While medication-assisted treatments (MAT), such as methadone and buprenorphine, are hailed as the gold standard for treating opioid use disorder (OUD), some patients with the condition instead opt for non-opioid medications. Clinicians too are much more likely to prescribe non-opioid medications.
These preferences, based on misinformation and misunderstandings, can keep patients from the most effective drugs with a proven track record of improving patient retention and saving lives.
“Instead of us asking how effective these are at helping relieve symptoms of withdrawal, I recommend we ask why someone would be recommended to receive these or would want to receive these rather than use the medications – buprenorphine or methadone – that effectively treat withdrawal and the underlying brain chemistry present in an opioid use disorder,” Dr. Eileen Barrett, senior medical director and vice president of quality at Workit Health, told Addiction Treatment Business.
Non-opioid medications, including lofexidine and clonidine, can help reduce symptoms of withdrawal, Barrett said, but do not treat the underlying SUD.
Ann Arbor, Michigan-based Workit provides Suboxone and Naltrexone via virtual appointments to treat opioid and alcohol use disorders (AUD), along with recovery groups and treatment for co-occurring conditions. The company has previously attracted investor attention, including a $118 million Series C funding round in 2021.
Barrett is also president-elect of the American Medical Women’s Association.
The most effective treatment
Buprenorphine or methadone, which are opioid-based medications, reduce the risk for overdose, return to use and death.
Research has demonstrated that both these drugs are effective, although methadone is even more effective. One study, led by Yale researchers, found that methadone reduces the risk of death by 38% and that buprenorphine reduces risk by 34%.
Methadone is also more effective than buprenorphine at keeping patients in care. A study found that methadone kept patients in treatment for a median of 66 days, compared to 30 days for buprenorphine or naloxone.
The drugs are also “incredibly safe,” according to Robert Heimer, a professor of epidemiology and pharmacology at Yale University.
“The drugs themselves, methadone and buprenorphine, you could take for a lifetime,” Heimer previously told ATB. “They don’t have kidney or liver toxicity. They don’t cause cardiovascular disease, COPD, or infectious disease complications.”
Despite buprenorphine and methadone’s proven efficacy, concerns exist about the potential for misuse. These claims are not completely unfounded.
There is a “minimal” risk of abuse for buprenorphine, and a “relatively small” risk for methadone, according to Dr. Steven Pratt, senior medical director for the employer segment within Magellan Healthcare.
Frisco, Texas-based Magellan Healthcare is a subsidiary of Magellan Health, which sells services, programs and solutions to payers. Magellan Healthcare provides behavioral health and other services.
Non-opioid options
Non-opioid options for OUD treatment do exist.
Many clinicians prescribe non-opioid options to help manage withdrawal symptoms when patients are transitioning from one medication to another or when they want to taper their doses down, Barrett said.
Withdrawal management options include lofexidine and clonidine. Naltrexone, also a non-opioid, can reduce the risk of relapse. Buprenorphine and methadone, on the other hand, treat both withdrawal symptoms and the underlying brain chemistry of OUD.
Non-opioid options have other limitations as well.
“One of the significant issues with non-opioid medications is that people do not start or do not continue them,” Pratt said. “In these situations, they are not effective and, in some cases, may be an obstacle for people who may psychologically see themselves as having failed at treatment.”
While buprenorphine and methadone are the most efficacious options, clinicians should always respect a patient’s preferences, Barrett said. When treating a patient requesting treatment other than buprenorphine or methadone for OUD, she recommends an “honest conversation” to establish trust. She usually uncovers that patients are concerned about the drugs’ risks and stigma from family, friends or society.
Barrett then informs patients that buprenorphine or methadone will help them “feel like themselves sooner,” and be more likely to prevent return to illicit drug use.
Stigma impacts clinicians as well as patients.
Despite the low risk and the body of research demonstrating better long-term outcomes with buprenorphine or methadone, clinicians are still “much more likely” to prescribe non-opioid treatment.
“This is probably primarily the result of two related issues,” Pratt said. “The first is the stigma that buprenorphine and methadone are opioids. Secondly, many providers still don’t accept that agonists or partial agonists are “treating” opioid addiction.”
Clinicians may perceive methadone or buprenorphine as controlled, ongoing substance use, Pratt said. Misconceptions abound that opioid-based treatments are simply swapping one drug for another.
These misconceptions can have life-ending consequences.
“I can’t tell you how many people I’ve met who lost loved ones because their provider told them they had to taper off suboxone to remain in a treatment facility or sober living – or who were discouraged from maintaining suboxone by their mental health therapist or drug counselor,” Stephanie Strong, founder and CEO of substance use disorder (SUD) treatment provider Boulder Care, previously told ATB.
Suboxone is a brand name of buprenorphine.
Providers should work to reduce stigma and prevent “needless” suffering, Pratt said.
To help more patients with OUD receive gold-standard care, recovery communities should embrace the use of buprenorphine or methadone, according to Barrett.
“I would also like to see health care professionals, health systems, clinics, hospitals, patient advocacy organizations, the carceral system, and lawmakers embrace this as the most dignified approach,” Barrett said.
