Medication-assisted treatments (MAT), methadone, buprenorphine, and extended-release naltrexone, approved by the FDA, have strong empiric evidence for superior outcomes compared with medication-free behavioral approaches or short-term detoxification. This slideshow presents the pros and cons of MAT modalities. For more on this topic, see Responding to the Opioid Epidemic and Expanding Access to Quality Treatment, on which this slideshow is based.
Methadone pros Easy induction following active drug use Lower medication costs but program fees vary High retention rates at 12 months (~80%) Lowers drug use and ccriminal activity Long history of successful use among pregnant women
Methadone cons Requires daily dosing initially for an extended period, often early morning Many states and rural areas have limited or no access to programs Programs can be targeted by drug dealers Patients may combine benzodiazepines or other medications to boost methadone levels (ie, “nodding out”) Can lead to cardiac arrhythmias Highly stigmatized
Pros for Buphrenorphine Minimal risk for overdose Can be prescribed like any other Schedule III controlled substance Flexible dosing (eg, daily or nightly, BID, TID) Very good pain control when dosed every 6–8 hours Often included in Prescription Drug Monitoring Programs (PDMPs) Likely has better outcomes for newborns with neonatal abstinence syndrome (compared to methadone) Somewhat less stigma New injectable forms are coming to market requiring less frequent dosing
Cons for Buphrenorphine Must be prescribed by a DEA-waivered clinician Patients must be in mild-moderate withdrawal before taking first dose (usually requires 12-36 h) Can precipitate painful withdrawal symptoms if taken too closely following full agonist opioids Has street value and can be sold/diverted Patients can intentionally space out doses and use in between Can be more easily manipulated and injected/abused than methadone dispensed from programs Stigma remains
XR-Naltrexone pros Also relieves cravings, like methadone and buprenorphine Patients no longer fear going into withdrawal Blocks opioid use of any kind (this may be less true for some high potency fentanyl analogs) Injection has twice the retention rates of oral naltrexone Less stigma
XR-Naltrexone cons Most difficult induction, requires full detoxification, typically >7 days Hard to find providers who have been trained to use Many insurers still do not cover as a pharmacy benefit and have tedious prior authorization processes hindering use No pain relief and must be stopped for surgery/opioid analgesia Lowers tolerance making patients more vulnerable to overdose risks with return to opioid use (this has been shown with oral naltrexone but not with XR-naltrexone)