Managing opioid use disorders requires medication

NEW YORK — Treatment of opioid use disorder that does not include medication is an insufficient approach, according to Adam Bisaga, MD, professor of psychiatry at Columbia University. What’s more, excluding medication from treatment is potentially harmful since patients are not protected from overdose and, subsequently, death, he explained.

“We have a major public health crisis; we have highly effective treatment, yet we’re not able to deliver treatment to patients. Very few doctors want to work with these patients, and a lot of patients go untreated and die, and it’s very unfortunate. We’re wondering whether psychiatrists may be the specialists that can take the lead in changing that,” he said during his presentation.

Though many evidence-based treatment approaches exist, such as psychosocial/behavioral treatment, self-help/mutual help support groups and recovery-oriented activities, none of these are sufficient without the use of medication.

Bisaga cited data from Kakko and colleagues from 2003 that compared buprenorphine with behavioral therapy among patients who detoxified. By the end of 2 months, most patients assigned to intensive behavioral therapy without medication dropped out, and the mortality rate was high.

“We no longer do these studies ... because they are unethical; we don’t really need them because it’s very clear that if you don’t offer medication you are really putting patients at very high risk of death and it’s not ethical, it’s no longer acceptable. ... Opioid use disorder has the highest mortality rate of all psychiatric disorders,” he said.

Medication options for OUD

Three medications are FDA-approved in the U.S. for treatment of opioid use disorder: buprenorphine, methadone and extended-release naltrexone. Both methadone and buprenorphine are agonists that stabilize the system’s functioning, prevent withdrawal and reduce cravings, Bisaga explained. Extended-release naltrexone is an antagonist and is equally as safe and effective as the agonists in reducing relapse and craving, according to data from two studies published this year from Lee and colleagues and Tanum and colleagues. However, the downside is patients must be detoxified for 7 to 10 days before injection initiation, which can be a hurdle that up to one-third of patients are unable to overcome. Bisaga and colleagues have developed a version of extended-release naltrexone that requires only 1 week from the time of opioid use to injection. Results of their study published in American Journal of Psychiatry in 2017 demonstrated that compared with patients assigned to buprenorphine, those assigned to the rapid method were more likely to complete induction.

How to treat

When it comes to treatment, Bisaga suggested paying attention to any psychiatric disorders patients may have, noting outcomes may be poor if underlying psychiatric issues are not treated. He also advocated for involving patients by educating them on the nature of their psychiatric disorder, discussing treatment options, asking their preference for medications and explaining the differences between each.

Once stable, patients can move to methadone maintenance or buprenorphine maintenance, and those taking either agonist for years can choose to switch to naltrexone, Bisaga said.

“We are much more flexible, thinking about staged treatment,” he said. “We’ve seen a lot of changes in how we see and treat opioid dependence in the last few years. We’re much more likely now to assume this is a chronic disease and we need to see these patients over the long-term.” – by Stacey L. Adams

Reference:

Bisaga A. Choosing the Right Treatment for Substance Use Disorders. Presented at: American Psychiatric Association Annual Meeting; May 5-9, 20178; New York.

Disclosures: Bisaga reports receiving grant/research support from Alkermes.