Question 19

Medication-for-addiction treatment (MAT) has been demonstrated by high-quality evidence to improve retention in addiction treatment, suppress illicit drug use, improve quality of life, and reduce mortality among patients with opioid use disorder.  Examples of MAT that are FDA approved to treat opioid use disorder include methadone, buprenorphine-naloxone and naltrexone (most effective when prescribed in the once monthly IM formulation).

Buprenorphine alone is unlikely to cause significant respiratory depression but in combination with benzodiazepines or other central nervous depressants (e.g., illicit opioids, alcohol) may result in sedation, respiratory depression, and overdose.

Buprenorphine is effective for treating acute opioid withdrawal. However, patients dependent on short-acting opioids (e.g., hydrocodone, oxycodone, heroin, fentanyl) should abstain from use for 12-24 hours prior to initiation of buprenorphine to reduce the risk of precipitated withdrawal.  Buprenorphine has a higher affinity for the mu opioid receptor and will displace those drugs from the receptor thus precipitating withdrawal.

When initiating patients on buprenorphine therapy (often called “induction”), it is best to do so when mild-moderate withdrawal is present to avoid precipitating withdrawal.  The Clinical Opioid Withdrawal Scale or COWS is one method for formally assessing opioid withdrawal.

Emergency department and hospital clinicians may order and administer doses of buprenorphine for up to 3 days to patients in acute withdrawal without having to complete the Waiver training.

Clinicians interested in prescribing buprenorphine-naloxone to patients with opioid use disorder must complete additional training that is offered via SAMHSA. Approved practitioners are then permitted to prescribe buprenorphine-naloxone for the maintenance and detoxification treatment for 30 patients with opioid use disorder in the first year. Clinicians who comply with the federal policies for MAT prescribing may apply for an increase in their patient limit thereafter.

In contrast to buprenorphine-naloxone, methadone must be prescribed and dispensed from specially licensed Opioid Treatment Programs (OTPs) when prescribed for the treatment of opioid use disorder.  However, similar to buprenorphine-naloxone, methadone can also be given for up to 3 days in the acute care setting for opioid detoxification.  None of these rules apply to the use of methadone or buprenorphine when used for the sole indication of treating pain.

Opioid Withdrawal

Opioid withdrawal may present with a constellation of signs and symptoms, including:

  • General: Restlessness, anxiety
  • HEENT: Dilated pupils, tearing, runny nose
  • CV: Tachycardia
  • GI: Nausea, vomiting, diarrhea, abdominal cramping
  • MSK: Muscle and joint pain
  • Skin: Sweating, goose bumps, yawning, tremors

The severity of withdrawal can be quantified using a tool such as the Clinical Opiate Withdrawal Score (COWS), which is available on MDCalc.

Medications aimed at these symptoms may help patients undergoing withdrawal experience some relief, including clonidine (an alpha-2 agonist that decreases norepinephrine release), antiemetics, antidiarrheals, antispasmodics and other non-opioid analgesics.

References:

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