The review article summarized here delves into a timely question: How long should treatment for opioid addiction last?
The authors, Anjali Dhanda, MD, and Edwin Salsitz, MD, look at best practices for treatment duration, discuss factors affecting the ideal length of treatment, and cover some of the many barriers to treatment—barriers that lead many people to either avoid opioid addiction treatment (OAT), or, if they’re in it, to drop out.
The review article, “The Duration Dilemma in Opioid Agonist Therapy,” covers the years 1964 to 2018. The article isn’t a structured literature review; instead, it’s what’s known as a review of articles of convenience.
The article was published in the July/August issue of the Journal of Opioid Management.
The authors set the stage by reiterating key points about opioid use disorder (OUD)—that only one patient in five with OUD receives evidence-based treatment—the same low percentage as 20 years ago; that opioid overdose is now the nation’s leading cause of accidental death; that OUD is a chronic disease, and discontinuing treatment opens the door to significant relapse to opioids; that a longer period of treatment is better than a shorter one; and that OAT reduces opioid use, morbidity, and mortality from OUD, as well as all-cause mortality.
Drs. Dhanda and Salsitz stress that investigators have never suggested limiting the length of treatment—nor did participants at the National Institute of Health consensus development conference on the treatment of opiate dependence. Nor did the authors of the Surgeon General’s Report on Alcohol, Drugs, and Health.
Two more points: OAT provides effective treatment; short-term detoxification carries high relapse rates. And discontinuing methadone maintenance treatment (MMT) has tragic consequences; 82% of patients who quit MMT relapse to heroin within one year.
How Methadone Works
SUD results in abnormalities in levels of neurotransmitters in the brain. (Neurotransmitters are chemical substances involved in transferring nerve impulses.)
These neurotransmitter abnormalities can lead to behaviors typically associated with addiction: craving, relapse, and loss of control.
Studies indicate that methadone treatment may mitigate these changes.
Here’s what the authors found regarding safety issues:
- Long-term use of OAT is generally safe when methadone or buprenorphine is properly prescribed and administered
- Constipation can occur, but is readily managed
- Long-term OAT does not damage the body
- The QTc interval is often a concern; although it may be prolonged in methadone patients, the prolongation “is reversible and readily treated”
Concurrent Conditions in Long-Term Treatment
A retrospective study of patients treated with methadone for an average of 11 to 18 years found that no additional disease related to methadone had developed. The authors said that concerns over the long-term adverse effects of OAT are not based on published evidence.
OAT is safe and effective for the mother-to-be, and should be continued throughout pregnancy to reduce the risk of relapse. Drs. Dhanda and Salsitz commented that long-term follow-up of newborns who were exposed to OAT before birth “has not shown any deleterious effects.”
Studies show that OAT can be safely discontinued during pregnancy, they said, but relapse rates are high.
Neonatal Abstinence Syndrome
About 60% to 80% of newborns exposed to buprenorphine or methadone before birth develop neonatal abstinence syndrome (NAS). The incidence and severity of NAS is unrelated to the medication dose, the doctors said. Well established treatment protocols on treating NAS are available.
Stigma, Misconceptions, and Other Barriers to Treatment
Here’s where the real problems come in—the barriers to treatment.
Misconceptions, myths, stigma, lack of education—these and other barriers can make it less likely patients will begin treatment, and they can negatively impact length of treatment, even end treatment—early, and abruptly.
The barriers are many. They include lack of stable housing. Unemployment. Lack of education. Legal problems. Medical and psychiatric conditions. All these factors can influence a person’s perception of the need for long-term treatment.
As if all these barriers weren’t enough, add regulatory problems. Methadone can be accessed only through federally regulated opioid treatment programs (OTPs), and the programs aren’t available in some areas.
OTPs function under heavy governmental regulations that can act as barriers to ongoing treatment.
In fact, the authors note, barriers to treatment “are many and formidable and can lead even patients who are doing well to try to taper, or withdraw from treatment.”
Unfortunately, even many treatment providers trained in addiction medicine believe in an arbitrary time limit for OAT. Why is this? Perhaps it’s the common misconception that OAT patients are not in recovery, or are not abstinent. Or perhaps it’s the belief that abstinence will follow once treatment ends. Patients who pick up such messages could feel they must discontinue treatment.
Sustained OAT has had significantly better long-term outcomes than short-term detoxification or time-limited maintenance. Optimal outcomes are dependent on an adequate duration of treatment.
When OAT is discontinued, however, the consequences are high relapse rates and a risk of overdose deaths.
The Authors’ Recommendations for HCPs
It is vital that health care professionals (HCPs) discuss the length of treatment with their patients, and that HCPs understand the patients support system and the stability of their relationships and living situations.
For patients who are thinking of discontinuing OAT, it is helpful to convey an understanding of what the patient has said. It’s also important to highlight positive outcomes the patient has had during OAT—sobriety, lack of cravings, and overall well-being.
HCPs have an obligation to discuss the high relapse rates that commonly follow when OAT is discontinued, and to ensure that the desire to discontinue OAT is based on fact, not fiction. For example, some women think that becoming pregnant means quitting OAT.
Having such a conversation helps educate patients and significant others, and can give the HCP a deeper understanding of a patient’s motives. It can also provide an opportunity for the HCP to recommend against discontinuing OAT.
At present, although there is no “cure” for any addictive disorder, the authors point out that there is effective treatment, the goals being recovery and remission.
To clarify for our readers, we contacted the authors and verified their use of the word recovery as it’s defined in the consensus statement of the Substance Abuse and Mental Health Services Administration (SAMHSA):
“a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential.”
In this section the authors make a final plea for continuing treatment. They note that no significant adverse effects have turned up for methadone and buprenorphine, even after 40 to 50 years. They point out the high relapse rates and risk of overdose deaths when OAT is discontinued or never implemented, and they warn of the potential danger people who use illicit drugs could face during the current fentanyl epidemic.
One never knows when the next lethal agent may appear, they point out, adding that staying on effective medication for OUD may avoid a significant adverse outcome.
They recognize the desire of many patients to taper off OAT and be “drug free”—a desire that patients with other chronic diseases, such as high blood pressure, may not share. And they hope that one day, with more education of patients, their significant others, and HCPs, OAT for OUD will be more likened to medication for high blood pressure.
“Addiction is a chronic brain disease and its treatment should be similar to the treatment of other chronic medical and psychiatric diseases. Long-term, sometimes lifetime, continuation of OAT for the treatment of OUD results in optimal outcomes when measuring morbidity and mortality. The accumulated evidence does not support any arbitrary limitation to the duration of OAT.”
And here’s the closing statement from Dr. Dhanda’s and Dr. Salsitz’ review article:
We recommend continued treatment with OAT for OUD, and no arbitrary time constraints be placed on the duration of treatment by HCPs, government agencies, or health insurers. We recommend indefinite treatment with OAT if there are no contraindications to treatment, no medical complications, and no adverse effects observed as the correct answer to the duration dilemma.
Dhanda A, Salsitz EA. The duration dilemma in opioid agonist therapy. J Opioid Manag. 2021;17(4):353-358. doi:10.5055/jom.2021.0668