Medication Adherence and Safety

Introduction to Opioid Use Disorder

Opioid use disorder is characterized by low rates of spontaneous remission without treatment, neurologic changes in the brain's reward center causing cravings and compulsive use, and potential for severe functional disruption, though some patients may maintain functioning in certain areas, as noted by the American Academy of Pediatrics 1
The rate of spontaneous remission from opioid use disorder without medical treatment is extremely low, with evidence showing that medication-assisted treatment is essential for most individuals to achieve and maintain sobriety, according to the American Academy of Pediatrics 1
Only 18% of people with substance use disorders receive any treatment, far below treatment rates for other chronic conditions, highlighting a significant treatment gap, as reported by the American College of Physicians 2

The American Society of Addiction Medicine recommends monthly injections to eliminate daily dosing, which can be beneficial for patients with unstable lifestyles, according to a study published in 2020 3
Monthly injections provide consistent buprenorphine blood levels without daily peaks and troughs, which may help reduce cravings and potential for supplemental drug use, as reported by the Mayo Clinic Proceedings in 2020 3
The injectable form of medication prevents diversion, selling, or sharing, which is a significant concern with sublingual Suboxone, as noted in a 2020 study 3

The American Academy of Pediatrics recommends buprenorphine as a preferred first-line option for patients 16 years and older due to its FDA approval for this age group 1
Methadone is a highly effective alternative, especially for patients with very high opioid tolerance or those who failed buprenorphine treatment, but it has limitations, including federal regulations prohibiting most methadone programs from admitting patients younger than 18 years 1
Naltrexone is an opioid antagonist option, particularly useful for patients with co-occurring alcohol use disorder or those in unstable or unsupervised housing, but it requires complete opioid detoxification before initiation 1
Buprenorphine, a partial opioid agonist, reduces illicit opioid use by approximately 80% in patients who remain in treatment, and can be prescribed in office-based settings by waivered physicians, as recommended by the American Academy of Pediatrics and supported by the American College of Physicians and the American Medical Association 1, 2, 4
Methadone has similar effectiveness to buprenorphine in reducing illicit opioid use, as reported by the American College of Physicians 2

The Clinical Opiate Withdrawal Scale (COWS) score should be used to confirm opioid withdrawal, with a score >8 indicating moderate withdrawal 5
Initial dosing of buprenorphine should start with 4-8mg sublingually based on withdrawal severity, with reassessment after 30-60 minutes and a target 16mg total first-day dose 5
Buprenorphine should be started at 4-8mg sublingually on the first day, with a target 16mg total first-day dose, and methadone should be initiated through an Opioid Treatment Program according to their protocols, as recommended by the American Academy of Pediatrics and the American Medical Association 1, 4
Naltrexone initiation requires confirmation of opioid-free status (7-10 days) and consideration of a naloxone challenge test, according to the American Academy of Pediatrics 1
Regular visits, urine drug testing, and prescription monitoring program checks are recommended for monitoring patients with OUD, as stated by the American Academy of Pediatrics and supported by the American Psychiatric Association (APA) and the National Institute on Drug Abuse (NIDA) 1, 4, 6
Maintenance dose typically ranges from 16-24mg daily, as recommended by the American Medical Association and the American Psychiatric Association 4

Adjunct analgesics, such as NSAIDs, acetaminophen, ketamine, gabapentin/pregabalin, dexmedetomidine, and lidocaine, can be used for perioperative pain management in patients with OUD, as suggested by the British Journal of Anaesthesia 7
Full mu-opioid agonists, such as morphine, fentanyl, and hydromorphone, can be added if needed for breakthrough pain while maintaining buprenorphine therapy, according to the Mayo Clinic Proceedings 8
Discontinuing buprenorphine perioperatively increases the risk of relapse and is not supported by evidence, as warned by the British Journal of Anaesthesia and the Mayo Clinic Proceedings 7, 8

Pregnant women should be treated with buprenorphine alone (without naloxone), with coordinated care with obstetric providers being essential, as recommended by the American College of Obstetricians and Gynecologists 9
Patients with hepatic impairment may require dose adjustments for buprenorphine and should be monitored periodically for liver function, as suggested by the American Medical Association, based on evidence from JAMA 10
For patients with co-occurring ADHD and OUD, Adderall may be considered with careful monitoring for signs of misuse of either medication, as recommended by the American Academy of Addiction Psychiatry 10
Mental health screening is essential, and rates of intimate partner violence exceed 50% in some settings with drug use disorders, according to the American Academy of Family Physicians 11

The combination of benzodiazepines and opioids increases overdose risk nearly four-fold, necessitating immediate assessment of overdose risk and enhanced monitoring in patients on Suboxone who test positive for benzodiazepines, as recommended by the Centers for Disease Control and Prevention (CDC) 12
Benzodiazepine withdrawal can be more dangerous than opioid withdrawal and can cause seizures or death if stopped abruptly, highlighting the need for careful management in patients on Suboxone who use benzodiazepines, as warned by the World Health Organization (WHO) and the American Society of Addiction Medicine (ASAM) 12

Less than 4% of prescribers (approximately 37,000 physicians) had buprenorphine waivers as of 2016, indicating a need for increased provider capacity, according to the American College of Physicians 2
Insurance restrictions on medication access and limited access to specialized treatment programs are systemic barriers to treatment, as noted by the American College of Physicians and the American Academy of Pediatrics 2, 1
Stigma and lack of awareness about opioid use disorder treatment can also serve as barriers to care, as reported by the American Society of Addiction Medicine (ASAM) 13