Approximately 4 million Americans are addicted to prescription and illegal opioid drugs. Opioid abuse is the second leading cause of accidental death in the U.S. – think Heath Ledger and Anna Nicole Smith. Unintentional deaths from prescription opioid painkillers exceeded those from cocaine and heroin combined.
Fortunately today, doctors have several pharmacologic options they can offer to patients suffering from opioid addiction. The use of medication to help addicts stay clean is referred to as Medically Assisted Treatment (MAT), or maintenance therapy. The medication helps prevent withdrawal symptoms, reduce cravings and enable recovering addicts to work a program of recovery, remain spiritually fit, and become productive, successful members of society.
Studies show that long-term MAT reduces risk and severity of relapse, decreases crime, has lowered the incidence of HIV and Hepatitis C infection, restores social functioning, and is cost effective.
Methadone has been used for extended maintenance of opioid dependence since 1974 and has a proven track record of benefit. Methadone is a pure agonist, which means it binds to opioid receptors in the brain and produces effects similar to other opioid drugs like oxycodone. It has an extended duration of action so a steady state blood level is achieved after several days of ingestion. Use of methadone is limited to clinics certified by the federal government which provide the medication under close scrutiny and regulated distribution.
In response to the explosion of opioid painkiller addiction, Congress passed the Drug Addiction Treatment Act of 2000, making Schedule III controlled drugs available for outpatient detox. The only approved drug for this purpose is buprenorphine, commercially available as Suboxone since 2004, which can only be prescribed by doctors possessing a special waiver from the DEA.
Buprenorphine is a partial agonist – it binds tightly to opioid receptors, exerting typical opioid effects for up to 72 hours, also providing a blocking effect of opioid drugs taken at the same time. Buprenorphine is used for detox and for prolonged maintenance of opioid recovery. It lacks efficacy if swallowed due to inactivation by the liver so it is taken under the tongue for maximal absorption and effect. Suboxone contains naloxone, a full opioid antagonist that has no activity when absorbed orally but will protect against overdose if the drug is injected intravenously.
Naltrexone, a full opioid antagonist, is available as an oral tablet taken daily, or as a monthly injection available as Vivitrol. It is approved for opioid and alcohol dependence as it blocks cravings for and euphoria from both substances. An individual on naltrexone will not experience the mood-altering effects from either substance.
Medically Assisted Treatment is beneficial over the long term but addiction specialists are not in agreement as to the duration of treatment. One to two years is a reasonable amount of time but treatment can continue indefinitely. This depends on the patient’s risks for relapse, social support, recovery program and emotional stability.
MAT is effective for extended treatment of addiction to opioid drugs, augmenting recovery.
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By Jonathan D. Kunis, MD
Jonathan D. Kunis, MD, CAP, is Board Certified in Addiction Medicine and can be reached at 2401 University Pkwy, Sarasota, 941-359-8700.