Opioid Use Disorder: Medical Treatment Options
Am Fam Physician. 2019 Oct 1;100(7):416-425.
Patient information: See related handouts on opioid use disorder and at https://familydoctor.org/condition/opioid-addiction/.
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Opioid use disorder is highly prevalent and can be fatal. At least 2.1 million Americans 12 years and older had opioid use disorder in 2016, and approximately 47,000 Americans died from opioid overdoses in 2017. Opioid use disorder is a chronic relapsing condition, the treatment of which falls within the scope of practice of family physicians. With appropriate medication-assisted treatment, patients are more likely to enter full recovery. Methadone and buprenorphine are opioid agonists that reduce mortality, opioid use, and HIV and hepatitis C virus transmission while increasing treatment retention. Intramuscular naltrexone is not as well studied and is harder to initiate than opioid agonists because of the need to abstain for approximately one week before the first dose. However, among those who start naltrexone, it can reduce opioid use and craving. Choosing the correct medication for a given patient depends on patient preference, local availability of opioid treatment programs, anticipated effectiveness, and adverse effects. Discontinuation of pharmacotherapy increases the risk of relapse; therefore, patients should be encouraged to continue treatment indefinitely. Many patients with opioid use disorder are treated in primary care, where effective addiction treatment can be provided. Family physicians are ideally positioned to diagnose opioid use disorder, provide evidence-based treatment with buprenorphine or naltrexone, refer patients for methadone as appropriate, and lead the response to the current opioid crisis.
Opioid use disorder has reached epidemic proportions in the United States. At least 2.1 million Americans 12 years and older had opioid use disorder in 2016,1 and approximately 47,000 Americans died from opioid overdoses in 2017.2 People with opioid use disorder experience a loss of control over their use that can lead to physical disease and psychosocial disruptions, including unemployment, family disruption, and incarceration. Opioid use disorder can be fatal, with mortality rates 10-fold higher than in the general population.3 Death can occur from overdose, cardiovascular disease, or infectious diseases such as hepatitis C virus, HIV, and sepsis.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Evidence rating | Comments |
|---|---|---|
All adult patients should be screened for opioid use disorder in primary care.11 | C | Expert opinion found in some clinical guidelines |
Patients with opioid use disorder should be offered maintenance treatment with pharmacotherapy.11,15–17,19,20,32 | A | Multiple clinical trials showing reduced opioid use and mortality |
Pharmacotherapy for opioid use disorder should be continued for as long as it helps the patient; patients should not be required to discontinue according to preset timelines.11,31 | A | Consistent results showing reduced mortality |
Participation in behavior therapies may be helpful for some patients with opioid use disorder, but studies are equivocal; it should not be a prerequisite for buprenorphine treatment.11,33,34 | B | Limited clinical trials |
Naloxone should be prescribed to all patients with opioid use disorder or high-risk prescription opioid use or who use any illicit drugs to prevent overdose.55–57 | C | Expert opinion andconsensus guidelines |
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 https://www.aafp.org/afpsort.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Evidence rating | Comments |
|---|---|---|
All adult patients should be screened for opioid use disorder in primary care.11 | C | Expert opinion found in some clinical guidelines |
Patients with opioid use disorder should be offered maintenance treatment with pharmacotherapy.11,15–17,19,20,32 | A | Multiple clinical trials showing reduced opioid use and mortality |
Pharmacotherapy for opioid use disorder should be continued for as long as it helps the patient; patients should not be required to discontinue according to preset timelines.11,31 | A | Consistent results showing reduced mortality |
Participation in behavior therapies may be helpful for some patients with opioid use disorder, but studies are equivocal; it should not be a prerequisite for buprenorphine treatment.11,33,34 | B | Limited clinical trials |
Naloxone should be prescribed to all patients with opioid use disorder or high-risk prescription opioid use or who use any illicit drugs to prevent overdose.55–57 | C | Expert opinion andconsensus guidelines |
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 https://www.aafp.org/afpsort.
Opioid use disorder should
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