program, such as Narcotics Anonymous or SMART Recovery. Most people, however, require an initial or extended period of professional treatment before being able to effectively utilize these valuable resources.

A combination of exploratory and more directive psychotherapeutic interventions, along with education, is the core of structured, intensive addiction treatment programs. Residential rehabilitation programs were at one time the only option, but intensive outpatient (“IOP”) programs have proven to be equally effective and, for many, more accessible (“Substance Abuse Intensive Outpatient Programs: Assessing the Evidence.” Psychiatric Services, Volume 65, Issue 6, June 2014, pp. 718-26). Other co-occurring psychiatric problems, most commonly mood, anxiety and trauma disorders, are common but not universal. When present, they are ideally treated simultaneously rather than sequentially with psychotherapy and medication.

I would encourage you to follow the many discussions that will likely take place in the coming months about how to best address the nation’s opioid use disorder epidemic. Here at Kolmac, we’ll continue to be a trusted resource for you as they unfold.