The Case for Wider Use of Medication for Opioid Addiction

We’re in these unique times where technology is outpacing many industries, while addiction rates are skyrocketing and new epidemics are exploding onto the scene faster than we can prepare for them. Providers often don’t have the time or resources to conduct field research, and academics are struggling to validate the wide variety of treatment options across an enormous spectrum of addictions. Most of all, we’re caring for patients who are often less than excited about treatment and have high reoccurrence rates. Medication Supported Recovery™ (MSR), a term we have trademarked at Ashley Addiction Treatment, is a powerful tool to overcome some of the most severe addictions, but it is sadly underutilized.

Opioid misuse has been, by far, the most horrific epidemic in addiction in recent years. Overdose deaths and other damages have jumped at rates never before seen in behavioral health. All visual summaries of the epidemic look like they’re charting the pathology of a deadly flu or other contagious disease.

Worse yet, the rise of super-concentrated opioids such as fentanyl has skyrocketed mortality rates from overdose and has even made certain treatments far more dangerous. It’s not uncommon for patients to enter recovery for a fentanyl addiction, and eventually to experience reoccurrence, only to overdose because their tolerance levels have dropped significantly while they still expect to need the same dosage for a high.

MSR offers us a potential solution in these cases, though it has not been universally adopted. The use of medication to support recovery has received a surprising amount of criticism, not just from the general public and some professionals, but also from other patients in recovery. Using an opioid to overcome the withdrawal symptoms and cravings in recovery may seem like giving a soda pop as a reward to someone for treating their diabetes. This mindset follows the long-ineffective cold turkey methods of cutting patients off entirely and hoping they can resist the withdrawal symptoms and cravings long enough to prosper. While this method has had some success in treating substance use disorders, the risk of death from opioid overdose makes this approach too risky when treating many opioid use disorders. Recovery and prolonged abstinence from a drug can lower a patient’s tolerance to it. After treatment, the patient may experience a reoccurrence and continue taking his/her normal quantity of the substance. In the case of fentanyl or other synthetic opioids, low dosage could prove to be lethal with a reduced tolerance.

Of course, we can’t control how a patient chooses to recover. Some will opt to use an opioid agonist, such as buprenorphine or methadone, while others could choose instead to use a non-opioid medication, such as naltrexone. Oral versions of naltrexone are offered, but have lower success rates (in part due to patient compliance) than the once-monthly injectable version, Vivitrol. Because these options are not opioids, they don’t produce an opiate high or trigger withdrawal symptoms once discontinued.

In some cases, buprenorphine might be a better fit. Oral buprenorphine is effective at reducing cravings and decreasing illicit opioid use, helping to keep people engaged in treatment and reducing mortality. There is now a long-acting injectable version available, as well as an implantable version of buprenorphine. Because of buprenorphine's partial effects at the opioid receptors, prolonged use can result in dependence, and abrupt discontinuation will result in withdrawal symptoms. If buprenorphine is used for a prolonged period, discontinuation should be done under close medical observation.

Given these options, patients have the opportunity to recover from an opioid addiction with fewer withdrawal symptoms, a much higher rate of success, and less chance of overdose in case of a reoccurrence. While some skepticism is healthy, and encouraged, the research currently shows MSR to be an effective technique for both recovery and risk management.

Overall, we’d love to see more research on the topic, as well as input from our professional colleagues on the successes and difficulties of MSR programs. The opioid epidemic is still growing to unprecedented levels, and it’s critical now more than ever to have safe and effective procedures in place to manage opioid dependence in recovery.