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rather that either/or. Finding a physician that is certified in addiction medicine and/or addiction psychiatry to facilitate treatment is second priority. In my experience nearly all treatment plans developed specifically for the patient and that patients needs are optimal. If the individual has healthcare insurance, that is also a factor to consider, and whether the care provider accepts the insurance or the patient will need to file with the insurance company for reimbursement. A decision by the physician, (initial appointment) whether treatment should begin with inpatient care or can occur in an outpatient setting is necessary. If there are co-occurring issues along with the substance abuse/dependence, such issues should also be part of the treatment plan. Usually treatment which includes medication assisted therapy (MAT) is standard of care. Participating in a combination of group and individual therapy sessions also enhances the treatment outcome. Optimal goal is stable sustained abstinence by the person. Of utmost importance is to always remember addiction is a disorder of brain chemistry and the brain reward system, thus, like diabetes or high blood pressure can be a disorder that goes into remission but can reoccur in the future, thus a chronic medical condition not a character defect.
Because OUD poses greater risks than other use disorders, it requires a different approach when evaluating risks and benefits of treatment. OUD is a chronic, relapsing disorder; therefore a treatment approach that involves only detoxification without maintenance medication is likely to be harmful because of the high risk of relapse and overdose death following periods of abstinence.
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.
Methadone, FDA approved in 1972, is taken once daily. Methadone fully stabilizes opioid receptors for approximately 24 hours. Methadone maintenance is the most well-established treatment for OUD and when given at adequate doses (typically > 60–120 mg/d), is associated with reducing illicit opioid use and overdose death, with decreasing criminality, and with increasing employment.(9) Methadone treatment for addiction is only available through strictly regulated opioid treatment programs accredited by the Substance Abuse and Mental Health Services Administration (SAMHSA). Persons with OUDs initially attend the opioid treatment program daily before receiving take-home doses.
Buprenorphine was FDA-approved in 2002 and works similarly to methadone but only partially activates opioid receptors, limiting overdose risk. Due to a lower risk of overdose than methadone, buprenorphine can be prescribed by physicians in general outpatient settings or attached to specialty treatment programs, also known as Office Based Opioid Treatment. Buprenorphine represents an important alternative maintenance treatment for patients unable or unwilling to attend methadone programs. Prescribers must go through a brief training and obtain a DEA “waiver.” Nurse practitioners and physician assistants can now also prescribe buprenorphine after obtaining a “waiver,” although they must first go through lengthier training.
A major limitation of buprenorphine-based MAT is that providers are hard to find, especially in rural areas.
In general, patients with OUD have a 50% reduction in all-cause mortality while actively in treatment with methadone or buprenorphine. Given the robust evidence for clinical effectiveness, methadone and buprenorphine are included on the World Health Organization list of essential medicines, intended to be available and utilized in health systems at all times. Because of the tremendous benefits of buprenorphine for stabilizing active opioid use and reducing overdose risk, increased attention has been paid to innovative models for expanding access to same-day inductions such as through emergency rooms as well as expanding caseloads via tele-medicine.