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Pros and Cons of Medication-Assisted Treatment for Opioid Use Disorder

July 12, 2018
Arthur Robin Williams, MD, MBE

Although these medication-assisted treatments have been approved by the FDA and have strong empiric evidence for superior outcomes, it is important to know the good and the bad.

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)

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