Update on pharmacotherapy for treatment of opioid use disorder

ABSTRACT

Introduction: Opioid Use Disorder (OUD) is a significant public health concern, negatively impacting the medical, psychological, and social domains of an individual’s life as well as creating substantial burdens for society. Effective treatment interventions are necessary for reduction of OUD and its consequences. Pharmacotherapy represents a central component of management.

Areas covered: This review focuses on pharmacologic strategies for OUD treatment, discussing both primary as well as adjunctive therapy modalities. We will discuss both medications used during detoxification to treat withdrawal, as well as those used as maintenance therapy. Detox medications include alpha-2 adrenergic agonists, such as clonidine, as well as the μ-opioid agonist, methadone, and the μ-opioid partial agonist, buprenorphine. Opioid maintenance treatment (OMT) is also discussed, focusing on those medications meant to substitute abused opioids and includes the agonists, methadone and buprenorphine, as well as supervised intravenous heroin, and opioid antagonist, naltrexone.

Expert opinion: Medication therapy for treatment of OUD has demonstrated efficacy and is of great clinical benefit. While agonist treatment with methadone or buprenorphine remains the gold standard, there is an important place for use of long-acting antagonist therapy with naltrexone. Continued investigation into treatment paradigms and behavioral platforms which optimize medication therapy is most needed.

KEYWORDS:

• Opioid use disorder
• pharmacotherapy
• methadone
• buprenorphine
• naltrexone

Article highlights

• The pharmacotherapeutic management of opioid use disorder has been an important focus of study since the 1960s, with initial focus on evaluation of medications that reduce opioid withdrawal symptoms and/or provide reestablishment of physiological homeostasis through μ-opioid receptor agonism.

• Over time, options for pharmacotherapy have expanded to include both partial agonist and antagonist medications, since these medications can block the euphorigenic effects seen with illicit opioid use and are less likely to be associated with misuse and diversion.

• Alpha-2 adrenergic agonists, such as clonidine and lofexidine, remain important agents for the treatment of opioid withdrawal with comparable efficacy to taper schedules using opioid agonist and partial agonist medications.

• Extended-release naltrexone represents an exciting option in treatment of opioid use disorder, since it has been associated with increasing overall time in treatment. However, patient adherence with the medication remains a clinical challenge.

• Novel formulations of medications, such as the buprenorphine implant, are an active area of research and may further reduce concerns regarding diversion of medications for treatment of opioid use disorder.

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Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Additional information

Funding

D Shorter was supported by Career Development Award 1IK2CX000946 from the United States (U.S.) Department of Veterans Affairs Clinical Sciences Research and Development Service. T R Kosten was supported by NIH/National Institute on Drug Abuse P50 DA018197. Additionally, this material is the result of work supported with resources and the use of facilities at the Michael E. DeBakey VA Medical Center. The contents of this publication do not represent the views of the U.S. Department of Veterans Affairs or the United States Government.