Buprenorphine Therapy for Opioid Use Disorder

 

Opioid misuse, including the use of heroin and the overprescribing, misuse, and diversion of opioid pain medications, has reached epidemic proportions in the United States. As a result, there has been a dramatic increase in opioid use disorder and associated overdoses and deaths. Addiction is a chronic brain disease with a genetic component that affects motivation, inhibition, and cognition. Patient characteristics associated with successful buprenorphine maintenance treatment include stable or controlled medical or psychiatric comorbidities and a safe, substance-free environment. As a partial opioid agonist, buprenorphine has a ceiling effect that limits respiratory depression and adds to its safety in accidental or intentional overdose. Buprenorphine and combinations of buprenorphine and naloxone are generally well tolerated; adverse effects include anxiety, constipation, dizziness, drowsiness, headache, nausea, and sedation. Family physicians who meet specific requirements can obtain a Drug Addiction Treatment Act of 2000 waiver by notifying the Substance Abuse and Mental Health Services Administration of their intent to begin dispensing and/or prescribing buprenorphine. Medication-assisted treatment with buprenorphine is as effective as methadone in terms of treatment retention and decreased opioid use when prescribed at fixed dosages of at least 7 mg per day; dosages of 16 mg per day are clearly superior to placebo. Sporadic opioid use is not uncommon in the first few months of medication-assisted treatment and should be addressed by increased visit frequency and more intensive engagement with behavioral therapies. Follow-up visits should include documentation of any relapses, reemergence of cravings or withdrawal, random urine drug testing, pill or wrapper counts, and checks of state prescription drug database records.

Opioid misuse is an epidemic in the United States. In 2016, approximately 11.5 million Americans 12 years and older misused opioid pain medications, and 1.8 million had a substance use disorder involving prescription pain medications.1 From 2000 to 2015, more than 500,000 persons died from opioid overdoses, with deaths generally increasing as prescription opioid sales increased.2 In 2012, clinicians wrote 259 million prescriptions for opioids, enough for every U.S. adult.3 Primary care physicians are the largest prescribers of opioids and have an important role in reversing these negative trends.4 Although most family physicians prescribe opioids, few prescribe buprenorphine medication-assisted therapy (MAT).5 This barrier to patient access is particularly stark in rural areas.6

WHAT IS NEW ON THIS TOPIC

Buprenorphine Therapy

From 2000 to 2015, more than 500,000 persons died from opioid overdoses, with deaths generally increasing as prescription opioid sales increased.

The Diagnostic and Statistical Manual of Mental Disorders, 5th ed., replaced the older terms opioid abuse and dependence with opioid use disorder, which is diagnosed when a patient meets at least 2 of the 11 revised diagnostic criteria.

Recent amendments to the Drug Addiction Treatment Act of 2000 have increased the patient limit to 275 for physicians who have had a waiver to treat 100 patients with buprenorphine for at least one year and who meet additional criteria.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Combined buprenorphine/naloxone medications are preferred over buprenorphine monotherapy because of their lower abuse potential, unless a patient is pregnant, lactating, or allergic to naloxone.

C

17, 19

Patient selection is one key to successful buprenorphine medication-assisted therapy in the primary care setting.

C

13, 17, 19

To reduce the risk of precipitated withdrawal, opioid-dependent patients should wait until they are experiencing mild to moderate withdrawal before taking the first dose of buprenorphine.

C

13, 15, 17, 19

Validated clinical scales that measure withdrawal symptoms may be used to assist in the evaluation of patients with opioid use disorder.

C

1719

Clonidine may be used at dosages of 0.1 to 0.3 mg every 6 to 8 hours to assist in the treatment of opioid use disorder.

C

17, 19, 20


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Combined buprenorphine/naloxone medications are preferred over buprenorphine monotherapy because of their lower abuse potential, unless a patient is pregnant, lactating, or allergic to naloxone.

C

17, 19

Patient selection is one key to successful buprenorphine medication-assisted therapy in the primary care setting.

C

13

The Authors

show all author info

ROGER ZOOROB, MD, MPH, FAAFP, is a professor in and chair of the Department of Family and Community Medicine at Baylor College of Medicine, Houston, Tex....

ALICIA KOWALCHUK, DO, is an associate professor in the Department of Family and Community Medicine at Baylor College of Medicine.

MARIA MEJIA de GRUBB, MD, MPH, is an assistant professor in the Department of Family and Community Medicine at Baylor College of Medicine.

Author disclosure: No relevant financial affiliations.

Address correspondence to Roger Zoorob, MD, MPH, FAAFP, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030 (e-mail: roger.zoorob@bcm.edu). Reprints are not available from the authors.

References

show all references

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