Review of medication-assisted treatment for opioid use disorder

As the opioid epidemic worsens, medical providers are searching for safe, effective means for treating opioid use disorder (OUD) [1]. The opioid crisis began in the 1990s as a result of pharmaceutical companies reassuring medical communities that opioid pain relievers had no risk of addiction. Misuse of both prescription and nonprescrip- tion opioids became rampant. In 2017, the United States Department of Human and Health Services declared a public health emergency, announcing strategies to com- bat the crisis [2].

There have been nearly 500,000 deaths from opioid overdose between 1999 and 2019 [3]. A study of 25 emer- gency departments in six states showed that opioid-related overdose visits increased from 3,020 in January 2018 to 3,486 in December 2020 [4]. In the United States, the eco- nomic cost of OUD and fatal opioid overdose during 2017 totaled $1,021 billion [5]. With the concurrence of the coronavirus disease 2019 (COVID-19) pandemic, it is esti- mated that the economic recession resulting from the pandemic may lead to a large increase in deaths from drug overdose, with projected excess deaths depending on the course of the pandemic and response[6].

Medication-assisted treatment (MAT) for OUD is an effective approach to treatment utilizing FDA-approved medications in conjunction with various behavioral health approaches [1]. The greater implementation of MAT will help address the growing public health crisis with devastating consequences such as opioid-related over- doses, misuse during pregnancy, rising incidence of neonatal abstinence syndrome, and increasing injection drug use contributing to the spread of infectious diseases such as HIV and hepatitis C [7].

Based on an educational module written to train health professionals about medication management for OUD and best practice methods, this review will define the compo- nents of MAT, consider the impact of MAT in the primary care setting, and identify barriers to effective MAT.

Methods

A literature search was conducted utilizing the database MEDLINE® with the Medical Subject Heading (MeSH) of “MAT” restricted to hu- man studies published from 2004 through 2021 yielding over 78,000 results, with 6,296 being clinical trials and 1,356 being meta-analyses. Reference lists from the identified articles were also reviewed. Clinical practice guidelines, major relevant professional organizations, and government legislation were reviewed. The literature search was conducted between December 2019 and February 2020. A second literature search was conducted in January 2021 to reflect the impact of the COVID-19 pandemic on MAT. Boolean operators and MeSH headings were applied including: MAT and primary care, MAT and telehealth, methadone, buprenorphine, naltrexone, MAT and osteo- pathic, MAT and group therapy, and MAT and COVID-19. Four authors screened and reviewed these results independently. A total of 54 articles were included in the final review.

Discussion

MAT in primary care

OUD treatment has been traditionally managed in specialty care settings. However, barriers to specialty care, such as long waitlists, lack of child care, and geographical access, can interfere with access to care. Primary care models, which can meet patients at their point of need, are an innovative approach to link vulnerable patients to the care they require [8].

When compared to specialty care treatment facilities, a systemic review by Lagisetty et al. [9] including 35 in- terventions (10 randomized controlled trials and 25 quasi- experimental interventions) found primary care models equally effective in treating OUD. Despite variabilities be- tween treatment models, successful primary care MAT pro- grams shared some similar components: the utilization ofintegrated clinical teams, incorporating patient agreements, and utilizing home inductions to increase convenience. Multidisciplinary and coordinated care delivery models are also suggested as an effective strategy in primary care; however, definitive research remains necessary.

A review by Korthuis et al. [10] examined primary care- based models for the treatment of OUD by conducting in- terviews with 11 informants (8 nonfederal and 3 federal) with experience implementing MAT. Four components were consistently noted: pharmacotherapy with bupre- norphine or naltrexone, provider and community educa- tional interventions, coordination of OUD treatment with other medical and psychological needs, and psychosocial services like counseling. Common themes included the importance of a nonphysician coordinator and the use of tiered approaches.

Primary care-based models also have the added advantage of addressing comorbidity outcomes. A study by Haddad et al. [11] evaluated the management of prevention healthcare outcomes with primary care management of OUD from an observational cohort study of 266 opioid-dependent patients. Greater than 3 months of treatment on buprenor- phine was positively associated with achieving a recom- mended quality composite health indicators screening score of ≥80%. Additionally, Roll et al. [12] surveyed 28 patients receiving shared medical appointments for buprenorphine management therapy. Researchers found that 60% of pa- tients learned more about comorbidities like hepatitis C and 43% reported receiving appropriate immunizations since starting the intervention.

Rural primary care providers may find themselves in a unique position to utilize MAT. In a retrospective cohort study of 7,930 Medicaid-enrolled adults residing in 23 rural counties in Pennsylvania, Cole et al. [1] examined the relationship between rural patients with OUD, their engagement in MAT, and the distance to MAT providers. Those enrolled with primary care showed higher MAT uti- lization with greater proportions receiving any MAT (32.7% vs 25%) and a higher mean number of buprenorphine or naltrexone injections (11.1 vs 9.3). Among 1,186 enrollees with OUD receiving MAT, the mean travel distance to pre- scribers ranged from 0.8 to 395.9 miles and the distance to the nearest MAT prescriber showed significant association to likelihood of receiving any MAT (p<0.001). This conclusion is also supported by a 2018 cross-sectional study by Jones et al. [13] where researchers compared deaths secondary to opioid overdose with the availability of buprenorphine providers in 846 counties across the United States. Although the availability of buprenorphine providers and the rate of opioid deaths were only weakly correlated (correlation coefficient 0.18, p<0.001), their re- sults demonstrate an imbalance between opioid overdose death burden and the availability of buprenorphine pro- viders, particularly in the Midwest and the South.

Methadone

Methadone is a slow-acting opioid agonist indicated in the treatment of OUD and opioid withdrawal management. Although methadone is only available through approved opioid treatment programs, federal and state laws allow take-home doses for select patients who have demon- strated treatment progress [14, 15].

Methadone treatment aims to suppress opioid with- drawal, block the effects of illicit opioids, reduce opioid craving, and facilitate patient engagement in psychosocial and nonpharmacological interventions. Methadone treat- ment has shown superiority over abstinence-based ap- proaches [16]. While methadone is a frequently utilized medication in MAT, both patients and providers should be aware of the potential risks associated with treatment. Methadone treatment increases the risk of arrhythmias including QT interval prolongation and torsades des pointes [17, 18]. Obtaining a history of structural heart disease, arrhythmia, syncope, and other risk factors for QT interval prolongation is critical before starting treatment. Methadone also presents with numerous drug-drug interactions due to cytochrome P450 isoenzymes involved in its metabolism. MAT providers should closely monitor for interactions that could potentiate or synergize methadone’s effects on a pa- tient. Methadone is safe for use in pregnant patients [14, 15].

Practice guidelines published by the American Society of Addiction Medicine (ASAM) Methadone Action Group [14, 15] recommend an initial dose range from 10 mg to 30 mg, reassessing every 2–4 h when peak levels are reached. Following an initiation period, methadone dosing is based on the goals of treatment and patient dependence. Less than 30 mg per day can lessen acute withdrawal but is not as effective in suppressing cravings. Most patients fare better if their initial 30 mg to 40 mg per-day dose is grad- ually increased to a 60 mg to 120 mg per day maintenance dose. Randomized trials have shown that patients demon- strate better retention in treatment with higher doses of 80–100 mg per day [19, 20]. A dose-response effect is observed for methadone treatment retention rates [21, 22]. Doses above 120 mg per day are utilized with select patients due to the increased purity of heroin and the strength of prescription opioids resulting in increased difficulty to block opioid effects. The optimal length of treatment is not well established; however, relapse rates are highest for patients who drop out [14, 15].

Naltrexone

Naltrexone is a long-acting, full opioid antagonist. Like buprenorphine, naltrexone can be prescribed in the outpa- tient setting for OUD. Unlike buprenorphine, naltrexone can also be prescribed outpatient for alcohol use disorder treatment [14, 15]. Both formulations, oral and extended- release (ER) injectable, have demonstrated treatment effi- cacy; however, oral naltrexone is not recommended except under limited circumstances because retention in depot naltrexone is better than usually observed in studies utiliz- ing oral naltrexone [23]. Trials are often limited due to high dropout rates and poor adherence [14, 15]. Adding an agent that improves dopaminergic function to complement naltrexone is a novel approach being studied to encourage adherence [24].

Treatment goals include prevention of relapse, inhi- bition of illicit opioid effects, opioid craving reduction, and the facilitation of patient engagement in psychosocial and nonpharmacological interventions [14, 15]. Oral naltrexone is best for those who can be closely supervised and are highly motivated because it has high rates of non- adherence and a high risk for overdose upon relapse [23]. ER injectable naltrexone is most effective for patients who have failed other MAT options or are unable to obtain agonist treatment. Both formulations are generally well tolerated; however, patients should be cautioned regarding the high-risk opioid overdose with subsequent relapse due to diminished tolerance and heightened sensitivity [14, 15].

Before naltrexone administration, the patient must be adequately detoxified from opioids with no physical dependence. A naloxone challenge can be utilized when uncertain of detoxification, monitoring for signs and symptoms of withdrawal. Oral naltrexone can be dosed at 50 mg daily or three times weekly with two 100 mg doses followed by one 150 mg dose. ER injectable naltrexone can be given every 3–4 weeks by deep intramuscular injection in the gluteal muscle at a set dosage of 380 mg per injection [14, 15].

Naltrexone ER is associated with side effects such as insomnia, clinically insignificant elevation of trans- aminases, hypertension, naso-pharyngitis, and influenza [25]. Although naltrexone does not reduce respiratory drive, relapse with high-dose opioids may result in acci- dental overdose death due to diminished opioid toler- ance. Unlike methadone and buprenorphine, naltrexone ER is not recommended for use in pregnant or breast- feeding women [14, 15].

Buprenorphine

Buprenorphine is a partial opioid agonist utilized to treat OUD [26]. Buprenorphine has the ability to relieve a pa- tient’s drug cravings while maintaining a higher safety profile than other MAT medications. Due to buprenor- phine’s “ceiling effect,” increasing dosages will not cause equally increasing respiratory depression in patients [27]. As such, buprenorphine is less likely to cause fatal respi- ratory depression during overdose [28, 29]. Caution should be applied when combining buprenorphine with other sedative medications, potentially causing higher levels of sedation. Buprenorphine, like methadone, is safe for use in pregnant patients [14, 15]. It demonstrates less peak-dosing suppression of fetal heart rate and less severe neonatal abstinence syndrome than methadone [25].

A critical distinction of buprenorphine therapy is its ability for outpatient prescription following the Drug Addiction Treatment Act (DATA) of 2000 [30]. Any physician can prescribe buprenorphine following completion of an online training course. This distinction can increase access to MAT in otherwise inaccessible patient populations. Following a closely monitored initiation phase, dosing is usually 2 mg to 4 mg to reduce the risk of precipitating withdrawal [14, 15]. If well tolerated, the dose can be increased fairly rapidly to a dose that provides stable effects for 24 h and is effective, with evidence suggesting that doses of 16 mg and greater may be more effective at suppressing illicit opioid use [23]. The FDA recommendation limits dosing to 24 mg per day because higher doses may increase diversion risk [14, 15]. Retention on buprenorphine across low (2 mg–6 mg per day), medium (7 mg–15 mg per day), and high (≥16 mg per day) doses is significantly superior to placebo [31]. However, only high-dose buprenorphine re- duces opioid use significantly compared to placebo [32].

Buprenorphine can also be administered with naloxone as a single-dose tablet or buccal film [14, 15]. The goal of combining naloxone, an opioid antagonist, with buprenor- phine is to discourage buprenorphine abuse. If the bupre- norphine/naloxone product is crushed for the purpose of injection, naloxone will antagonize the agonistic effects of buprenorphine [33]. The FDA recently approved several new buprenorphine formulations for the treatment of OUD, including an ER injection, but data regarding their effec- tiveness are limited [14, 15]. Some emergency departments are now initiating buprenorphine therapy to patientsexperiencing withdrawal symptoms [34]. This new strategy has demonstrated promising results toward improving rates of MAT initiation, and its expansion is likely to continue over time [34, 35].

The Substance Abuse and Mental Health Services Administration (SAMHSA) recommends appropriate coun- seling and social support programs for patients receiving buprenorphine therapy [36] “Group-based” buprenorphine treatments have gained interest since their inception, providing both buprenorphine prescription and group counseling together in a destigmatized environment. This model also increases the number of patients that a single physician could treat, addressing areas with limited access to MAT providers [37]. Some studies have suggested possible benefits of this treatment model [38, 39], particularly in prolonging treatment retention. Despite these advantages, the available supporting research has been limited and varied [38]. A 2017 literature review [39] examined 10 studies, 4 of which utilized small-group models and 6 of which utilized group psychotherapy. The authors concluded that there was limited evidence to support group-based buprenorphine therapy but that much of the literature available was either weak or potentially biased. Based on the limited research available and isolated reports of suc- cess, this practice has some feasibility and expands bupre- norphine access for patients.

Osteopathic supplementation to MAT

A report issued by SAMHSA noted that in the last 20 years, there have been over 100,000 deaths in the United States that resulted from prescription opioids [36, 40]. In the United States, chronic pain affects 100 million adults, reducing quality of life and productivity. Of those who receive opioids for the treatment of chronic pain, one in four struggle with opioid addiction. Dependence and tolerance to opioids increases the likelihood of developing addiction by 40 times. Although opioid medications are effective, they are best utilized for postsurgical pain, brief periods of acute pain, acute cancer pain, and palliative or end-of-life care [41].

Application of an osteopathic approach when treating chronic pain encourages utilization of an integrative treatment approach. A similar approach may be adopted in the treatment of OUD, particularly with co-occurring chronic pain [41]. A randomized controlled trial with 455 patients analyzing OMT and ultrasound therapy for chronic lower back pain showed a statistically significant decrease in prescription drug use in those receiving OMT treatment. As an adjunctive therapy, OMT serves as a noninvasive treatment with minimal side effects that can play a key role in holistic patient treatment [42].

A cross-sectional cluster observational study con- ducted by Rodondi et al. [43] investigated the prevalence of use and the perceived usefulness of treatment modalities for recurrent pain in primary care among 499 patients with chronic or recurrent low back pain. The five most frequent modalities utilized by patients were physical therapy (81.8%), osteopathic treatment (63.4%), exercise therapy (53.4%), opioids (52.5%), and massage therapy (50.8%). Women were significantly more likely to utilize osteopathic treatment whereas patients >75 years old were less likely to utilize osteopathic treatment. Higher level of education was significantly associated with increased use of osteo- pathic treatment for chronic lower back pain. Additionally, current smoking was associated with significantly greater odds of having utilized opioids and significantly lower odds of having followed exercise therapy. More research is necessary to characterize the patient demographic most likely to utilize osteopathic medicine as a treatment for chronic pain instead of opioids.

Barriers to MAT

Barriers to facilitating MAT successfully include inade- quate provider education, cost-related barriers, and the inability to implement a coordinated care approach that is associated with greater benefit [10]. A qualitative study of MAT-providing physicians demonstrated that physi- cians request further training with respect to medication tapering, billing, and additional training for support staff [44]. Additional barriers to effective MAT include the lack of trained primary care providers, reimbursement models that do not support care coordination and psychosocial services, the persistent stigma associated with MAT, and long travel times for patients in rural areas [10]. Providers also note that coordinated care is crucial in busy academic settings where physicians have limited availability during clinic hours [45].

MAT selection

When considering MAT options, individualized and popu- lation management treatment approaches must be consid- ered. An individualized approach to MAT examines the individual patient’s access to MAT, treatment setting, occupational risks, comorbid conditions, and patient moti- vation. A population management approach considers the public health impact of OUD and the cost-effectiveness of treatment options. It plays a larger role in the prevention of community opioid diversion, overdose deaths, and infec- tious disease transmission [46].

Begin by assessing whether the patient is actively seeking to abstain from illicit opioid use. If the patient is actively abstaining, consider either antagonist or agonist MAT. If the patient is not actively abstaining, consider agonist MAT to maintain opioid tolerance and risk reduc- tion of accidental opioid overdose death. Next, assess whether the patient has significant co-occurring chronic pain. If the patient does have co-occurring pain, consider agonist MAT to reduce pain-related opioid relapse. If there is no chronic pain, consider implementing either an agonist or antagonist treatment [46].

Additional considerations include exclusions to ER antagonist therapy including patients who are pregnant or are planning a pregnancy, those who have experienced a recent opioid overdose, or a patient currently displaying high overdose risk behavior. An office-based outpatient setting is favorable to patients committed to complete abstinence from substance abuse and have no recent acci- dental or intentional substance overdose or opioid diver- sion. Structured care settings should be considered for patients who have recently stabilized alcohol or substance use disorders, those with a recent history of substance overdose, and patients receiving agonist MAT who have a recent history of opioid diversion [25].

COVID-19 impact

The treatment of OUD has been significantly impacted by the COVID-19 pandemic, necessitating the use of novel strategies to accommodate patient management. National organizations are providing guidance on how to meet the needs of patients during the COVID-19 pandemic. The Drug Enforcement Administration (DEA) has adopted policies to allow DEA-registered practitioners to prescribe controlled substances without having to interact in per- son with their patients. Of note, methadone cannot be prescribed for maintenance or detoxification treatment and must still be administered or dispensed directly to the patient for that purpose [47, 48]. Regular face-to-face appointments for high-acuity patients should still be considered in accordance with current restrictions. While there is concern over the inability to conduct urine drug screens through telehealth visits, unnecessary exposure to COVID-19 should be considered in an overall harm reduction approach to OUD [49].

Prior research has demonstrated comparable patient retention, ratings of therapeutic alliance, and medication adherence for telehealth-delivered medication mainte- nance treatment compared to in-person treatment [50, 51]. The Rhode Island Buprenorphine Hotline is a phone hot- line that functions as a tele-bridge clinic where people with moderate to severe OUD can be linked with a DATA 2000 waivered provider who provides an initial assessment and, if appropriate, prescribes buprenorphine for unobserved induction and linkage to outpatient treatment. This service has been viewed as a promising model to bridge gaps in treatment access that both preceded and are exacerbated by the COVID-19 pandemic [52].

Access to medication is a major concern for MAT dur- ing the COVID-19 pandemic. Many insurance providers have adjusted policies to allow for enhanced reimburse- ment, and pharmacies have allowed for early/extended refills during the pandemic. MAT providers need to ensure that patients have access to medication to increase treat- ment retention and success during and after the pandemic [47, 53].

Limitations

This review is limited to a single database. As such, studies outside of MEDLINE were not included. Addi- tional limitations include studies with small sample sizes, particularly in assessing group-based MAT and barriers to MAT. The ASAM practice guideline utilized in this review was published in 2015; however, an updated guideline was published in the May/June 2020 issue of the Journal of Addiction Medicine [15]. Initiation and maintenance doses listed in this review have been updated to reflect this. The nature of MAT initiation and management has been quickly evolving as a result of the COVID-19 pandemic, and a second literature search was conducted to include these changes.

Conclusions

Expanding access to MAT is a crucial component of OUD treatment. Primary care-based models for MAT are shown to reduce mortality for OUD and have equivalent efficacy to MAT in specialty substance treatment facilities. However, research directly comparing specific structures and pro- cesses of care models is still needed [9, 10]. Patients may require novel point-of-care approaches, demonstrated by the modifications made to MAT administration during the COVID-19 pandemic [9]. Despite the effectiveness of MAT for OUD, current rates of engagement and retention sug- gest that new medications and devices need to be explored. Improved outcomes may motivate changes in societal at- titudes toward OUD [49].

SAMHSA-funded “Providers Clinical Support System for MAT” is a free resource that offers learning opportunities for providers interested in prescribing MAT. Interested pro- viders should view their website at http://pcssmat.org/for more information [54].

Summary

Medication-assisted treatment (MAT) for opioid use disorder (OUD) is a crucial public health intervention. The escalating opioid crisis necessitates the exploration of effective and accessible treatment modalities. This review examines MAT's efficacy in primary care settings, analyzes various MAT medications (methadone, naltrexone, buprenorphine), considers the integration of osteopathic medicine, and addresses barriers to successful MAT implementation. The impact of the COVID-19 pandemic on MAT delivery and access is also discussed.

MAT in Primary Care

Traditional specialty care models for OUD face accessibility challenges. Primary care-based MAT offers an innovative approach, demonstrating comparable efficacy to specialty care in reducing OUD morbidity and mortality. Successful primary care MAT programs often incorporate integrated clinical teams, patient agreements, home inductions, and multidisciplinary care. Furthermore, primary care settings facilitate the effective management of comorbidities frequently associated with OUD. Research suggests that geographic proximity to MAT providers significantly influences treatment utilization, particularly in rural areas, highlighting the importance of expanding access to these services in underserved communities.

Methadone

Methadone, an opioid agonist, effectively suppresses opioid withdrawal symptoms, reduces cravings, and facilitates engagement in psychosocial interventions. While highly effective, methadone requires careful monitoring due to potential risks such as QT interval prolongation and numerous drug interactions. Dosing strategies vary depending on treatment goals, with higher doses generally associated with improved retention, although optimal treatment duration remains undefined.

Naltrexone

Naltrexone, a long-acting opioid antagonist, is available in both oral and extended-release injectable formulations. While effective in preventing relapse and reducing cravings, oral naltrexone suffers from poor adherence. The extended-release injectable formulation offers superior retention but is contraindicated in pregnant or breastfeeding women.

Buprenorphine

Buprenorphine, a partial opioid agonist, provides effective craving relief with a relatively high safety profile due to its "ceiling effect," minimizing the risk of respiratory depression. Its outpatient prescription accessibility through the Drug Addiction Treatment Act (DATA) of 2000 has significantly broadened MAT access. Higher doses of buprenorphine have demonstrated superior efficacy in reducing illicit opioid use. Novel formulations, including extended-release injections, continue to be developed. Group-based buprenorphine treatments are emerging, offering a combined approach to medication management and counseling, though further research is needed to establish their comprehensive effectiveness.

Osteopathic Supplementation to MAT

The integration of osteopathic manipulative treatment (OMT) into OUD treatment, particularly in patients with co-occurring chronic pain, presents a promising holistic approach. OMT offers a non-invasive, adjunctive therapy with minimal side effects that may reduce opioid dependence and improve overall patient outcomes. Research on the effectiveness of OMT in managing chronic pain needs expansion.

Barriers to MAT

Barriers to effective MAT implementation include inadequate provider training, cost-related issues, insufficient care coordination, persistent stigma, and limited access, particularly in rural areas. Addressing these barriers requires comprehensive strategies that encompass provider education, improved reimbursement models, and community-based initiatives.

MAT Selection and COVID-19 Impact

MAT selection depends on patient-specific factors and population-level considerations. Individualized approaches assess patient factors, while population management strategies address broader public health implications. The COVID-19 pandemic significantly impacted MAT delivery, necessitating adaptations such as telehealth services and modified dispensing protocols. Telehealth has shown promise in maintaining treatment engagement, while ensuring medication access remains crucial for successful MAT outcomes during and beyond the pandemic.

Limitations and Conclusions

This review has limitations due to its reliance on a single database and the inclusion of studies with varying sample sizes. Expanding access to MAT through various strategies remains paramount in combating the opioid crisis. Primary care-based MAT programs represent a crucial component of OUD treatment, but further research is needed to optimize their structure and processes. Addressing barriers to MAT access and exploring innovative approaches, particularly in the context of evolving public health challenges, are essential steps toward improving OUD treatment outcomes.

Summary

The opioid crisis necessitates effective treatment for opioid use disorder (OUD). Medication-assisted treatment (MAT), utilizing FDA-approved medications alongside behavioral health interventions, offers a crucial approach. This review examines MAT components, its efficacy in primary care, and barriers to its effective implementation, considering the impact of the COVID-19 pandemic.

MAT in Primary Care

Traditional OUD treatment in specialized settings faces accessibility challenges. Primary care offers a more accessible and patient-centered approach. Studies demonstrate equivalent efficacy of primary care MAT compared to specialty care, highlighting the importance of integrated clinical teams, patient agreements, and convenient methods like home inductions. Multidisciplinary care models are also suggested, although further research is warranted. Primary care settings also facilitate addressing comorbidities, improving overall patient health outcomes. Rural primary care plays a unique role, influencing MAT access and utilization, although disparities in provider distribution remain.

Methadone

Methadone, an opioid agonist, effectively manages OUD and withdrawal. Available through approved programs, take-home doses are permitted for compliant patients. While superior to abstinence-based approaches, potential risks, including cardiac arrhythmias and drug interactions, necessitate careful patient monitoring and assessment of cardiac risk factors. Dosage varies depending on individual needs and response, with higher doses often associated with better treatment retention.

Naltrexone

Naltrexone, an opioid antagonist, can be prescribed in outpatient settings for both OUD and alcohol use disorder. While both oral and extended-release (ER) injectable forms are effective, ER injectable is preferred due to better patient adherence. Treatment goals include prevention of return to use and craving reduction. Careful detoxification is needed before administration, and patients should be aware of the increased overdose risk upon relapse due to diminished tolerance. ER injectable naltrexone is not recommended for pregnant or breastfeeding women.

Buprenorphine

Buprenorphine, a partial opioid agonist, offers a safer profile than other MAT medications due to its ceiling effect, limiting respiratory depression risk. The Drug Addiction Treatment Act (DATA) of 2000 facilitates increased access by allowing physicians to prescribe it after completing training. Dosing strategies vary, with higher doses potentially more effective in suppressing illicit opioid use, although the FDA recommends a maximum daily dose to minimize diversion risk. Combination with naloxone discourages misuse. Novel administration methods and group-based treatment models are emerging, but research on their efficacy is still developing.

Osteopathic Supplementation to MAT

An osteopathic approach, particularly useful in managing chronic pain often co-occurring with OUD, offers a holistic, non-invasive treatment adjunct. Studies suggest OMT can reduce prescription drug use in patients with chronic back pain, though further research is needed to establish its role within MAT for diverse patient populations.

Barriers to MAT

Barriers to successful MAT implementation include inadequate provider training, cost issues, and difficulties in implementing coordinated care. Additional challenges involve a shortage of trained providers, unsuitable reimbursement models, persistent stigma, and geographic limitations. Improving access to training and funding for comprehensive care models is essential.

MAT Selection and COVID-19 Impact

MAT selection requires individualized and population-level considerations, factoring in patient characteristics, access, and community health implications. The COVID-19 pandemic significantly impacted MAT delivery, necessitating telehealth adaptations and modifications to access and maintenance protocols. While telehealth has shown comparable efficacy, challenges remain regarding urine drug screening and ensuring medication access.

Limitations and Conclusions

Limitations of this review include its reliance on a single database and the inclusion of some studies with small sample sizes. Despite these limitations, expanding access to MAT is paramount. Primary care-based models offer increased accessibility and equivalent efficacy to specialty care. Ongoing research focusing on specific care models, innovative approaches, and novel medications is crucial to further improve outcomes and address societal attitudes towards OUD.

Summary

The opioid crisis is a serious public health issue causing many overdose deaths and immense economic costs. Medication-assisted treatment (MAT) offers an effective approach using FDA-approved medications combined with behavioral therapies. This review examines MAT components, its role in primary care, and barriers to its effectiveness.

MAT in Primary Care

Traditionally, OUD treatment occurred in specialized facilities. However, issues like wait times and geographical limitations hinder access. Primary care offers a more convenient approach. Studies show primary care MAT programs are equally effective as specialty care, especially when using integrated teams and patient agreements. Successful programs often incorporate multidisciplinary care and address co-occurring health problems. Rural primary care plays a unique role, as distance to MAT providers significantly impacts access for patients with OUD.

Methadone

Methadone is an opioid agonist used to manage OUD and withdrawal. It’s available through special programs but take-home doses are permitted for patients progressing well. While effective at reducing cravings and withdrawal, it carries risks like arrhythmias and drug interactions. Careful monitoring and patient history are crucial. Higher doses (60-120mg/day) are generally more effective, though optimal treatment length isn't fully established.

Naltrexone

Naltrexone is a long-acting opioid antagonist. Both oral and extended-release (ER) injectable forms are effective, though oral use is less common due to poor adherence. Patients must be opioid-free before starting. ER injectable naltrexone is better for those who haven't succeeded with other MAT options. It has potential side effects, and it’s not recommended for pregnant or breastfeeding women.

Buprenorphine

Buprenorphine is a partial opioid agonist offering a safer profile than other MAT medications due to its ceiling effect, limiting respiratory depression risk. It can be prescribed in outpatient settings, improving access. Higher doses (16mg+) show greater effectiveness in suppressing illicit opioid use, although the FDA recommends a maximum of 24mg/day. Combining it with naloxone discourages misuse. Group-based buprenorphine treatment, offering both medication and counseling, shows promise but needs more research.

Osteopathic Supplementation to MAT

An osteopathic approach, especially with co-occurring chronic pain, may enhance OUD treatment. Studies show osteopathic manipulative treatment (OMT) can reduce prescription drug use in patients with chronic pain. While more research is needed to define its role specifically in OUD, its potential as adjunctive therapy exists.

Barriers to MAT

Barriers to effective MAT include inadequate provider training, cost, and a lack of coordinated care. Other obstacles involve limited trained primary care providers, inadequate reimbursement models, persistent stigma, and geographical limitations (especially in rural areas).

MAT Selection

Choosing the right MAT involves individual and population-level considerations. Individual factors include patient access, setting, risks, co-occurring conditions, and motivation. Population considerations include public health impact and cost-effectiveness. Assessment of active opioid abstinence, co-occurring pain, and risk of overdose guides treatment selection. Pregnancy, recent overdose, and opioid diversion history may influence treatment choice.

COVID-19 Impact

The COVID-19 pandemic significantly altered OUD treatment. Telehealth became crucial. While this maintains access, there are concerns about urine drug screening. Ensuring medication access remains vital for treatment success.

Limitations

This review used a single database, limiting its scope. Some studies had small sample sizes. The review reflects information available up to 2020, and newer research may have further insights.

Conclusions

Expanding MAT access is critical for effective OUD treatment. Primary care-based MAT is as effective as specialty care, but further research on various models is needed. New approaches and medications are needed to improve outcomes and societal attitudes towards OUD.

Summary

Many people get sick from opioid use. Doctors are working hard to help these people get better. Opioids are very strong pain relievers, but they can be dangerous if misused. Many people have died from taking too many.

Medication-Assisted Treatment (MAT)

MAT helps people who are addicted to opioids. It uses special medicines along with other ways to help people get better, like talking to a counselor. MAT helps stop overdoses, and keeps babies born to moms using opioids healthy.

MAT in Doctor's Offices

Getting help for opioid addiction is easier when it’s available at regular doctor's offices. Studies show that getting MAT at a regular doctor’s office works just as well as at special clinics. It’s more convenient for people to get help closer to home.

Methadone

Methadone is a medicine that helps people stop using opioids. It reduces cravings and withdrawal symptoms. It’s given at special clinics, but people who are doing well can sometimes take it home. It's important to tell your doctor about any other medicines you’re taking.

Naltrexone

Naltrexone is another medicine that helps people stop using opioids. It blocks the effects of opioids, so they don't feel good anymore. It comes as a pill or a shot. The shot lasts longer.

Buprenorphine

Buprenorphine is a medicine that helps ease cravings and withdrawal. It's safer than other opioid medicines because it’s harder to overdose on. Doctors can prescribe it in their offices, which makes it easier for people to get help. It can also be given with another medicine to make it harder to misuse.

Osteopathic Medicine and MAT

Osteopathic doctors also help people with chronic pain. Sometimes, opioid addiction goes along with chronic pain, so osteopathic medicine can be helpful. It's a gentle treatment that can work with MAT to help people feel better.

Problems with Getting MAT

Some things make it hard for people to get MAT. Doctors sometimes need more training, and sometimes it's expensive. Also, many people feel ashamed to ask for help.

Choosing the Right MAT

Doctors choose the best MAT medicine for each person. They think about the person's health, what other problems they have, and how much help they need.

COVID-19 and MAT

The COVID-19 pandemic made it harder for people to get MAT. Doctors found new ways to give treatment remotely, using phones and video calls.

Important Note

This information is for kids and is simplified. If you or someone you know has an opioid problem, please talk to a doctor or other health professional for more information and support.