Opioid Agonists and Partial Agonists (Maintenance Medications)
Studies show that people with opioid use disorder who follow detoxification with complete abstinence are very likely to relapse, or return to using the drug. While relapse is a normal step on the path to recovery, it can also be life threatening, raising the risk for a fatal overdose. Thus, an important way to support recovery from heroin, fentanyl, or prescription opioid use disorder is to maintain abstinence from those drugs. Someone in recovery can also use medications that reduce the negative effects of withdrawal and cravings without producing the euphoria that the original drug of abuse caused. Methadone and buprenorphine are medications approved for this purpose.
Methadone is a synthetic opioid agonist that eliminates withdrawal symptoms and relieves drug cravings by acting on opioid receptors in the brain—the same receptors that other opioids such as heroin, morphine, fentanyl, and opioid pain medications activate. Although it occupies and activates these opioid receptors, it does so more slowly than other opioids and, in an opioid-dependent person, treatment doses do not produce euphoria. It has been used successfully for more than 70 years to treat opioid use disorder and must be dispensed through specialized opioid treatment programs.
Buprenorphine is a partial opioid agonist, meaning that it binds to those same opioid receptors but activates them less strongly than full agonists do. Like methadone, it can reduce cravings and withdrawal symptoms in a person with an opioid use disorder without producing euphoria. Buprenorphine has been available for opioid use disorders since 2002 as a tablet and since 2010 as a sublingual film. The FDA approved a 6-month subdermal buprenorphine implant in May 2016 and a once-monthly buprenorphine injection in November 2017. These formulations are available to patients stabilized on buprenorphine and will eliminate the treatment barrier of daily dosing for these patients.
Opioid Antagonists
Naltrexone is an opioid antagonist, which means that it works by blocking the activation of opioid receptors. Instead of controlling withdrawal and cravings, it treats opioid use disorder by preventing any opioid drug from producing rewarding effects such as euphoria. Its use for ongoing opioid use disorder treatment has been somewhat limited because of poor adherence and tolerability by patients. In 2010, an injectable, long-acting form of naltrexone (Vivitrol), originally approved for treating alcohol use disorder, was FDA-approved for treating opioid use disorder. Because its effects last for weeks, Vivitrol is a good option for patients who do not have ready access to health care or who struggle with taking their medications regularly.
Because each medication works differently, a treatment provider should decide on the optimal medication in consultation with the individual patient and should consider the patient’s unique history and circumstances.
Opioid treatment programs are the only providers authorized to utilize all three FDA approved medications to treatment opioid use disorder.
*Data and Reference Information Obtained from NIDA.gov